Lessons learnt from the COVID-19 pandemic in selected countries to inform strengthening of public health systems: a qualitative study

INTRODUCTION

The COVID-19 pandemic has prompted governments internationally to consider strengthening their public health systems. To support the work of Ireland's Public Health Reform Expert Advisory Group, the Health Information and Quality Authority, an independent governmental agency, was asked to describe the lessons learnt regarding the public health response to COVID-19 internationally and the applicability of this response for future pandemic preparedness.

METHODS

Semi-structured interviews with key public health representatives from nine countries were conducted. Interviews were conducted in March and April 2022 remotely via Zoom and were recorded. Notes were taken by two researchers, and a thematic analysis undertaken.

RESULTS

Lessons learnt from the COVID-19 pandemic related to three main themes: 1) setting policy; 2) delivering public health interventions; and 3) providing effective communication. Real-time surveillance, evidence synthesis, and cross-sectoral collaboration were reported as essential for policy setting; it was noted that having these functions established prior to the pandemic would lead to a more efficient implementation in a health emergency. Delivering public health interventions such as testing, contact tracing, and vaccination were key to limiting and or mitigating the spread of the SARS-CoV-2 virus. However, a number of challenges were highlighted such as staff capacity and burnout, delays in vaccination procurement, and reduced delivery of regular healthcare services. Clear, consistent, and regular communication of the scientific evidence was key to engaging citizens with mitigation strategies. However, these communication strategies had to compete with an infodemic of information being circulated, particularly through social media.

CONCLUSIONS

Overall, functions relating to policy setting, public health interventions, and communication are key to pandemic response. Ideally, these should be established in the preparedness phase so that they can be rapidly scaled-up during a pandemic.

Real-Time Suicide Surveillance: Comparison of International Surveillance Systems and Recommended Best Practice

OBJECTIVE

Some countries have implemented systems to monitor suicides in real-time. These systems differ because of the various ways in which suicides are identified and recorded. The main objective of this study was to conduct an international comparison of major real-time suicide mortality surveillance systems to identify joint strengths, challenges, and differences, and thereby inform best-practice criteria at local, national, and international levels.

METHODS

Five major real-time suicide mortality surveillance systems of various coverage levels were identified and selected for review via an internet-based scoping exercise and prior knowledge of existing systems. Key information including the system components and practices was collated from those organizations that developed and operate each system using a structured template. The information was narratively and critically synthesized to determine similarities and differences between the systems.

RESULTS

The comparative review of the five established real-time suicide surveillance systems revealed more commonalities than differences overall. Commonalities included rapid, routine surveillance based on minimal, provisional data to facilitate timely intervention and postvention efforts. Identified differences include the timeliness of case submission and system infrastructure.

CONCLUSION

The recommended criteria could promote replicable components and practices in real-time suicide surveillance while offering flexibility in adapting to regional/local circumstances and resource availability.HIGHLIGHTSEvidence-informed recommendations for current best practice in real-time suicide surveillance.Proposed comprehensive framework can be adapted based on available resources and capacity.Real-time suicide mortality data facilitates rapid data-driven decision-making in suicide prevention.

The power of effective study design in animal Experimentation: Exploring the statistical and ethical implications of asking multiple questions of a data set

One of the chief advantages of using highly standardised biological models including model organisms is that multiple variables can be precisely controlled so that the variable of interest is more easily studied. However, such an approach often obscures effects in sub-populations resulting from natural population heterogeneity. Efforts to expand our fundamental understanding of multiple sub-populations are in progress. However, such stratified or personalised approaches require fundamental modifications of our usual study designs that should be implemented in Brain, Behavior and Immunity (BBI) research going forward. Here we explore the statistical feasibility of asking multiple questions (including incorporating sex) within the same experimental cohort using statistical simulations of real data. We illustrate and discuss the large explosion in sample numbers necessary to detect effects with appropriate power for every additional question posed using the same data set. This exploration highlights the strong likelihood of type II errors (false negatives) for standard data and type I errors when dealing with complex genomic data, where studies are too under-powered to appropriately test these interactions. We show this power may differ for males and females in high throughput data sets such as RNA sequencing. We offer a rationale for the use of alternative experimental and statistical strategies based on interdisciplinary insights and discuss the real-world implications of increasing the complexities of our experimental designs, and the implications of not attempting to alter our experimental designs going forward.

Gender-specific effects of COVID-19 lockdowns on scientific publishing productivity: Impact and resilience

RATIONALE

The SARS-CoV2 pandemic led to drastic social restrictions globally. Early data suggest that women in science have been more adversely affected by these lockdowns than men, with relatively fewer scientific articles authored by women. However, these observations test broad populations with many potential causes of disparity. Australia presents a natural experimental condition where several states of similar demographics and disease impact had differing approaches in their social isolation strategies. The state of Victoria experienced 280 days of lockdowns from 2020 to 2021, whereas the comparable state of New South Wales experienced 107 days, most of these in 2021, and other states even fewer restrictions.

OBJECTIVE AND METHODS

To assess how the gender balance changed in Australian biomedical publishing with the lockdowns, we created a custom workflow to analyse PubMed data from more than 120,000 published articles submitted in 2019-2021 from Australian authors.

RESULTS

Broadly, Australian women have been incredibly resilient to the challenges faced by the lockdowns. There was an increase in the number of published articles submitted in 2020 that was equally due to women as men, including from Victoria. On the other hand, articles specifically addressing COVID-19 were significantly less likely to be authored by women than those on other topics, a finding not likely due to particular gender imbalance in virology or viral epidemiology, since publications on HIV followed similar patterns to previous years. By 2021, this imbalance had reversed, with more COVID-19-related papers authored by women than men.

CONCLUSIONS

These data suggest women from Victoria were less able to rapidly transition to new research early in the pandemic but had accommodated to the new conditions by 2021. This work indicates we need strategies to support women in science as the pandemic continues and to continue to monitor the situation for its impact on vulnerable groups.

251 PREVALENCE AND CHARACTERISTICS OF SWALLOWING/COMMUNICATION IMPAIRMENTS IN FRAIL OLDER ADULTS ATTENDING THE EMERGENCY DEPARTMENT: A RETROSPECTIVE COHORT STUDY

Background

The presentation of frail older adults to the Emergency Department (ED) may be complicated by swallowing and/or communication impairment. Adults with communication impairment may experience difficulty accessing healthcare. Dysphagia is associated with frailty irrespective of age and/or number of chronic diseases [1]. This study aims to determine the prevalence and characteristics of swallowing and/or communication impairments among frail older adults attending the ED.

Methods

A retrospective cohort study of consecutive ED attendees aged ≥ 75 years assessed by an interdisciplinary Gerontological ED team between October 2021 – February 2022 was conducted. A swallow/communication screening tool determined requirement for Speech and Language Therapy (SLT) referral. Data related to demographics and SLT interventions was extracted. Data analysis was completed using STATA Version 12. Ethical approval was obtained.

Results

Among 518 patients, 118 (23%) (mean age 82.4 (+/-6.4) years, 54% male) required SLT assessment. These patients had high rates of frailty (Median CFS= 6 (IQR 5-7), suspected delirium (4AT ≥ 4 in 45%), suspected malnutrition (MNA score 0-11 in 75%), and probable sarcopenia (SARC-F= ≥ 4 in 75%). Therapy Outcome Measurement Scales and the Functional Oral Intake Scale were used in this first episode of SLT care. Oropharyngeal dysphagia was identified for 43% (27% mild, 10% moderate, 3% moderate-severe, 3% severe), with 6% presenting with signs/symptoms of oesophageal dysphagia. Changes in baseline communication was identified for 57%; cognitive communication difficulties (38%), dysarthria (11%), dysphonia (8%). SLT intervention and management approaches were initiated in the ED.

Conclusion

Findings indicate a high prevalence of swallowing/communication impairment in frail older adults attending the ED. Future research should explore SLT outcomes at point of discharge to refine these swallowing/communication presentations.

Reference

1. Bahat G et al. Association between dysphagia and frailty in community-dwelling older adults. The Journal of Nutrition, Health & Ageing. 2019:23, 571–577.

204 DEDICATED NURSING HOME SERVICE IN A TERTIARY HOSPITAL: EFFECT ON ADMISSION NUMBERS AND LENGTH OF STAY

Background

In 2019 a dedicated Nursing Home (NH) in-patient service was established in a tertiary hospital, comprising a Consultant Geriatrician, clinical nurse specialist, NCHD and administrative support. All NH residents over 65 with medical diagnoses were admitted by the NH team who also provide a consult service for NH residents under other specialties.

Methods

Data were sourced from the Hospital Inpatient Enquiry system on length of stay of patients identified as admitted from a nursing home compared to those admitted under the NH team and their average lengths of stay over 2019-2021.

Results

In 2019, 749 NH residents were admitted to hospital with an average length of stay (ALOS) of 7.93 days, the NH inpatient service was established in July 2019 and showed a reduction of ALOS from 9.25 to 6.6 days in the 6 months following its establishment (29% difference.) In 2020, 707 NH residents were admitted with 352 admitted under the NH team. The ALOS of NH residents admitted under the NH team was 5.66 days in 2020 compared to 8.65 overall (35% difference.) In 2021, 765 NH residents were admitted with 402 under the NH team. ALOS of NH residents admitted under the NH team was 5.33 days in 2021 compared to 8.28 overall (36% difference.)

Conclusion

Within six months of its commencement the dedicated NH service had decreased length of stay by 29%. The average length of stay across all services has decreased year on year from 6.6 to 5.3 days from 2019 to 2021. The ALOS in the total cohort (including residents admitted surgically and those under 65) was 29-36% higher. Though difficult to accurately compare these cohorts due to different presenting diagnoses and medical backgrounds in those admitted surgically or those under 65, the overall reduction in length of stay over the three years does highlight the benefit from this dedicated service.

High level review of configuration and reform of Public Health systems in selected countries

Background

The impact of the COVID-19 pandemic has prompted governments internationally to consider reform and strengthening of their Public Health systems. To support this work in Ireland, we undertook a review Public Health systems internationally (research question [RQ] 1), and identified lessons learned from the COVID-19 pandemic (RQ2).

Methods

Data relating to Public Health systems (RQ1), and lessons learned (RQ2) for a select group of 12 countries were identified from organisations’ websites, an electronic database and grey literature search and representatives from key national-level organisations. Data for RQ1 were extracted, mapped to the 12 Essential Public Health functions (EPHFs) at national, regional and local levels, and verified by participating representatives. For RQ2, thematic analysis of semi-structured interviews with participating representatives was undertaken and.

Results

Typically, across all included countries, there is national strategic oversight of all EPHFs and, for certain functions, there is regional and local level implementation. Lessons learned from the COVID-19 pandemic broadly related to the themes of legislation and decision making; data collection, surveillance, evidence synthesis and collaboration; public health interventions; public participation, public messaging and communication; continuation of healthcare services; and workforce capacity and resilience.

Conclusions

When structuring Public Health systems, there is a need to identify which functions, and or which elements of a function, should be delivered at a national, regional or local level to ensure a sustainable and comprehensive Public Health system. Appropriate IT infrastructure, strong communication and an established evidence synthesis function are key to timely and informed decision making. Ideally, these functions should be established during periods of relative stability to permit a faster response during a pandemic or emergency situation.

Organisational perspectives on Public Health delivery in Ireland: Lessons learned from COVID-19

Background

The COVID-19 pandemic has placed healthcare systems worldwide under unprecedented pressure, with the Irish Public Health system no different. To strengthen delivery of Essential Public Health Functions (EPHFs) and increase future pandemic preparedness, Public Health leaders are now focused on identifying learnings from the pandemic. Within Ireland, given their experience, organisations situated within the Public Health system may be in a unique position to provide valuable information around the delivery of EPHFs, both prior to and in light of the COVID-19 pandemic, and how this can be improved in the future.

Methods

An online survey was distributed by the Department of Health, from 2 March 2022 to 25 March 2022, amongst organisations situated within the Public Health domain in Ireland. The survey consisted of six open-ended questions around the delivery of EPHFs prior to and in light of the pandemic, success stories that could provide scalable solutions to EPHF delivery and current health system barriers, key areas in the public health system that require strengthening, and barriers to achieving these actions. Thematic analysis to identify key themes was conducted on survey responses.

Results

Twenty-eight organisational responses were received. Themes around the workforce were apparent throughout, with staff training, staff diversity and staff morale, identified as areas for strengthening EPHF delivery. Themes around ICT, data collection and research were frequently identified with a lack of adequate ICT identified as a key lesson from the pandemic, while the Public Health ICT strategy was identified as key to strengthening future EPHF delivery.

Conclusions

In general, themes around the workforce; leadership, management and governance and ICT, data collection and research were reoccurring across organisational responses and therefore may be key areas for consideration when strengthening delivery of the EPHFs in Ireland.

Speakers/Panelist

Louise Hendricks

Department of Health, Ireland

Sohel Saikat

WHO, Geneva, Switzerland

Coronary wave energy to predict functional recovery in patients with ischemic left ventricular dysfunction

Background

Invasive coronary angiography and non-invasive viability testing are the cornerstones of diagnosing and managing ischemic left ventricular dysfunction. At present there is no single test which serves both needs but, if developed, could revolutionise investigation of this condition. Coronary wave intensity analysis (cWIA) interrogates both contractility and microvascular physiology of the subtended myocardium [1,2] and therefore has the potential to fulfil this goal.

Objectives

We hypothesized that cWIA measured during coronary angiography would predict functional recovery with a similar accuracy to late gadolinium enhanced cardiac magnetic resonance imaging (LGE-CMR).

Methods

Patients with a left ventricular ejection fraction ≤40% and extensive coronary disease were enrolled. cWIA, fractional flow reserve and microvascular resistance were assessed with a simultaneous coronary Doppler and pressure-sensing guidewire during cardiac catheterization at rest, during hyperaemia and during low-dose dobutamine stress. Viability was assessed using LGE-CMR. Regional left ventricular function was assessed at baseline and 6-month follow up after optimization of medical therapy +/− revascularization, using transthoracic echocardiography. The primary outcome was regional functional recovery.

Results

Forty participants underwent baseline physiology, LGE-CMR and thirty had echocardiography at baseline and 6 months; 21/42 territories demonstrated functional recovery. Resting backward compression wave energy was significantly greater in recovering than non-recovering territories (−5240±3772 vs. −1873±1605 W m–2 s–1, p=0.099, Figure 1), and had comparable diagnostic accuracy to CMR (area under the curve 0.812 vs. 0.757, p=0.649, Figure 2); a threshold of −2500 W mm–2 s–1 had 86% sensitivity and 76% specificity at predicting recovery. Backward expansion wave energy did not predict recovery. FFR was numerically higher in recovering territories (0.81±0.17 vs. 0.71±0.16, p=0.058), whilst hyperaemic microvascular resistance did not differentiate recovering from non-recovering territories (1.97±0.73 vs. 2.29±1.00, p=0.287). The likelihood of functional recovery was similar in revascularised and non-revascularised territories (15/29 vs. 6/13 respectively, p=0.739). Low-dose dobutamine stress increased the energy of all waves, but did not improve the accuracy of cWIA in predicting recovery. In a regression model, resting backward compression wave energy and optimization of medical therapy predicted functional recovery; fractional flow reserve and hyperemic microvascular resistance did not.

Conclusions

Backward compression wave energy has similar accuracy to LGE-CMR in the prediction of functional recovery. cWIA has the potential to revolutionise the management of ischaemic left ventricular dysfunction, in a manner analogous to the effect of fractional flow reserve on the management of stable angina.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The British Heart Foundation Clinical Research Training Fellowship

The development and validation of a dashboard prototype for real-time suicide mortality data

Introduction/Aim

Data visualisation is key to informing data-driven decision-making, yet this is an underexplored area of suicide surveillance. By way of enhancing a real-time suicide surveillance system model, an interactive dashboard prototype has been developed to facilitate emerging cluster detection, risk profiling and trend observation, as well as to establish a formal data sharing connection with key stakeholders via an intuitive interface.

Materials and Methods

Individual-level demographic and circumstantial data on cases of confirmed suicide and open verdicts meeting the criteria for suicide in County Cork 2008–2017 were analysed to validate the model. The retrospective and prospective space-time scan statistics based on a discrete Poisson model were employed via the R software environment using the “rsatscan” and “shiny” packages to conduct the space-time cluster analysis and deliver the mapping and graphic components encompassing the dashboard interface.

Results

Using the best-fit parameters, the retrospective scan statistic returned several emerging non-significant clusters detected during the 10-year period, while the prospective approach demonstrated the predictive ability of the model. The outputs of the investigations are visually displayed using a geographical map of the identified clusters and a timeline of cluster occurrence.

Discussion

The challenges of designing and implementing visualizations for suspected suicide data are presented through a discussion of the development of the dashboard prototype and the potential it holds for supporting real-time decision-making.

Conclusions

The results demonstrate that integration of a cluster detection approach involving geo-visualisation techniques, space-time scan statistics and predictive modelling would facilitate prospective early detection of emerging clusters, at-risk populations, and locations of concern. The prototype demonstrates real-world applicability as a proactive monitoring tool for timely action in suicide prevention by facilitating informed planning and preparedness to respond to emerging suicide clusters and other concerning trends.

Hemorrhagic Transformation Rates following Contrast Media Administration in Patients Hospitalized with Ischemic Stroke

BACKGROUND AND PURPOSE

Hemorrhagic transformation is a critical complication associated with ischemic stroke and has been associated with contrast media administration. The objective of our study was to use real-world in-hospital data to evaluate the correlation between contrast media type and transformation from ischemic to hemorrhagic stroke.

MATERIALS AND METHODS

We obtained data on inpatient admissions with a diagnosis of ischemic stroke and a record of either iso-osmolar or low-osmolar iodinated contrast media for a stroke-related diagnostic test and a treatment procedure (thrombectomy, thrombolysis, or angioplasty). We performed multivariable regression analysis to assess the relationship between contrast media type and the development of hemorrhagic transformation during hospitalization, adjusting for patient characteristics, comorbid conditions, procedure type, a threshold for contrast media volume, and differences across hospitals.

RESULTS

Inpatient visits with exclusive use of either low-osmolar (n = 38,130) or iso-osmolar contrast media (n = 4042) were included. We observed an overall risk reduction in hemorrhagic transformation among patients who received iso-osmolar compared with low-osmolar contrast media, with an absolute risk reduction of 1.4% (P = .032), relative risk reduction of 12.5%, and number needed to prevent harm of 70. This outcome was driven primarily by patients undergoing endovascular thrombectomy (n = 9211), in which iso-osmolar contrast media was associated with an absolute risk reduction of 4.6% (P = .028), a relative risk reduction of 20.8%, and number needed to prevent harm of 22, compared with low-osmolar contrast media.

CONCLUSIONS

Iso-osmolar contrast media was associated with a lower rate of hemorrhagic transformation compared with low-osmolar contrast media in patients with ischemic stroke.

Work-Life Balance Inequalities among Veterinary and Allied Professionals: A Qualitative Review

Background

This study aimed to review qualitative psychological and non-psychologically based literature for work-life balance (WLB) inequalities within the veterinary and other allied professions.

Methods

The PECO framework includes qualitative studies published in any language but with an English translation involving adult workers in the veterinary or allied profession and outcomes around work-life balance. Seven relevant electronic databases EMBASE, PsycARTICLES, PsycINFO, MEDLINE, Social Policy and Practice, HMIC Health Management Information Consortium, and Global Health, were used. The retrieved hits were exported to Endnote Desktop (Version 7.7.1) for sorting and management.

Results

Of the 3610 hits, 31 studies were eligible for narrative synthesis. The studies were published from 1980-2017 and came from 15 countries. 9(29%) of the 31 studies were from the USA. 22 of the 31 studies (71%) focused on a mix of professions. Data were collected in six different ways, with the most common being interviews (17 (54.8%) of 31 studies). Twenty-three questions were used to assess WLB. The most common ones focused on women becoming mothers, maternity leave, and return to work (five (16.1%) of 31 articles). Secondly were attitudes of ethnic minorities concerning education, employment, role-family conflict, etc., and family commitments (three (9.7%) of the 31 papers). Findings came under 74 different topics. Nineteen (25.7%) of the 74 topics occurred more than four times and were allocated under the appropriate sub-theme. The nine sub-themes include pregnancy, breastfeeding, motherhood, job/life satisfaction, age/gender/ethnic inequalities, return to work (RTW), health and lifestyle, dual-earning couples/family, workplace support, and work-family/family-work conflicts.

Conclusions

The review suggests that women, ethnic minorities, older staff, and those with health concerns are negatively impacted by inequalities around WLB in veterinary and allied professions.

Key messages

The findings from the review were used to support the development of psychological measures of work-life balance and gender differences. The results were used in online questionnaires/surveys for future participants within the veterinary profession in addressing inequalities.

Media coverage of evidence outputs during the COVID-19 pandemic: findings from one national agency

Background

The COVID-19 Evidence Synthesis Team within the Health Information and Quality Authority (HIQA) in Ireland produced a range of evidence-based reports on a broad range of public health topics related to COVID-19. These evidence outputs (EO) arose directly from questions posed by policy makers and clinicians supporting Ireland's National Public Health Emergency Team (NPHET). Findings from these EOs informed the national response to the COVID-19 pandemic in Ireland and influenced international public health guidance. How research findings are presented through domestic news can influence behaviour and risk perceptions.

Methods

We investigated traditional media coverage of nine COVID-19 EOs and associated press releases, published (April to July 2020) by HIQA. NVivo was used for conceptual content analysis of manifest content. ‘Core messages' from each evidence output were proposed and 488 sources from national and regional broadcast, print, and online media were coded at the phrase level. The presence of political and public health actors in coverage were also coded.

Results

Coverage largely did not distort or misrepresent the results of the EOs, however, there was variability in terms of what content was reported on and to what extent different stakeholders were involved in the contextualization of the findings of the EOs. Coverage appeared to focus more on ‘human-interest' stories as opposed to more technical reports (e.g. focusing on viral load, antibodies, testing, etc.). Selective reporting and the variability in the use of quotes from governmental and public health stakeholders changed and contextualized results in different manners than perhaps originally intended in the press release.

Conclusions

Our findings provide a case-study of European media coverage of evidence reports produced by a national agency. Results highlighted several strengths and weaknesses of current communication efforts.

Evaluating rapid review provision to inform policy during the COVID-19 pandemic

Background

Evidence based decision making is central to population health, particularly during a pandemic. Few studies examine the production and use of evidence in decision-making during crisis management. This study describes and evaluates the provision of rapid evidence products by a single agency to support national decision making.

Methods

Semi-structured interviews were conducted with a convenience sample of evidence providers (who gathered and disseminated the required evidence) and service users (policy makers). Interviews were transcribed verbatim and analysed using thematic analysis. Quantitative data of work activity were summarised descriptively.

Results

Three themes were generated from the data: the work, the use and the future, with a fourth theme cross-cutting across these: the team. The work followed clear protocols and was centrally managed. The scope and changing nature of the evidence were highlighted as issues. The service providers reported a strong sense of team work and ‘being in this together', however, the majority of the participants felt that the workload was huge and exhausting and not sustainable long-term. Overall the service users thought the rapid evidence synthesis was indispensable to the decision-making process and had trust and confidence in the work, largely based on existing working relationships with the team. While they recognised that the evidence synthesis support would be an essential component of the continued pandemic response, they did query the sustainability of the process and reflected on the amount of work the team performed.

Conclusions

This evaluation, drawing on qualitative data, has highlighted that, across the services users and evidence providers, the support provided by HIQA was generally perceived as positive. From the service users' perspective, having access to the team was indispensable to the decision making process. However, the sustainability of the work load was identified as a major challenge.

Evidence Synthesis to support the public health response during the COVID-19 pandemic

Background

In January 2020, the Irish National Public Health Emergency Team (NPHET) for COVID-19 was established. NPHET oversees and provides national direction, guidance, support and expert advice on the development and implementation of strategies to contain COVID-19 in Ireland. Since March 2020, HIQA's COVID-19 Evidence Synthesis Team has provided research evidence to support the work of NPHET and associated groups and inform the development of national public health guidance. From September 2020, as part of the move towards a sustainable response to the public health emergency, HIQA also provides evidence based advice in response to requests from NPHET. The advice provided to NPHET is informed by research evidence developed by HIQA's COVID-19 Evidence Synthesis Team and with expert input from HIQA's COVID-19 Expert Advisory Group.

Methods

This presentation describes the establishment and organisation of the COVID-19 Evidence Synthesis Team, with an overview of the processes and methodological approaches involved. The role of HIQA's COVID-19 Evidence Synthesis Team in informing the public health response during the COVID-19 pandemic is discussed, along with the challenges and opportunities this presents. The relevance now and for future pandemic preparedness is outlined.

Results

As of 19 April 2021, HIQA has produced, and in some instances has regularly updated, 25 evidence summaries, 11 advice documents, 9 reviews of international guidance, 3 scoping reports, 5 reviews of care pathways, 2 analyses/models and 2 databases.

Conclusions

In the context of the COVID-19 pandemic, HIQA has developed and implemented a process to ensure rapid access to the best available evidence relevant to the COVID-19 outbreak to inform decision-making at each stage of the pandemic.

COVID-19 Public Health Guidance Database

Background

Since March 2020, members of the Health Technology Assessment (HTA) team in HIQA have been identifying, reviewing and presenting COVID-19 public health guidance produced by international organisations. The aim of this work has been to inform the development of public health guidance and policy by the Health Protection Surveillance Centre (HPSC), Department of Health and Health Service Executive (HSE), using international evidence and best practice.

Methods

International resources are searched on a weekly basis to identify new or updated public health guidance on COVID-19. The three distinct steps in the process include, searching relevant international resources, reviewing identified relevant public health guidance for COVID-19, and presenting new or updated guidance in a COVID-19 Public Health Guidance Database, which was created by the team using Microsoft Excel. The international organisations reviewed include the World Health Organisation, European Centre for Disease Prevention and Control and Centers for Disease Control and Prevention, as well as a range of ministries of health and public health agencies from 10 countries. These were chosen, based on guidance being available in English, widespread use of the organisation's advice, and/or the working constraints of the HTA team.

Results

The COVID-19 Public Health Guidance Database is updated weekly and provided to the relevant individuals within HPSC, Department of Health, and HSE, who are responsible for developing public health and infection, prevention and control guidance related to COVID-19 in Ireland. Following this the database is published online and may be utilised by the public or other international organisations.

Conclusions

The COVID-19 Public Health Guidance Database is used to inform the ongoing response to the COVID-19 pandemic, specifically, to inform the development of public health and infection, prevention and control guidance to prevent the spread of COVID-19.

COVID-19 - Interventions and lifestyle factors that prevent infection or minimise progression to severe disease

Background

This evidence summary synthesised the evidence relating to pharmacological and non-pharmacological interventions in the community to prevent COVID-19/progression to severe disease. An additional aim was to identify potentially modifiable lifestyle factors associated with reduced risk of infection/progression to severe disease.

Methods

A systematic search of published peer-reviewed articles and non-peer-reviewed pre-prints was undertaken from 1 January 2020 to 19 April 2021; no language restrictions were applied. All potentially eligible papers were exported to Covidence. Titles/abstracts and full texts were single screened for relevance. Data extraction and quality appraisal of included studies was completed by a single reviewer and checked by a second.

Results

In total, 50 studies, three randomised controlled trials (RCTs), one non-RCT and 46 cohort studies were included. The four included controlled trials tested variations of the pharmacological intervention, ivermectin. While these controlled trials reported a protective effect for ivermectin use, these trials were of poor quality and had serious risk of bias. Across 46 cohort studies, the modifiable lifestyle risk factors identified were obesity, smoking, vitamin D status, physical activity, alcohol consumption and processed meat consumption. These studies reported mixed results in terms of the association between modifiable lifestyle risk factors and poor COVID-19 outcomes.

Conclusions

At the time of writing there is no high quality evidence of benefit to support pharmacological interventions to prevent COVID-19. Although there were mixed results for the risk factors identified, maintenance of healthy weight, smoking cessation, engaging in physical activity and moderation of alcohol and processed meat consumption are likely to be beneficial to health and should continue to be encouraged.

Shelling the myth: allergies to Iodine containing substances and risk of reaction to Iodinated contrast media

PURPOSE

In excess of 100 million procedures using iodinated radio-contrast media are conducted each year. There is a common misunderstanding regarding the links between allergy to iodinated substances and the risk of allergic reaction to intravenous iodinated contrast agents. These perceived risks are managed via administration of corticosteroids or avoidance of iodinated contrast altogether.

METHODS

An extensive review of published literature on scientific databases and international guidelines was conducted in order to inform the research question. A questionnaire was formulated and distributed to hospital doctors in four tertiary centres. Within this questionnaire, hospital doctors were presented with six different scenarios of bona fide allergy to iodinated substances (e.g. shellfish) and asked to select the treatment response option which they deemed to be the most suitable from a choice of three (standard contrast scan/delay scan with pre-medication/change to non-contrast scan).

RESULTS

Eighty-seven questionnaire responses were received. Contrast (standard protocol) was the most appropriate regimen in the setting of all the listed allergies. This was identified correctly by 76%, 69%, 44%, 32%, 18% and 14% for kiwi, fish, poly-food, shellfish, betadine and tincture of iodine allergies, respectively.

CONCLUSIONS

There is a lack of understanding amongst local junior medical staff regarding administration of iodinated contrast media to patients with a history of allergy to iodinated substances. These misconceptions may potentiate the unnecessary usage of pre-medication and ordering of non-contrast scans in the setting of a gold-standard enhanced scan. Findings from this study suggest that there is a need for future education efforts targeted during the basic specialty training stage.

Anticholinergic drug use and risk of mortality for people with dementia in Northern Ireland

OBJECTIVE

Anticholinergic burden refers to the cumulative effect of medications which contain anticholinergic properties. We assessed how anticholinergic burden and different types of anticholinergic medications influence mortality rates among people with dementia in Northern Ireland. Our secondary aim was to determine what demographic characteristics predict the anticholinergic burden of people with dementia.

METHODS

Data were extracted from the Enhanced Prescribing database for 25,418 people who were prescribed at least one dementia management medication between 2010 and 2016. Information was also extracted on the number of times each available anticholinergic drug was prescribed between 2010 and 2016, allowing the calculation of an overall anticholinergic burden. Cox proportional hazard models were used to determine how anticholinergic burden influenced mortality whilst multilevel model regression determined what demographic characteristics influence overall anticholinergic burden.

RESULTS

Of the 25,418 people with dementia, only 15% (n = 3880) had no anticholinergic burden. Diazepam (42%) and risperidone (18%) were the two most commonly prescribed drugs. Unadjusted Cox proportional hazard models indicated that higher anticholinergic burden was associated with significantly higher mortality rates in comparison to people with dementia who had no anticholinergic burden (HR = 1.59: 95% CI = 1.07-2.36). In particular, urological (HR = 1.20: 95% CI = 1.05-1.38) and respiratory (HR = 1.17: 95% CI = 1.08-1.27) drugs significantly increased mortality rates. People with dementia living in areas with low levels of deprivation had significantly lower anticholinergic burden (HR=-.39: 95% CI=-.47:-30).

CONCLUSIONS

Reducing anticholinergic burden is essential for people with dementia. Further research should address the unfavourable prognosis of people living with dementia in highly deprived areas.

An agenda for research and action toward diverse and just futures for life on Earth

Decades of research and policy interventions on biodiversity have insufficiently addressed the dual issues of biodiversity degradation and social justice. New approaches are therefore needed. We devised a research and action agenda that calls for a collective task of revisiting biodiversity toward the goal of sustaining diverse and just futures for life on Earth. Revisiting biodiversity involves critically reflecting on past and present research, policy, and practice concerning biodiversity to inspire creative thinking about the future. The agenda was developed through a 2-year dialogue process that involved close to 300 experts from diverse disciplines and locations. This process was informed by social science insights that show biodiversity research and action is underpinned by choices about how problems are conceptualized. Recognizing knowledge, action, and ethics as inseparable, we synthesized a set of principles that help navigate the task of revisiting biodiversity. The agenda articulates 4 thematic areas for future research. First, researchers need to revisit biodiversity narratives by challenging conceptualizations that exclude diversity and entrench the separation of humans, cultures, economies, and societies from nature. Second, researchers should focus on the relationships between the Anthropocene, biodiversity, and culture by considering humanity and biodiversity as tied together in specific contexts. Third, researchers should focus on nature and economies by better accounting for the interacting structures of economic and financial systems as core drivers of biodiversity loss. Finally, researchers should enable transformative biodiversity research and action by reconfiguring relationships between human and nonhuman communities in and through science, policy, and practice. Revisiting biodiversity necessitates a renewed focus on dialogue among biodiversity communities and beyond that critically reflects on the past to channel research and action toward fostering just and diverse futures for human and nonhuman life on Earth.

An agenda for research and action toward diverse and just futures for life on Earth

Decades of research and policy interventions on biodiversity have insufficiently addressed the dual issues of biodiversity degradation and social justice. New approaches are therefore needed. We devised a research and action agenda that calls for a collective task of revisiting biodiversity toward the goal of sustaining diverse and just futures for life on Earth. Revisiting biodiversity involves critically reflecting on past and present research, policy, and practice concerning biodiversity to inspire creative thinking about the future. The agenda was developed through a 2-year dialogue process that involved close to 300 experts from diverse disciplines and locations. This process was informed by social science insights that show biodiversity research and action is underpinned by choices about how problems are conceptualized. Recognizing knowledge, action, and ethics as inseparable, we synthesized a set of principles that help navigate the task of revisiting biodiversity. The agenda articulates 4 thematic areas for future research. First, researchers need to revisit biodiversity narratives by challenging conceptualizations that exclude diversity and entrench the separation of humans, cultures, economies, and societies from nature. Second, researchers should focus on the relationships between the Anthropocene, biodiversity, and culture by considering humanity and biodiversity as tied together in specific contexts. Third, researchers should focus on nature and economies by better accounting for the interacting structures of economic and financial systems as core drivers of biodiversity loss. Finally, researchers should enable transformative biodiversity research and action by reconfiguring relationships between human and nonhuman communities in and through science, policy, and practice. Revisiting biodiversity necessitates a renewed focus on dialogue among biodiversity communities and beyond that critically reflects on the past to channel research and action toward fostering just and diverse futures for human and nonhuman life on Earth.

Myocardial perfusion quantification by CMR for detection of obstructive coronary artery disease in patients with previous coronary artery bypass surgery

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): British Heart Foundation

Background

Coronary artery bypass grafting (CABG) is an established treatment for patients with advanced coronary artery disease (CAD). A subsequent recurrence of symptoms can cause the need for re-assessment of the coronary circulation. The accuracy of visually assessed stress perfusion cardiovascular magnetic resonance (CMR) for the detection of obstructive CAD is reduced in patients with prior CABG. In patients with complex multi-vessel CAD, myocardial perfusion quantification by CMR is superior to visual assessment (VA) for detection of obstructive disease however patients with CABG have been absent from previous studies.

Purpose

This study sought to assess the performance of myocardial perfusion quantification by CMR against invasive coronary angiography (ICA) for detecting obstructive CAD in patients with previous CABG.

Methods

Twenty-nine patients with a history of previous CABG and subsequent clinically indicated perfusion CMR study and invasive coronary angiography were recruited. Patients underwent a dual bolus stress perfusion CMR with late gadolinium enhancement (LGE) imaging at 3 Tesla. Stress myocardial blood flow (MBF) was estimated at the coronary territory level according to the AHA 16 segment model using Fermi function-constrained deconvolution. Segments with transmural LGE were excluded from MBF analysis. Stress perfusion images were analysed visually alongside LGE images and matched perfusion-LGE defects were considered negative. On ICA, coronary territories with lumen stenosis >70% without an unobstructed bypass graft (<70% stenosis) were considered positive.

Results

86/87 coronary territories were suitable for analysis. Sixty-five territories had at least one bypass graft including 32 territories with arterial grafts. 28/86 territories (33%) had obstructive disease on angiography. Territories with obstructive CAD had significantly lower stress MBF than unobstructed territories (1.21 [IQR: 0.96–1.45] vs 1.58 [1.40–1.84] ml/g/min, p < 0.001, Figure 1). Stress MBF had good accuracy to detect coronary territories with obstructive CAD (sensitivity 71%, specificity 84%, area under the curve (AUC) 0.83, p < 0.001, Figure 2A). For visual assessment, sensitivity was 79%, specificity 78% and diagnostic accuracy 78%. When analysis was confined to only territories with bypass grafts, stress MBF had 78% sensitivity, 81% specificity and AUC of 0.85, p < 0.001 (Figure 2B).. In this subgroup, VA had a sensitivity of 78%, specificity of 76% and a 77% diagnostic accuracy.

Conclusions

In patients with previous surgical revascularisation, quantification of stress myocardial blood flow by CMR offers good diagnostic accuracy for the detection and localisation of anatomically significant stenoses. Accuracy is reduced compared with published data in patients without coronary grafts but remains comparable to expert visual assessment.

Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation

Background

Early warning systems (EWSs) are used to assist clinical judgment in the detection of acute deterioration to avoid or reduce adverse events including unanticipated cardiopulmonary arrest, admission to the intensive care unit and death. Sometimes healthcare professionals (HCPs) do not trigger the alarm and escalate for help according to the EWS protocol and it is unclear why this is the case. The aim of this qualitative evidence synthesis was to answer the question ‘why do HCPs fail to escalate care according to EWS protocols?’ The findings will inform the update of the National Clinical Effectiveness Committee (NCEC) National Clinical Guideline No. 1 Irish National Early Warning System (INEWS).

Methods

A systematic search of the published and grey literature was conducted (until February 2018). Data extraction and quality appraisal were conducted by two reviewers independently using standardised data extraction forms and quality appraisal tools. A thematic synthesis was conducted by two reviewers of the qualitative studies included and categorised into the barriers and facilitators of escalation. GRADE CERQual was used to assess the certainty of the evidence.

Results

Eighteen studies incorporating a variety of HCPs across seven countries were included. The barriers and facilitators to the escalation of care according to EWS protocols were developed into five overarching themes: Governance, Rapid Response Team (RRT) Response, Professional Boundaries, Clinical Experience, and EWS parameters. Barriers to escalation included: Lack of Standardisation, Resources, Lack of accountability, RRT behaviours, Fear, Hierarchy, Increased Conflict, Over confidence, Lack of confidence, and Patient variability. Facilitators included: Accountability, Standardisation, Resources, RRT behaviours, Expertise, Additional support, License to escalate, Bridge across boundaries, Clinical confidence, empowerment, Clinical judgment, and a tool for detecting deterioration. These are all individual yet inter-related barriers and facilitators to escalation.

Conclusions

The findings of this qualitative evidence synthesis provide insight into the real world experience of HCPs when using EWSs. This in turn has the potential to inform policy-makers and HCPs as well as hospital management about emergency response system-related issues in practice and the changes needed to address barriers and facilitators and improve patient safety and quality of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00403-9.

A new approach to comprehensively evaluate the morphological properties of the human femoral head: example of application to osteoarthritic joint

Osteoarthritis affects the morphological properties of the femoral head. The goal of this study was to develop a method to elucidate whether these changes are localised to discrete regions, or if the reported trends in microstructural changes may be identified throughout the subchondral bone of the human femoral head. Whole femoral heads extracted from osteoarthritic (n = 5) and healthy controls (n = 5) underwent microCT imaging 39 μm voxel size. The subchondral bone plate was virtually isolated to evaluate the plate thickness and plate porosity. The trabecular bone region was divided into 37 volumes of interest spatially distributed in the femoral head, and bone morphometric properties were determined in each region. The study showed how the developed approach can be used to study the heterogeneous properties of the human femoral head affected by a disease such as osteoarthritis. As example, in the superior femoral head osteoarthritic specimens exhibited a more heterogeneous micro-architecture, with trends towards thicker cortical bone plate, higher trabecular connectivity density, higher trabecular bone density and thicker structures, something that could only be observed with the newly developed approach. Bone cysts were mostly confined to the postero-lateral quadrants extending from the subchondral region into the mid trabecular region. Nevertheless, in order to generalise these findings, a larger sample size should be analysed in the future. This novel method allowed a comprehensive evaluation of the heterogeneous micro-architectural properties of the human femoral head, highlighting effects of OA in the superior subchondral cortical and trabecular bone. Further investigations on different stages of OA would be needed to identify early changes in the bone.

Effect of size and location of simulated lytic lesions on the structural properties of human vertebral bodies, a micro-finite element study

Currently, the Spinal Instability Neoplastic Score system is used in clinics to evaluate the risk of fracture in patients with spinal metastases. This method, however, does not always provide a clear guideline due to the complexity in accounting for the effect of metastatic lesions on vertebral stability. The aim of this study was to use a validated micro Finite Element (microFE) modelling approach to analyse the effect of the size and location of lytic metastases on the mechanical properties of human vertebral bodies. Micro Computed Tomography based microFE models were generated with and without lytic lesions simulated as holes within a human vertebral body. Single and multiple lytic lesions were simulated with four different sizes and in five different locations. Bone was assumed homogenous, isotropic and linear elastic, and each vertebra was loaded in axial compression. It was observed that the size of lytic lesions was linearly related with the reduction in structural properties of the vertebral body (reduction of stiffness between 3% and 30% for lesion volume between 4% and 35%). The location of lytic lesions did not show a clear effect on predicted structural properties. Single or multiple lesions with the same volume provided similar results. Locally, there was a homogeneous distribution of axial principal strains among the models with and without lytic lesions. This study highlights the potential of microFE models to study the effect of lesions on the mechanical properties of the human vertebral body.

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MicroFE models can show the effect of lytic lesions on vertebral properties.

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The size of the lesions was more critical than the location of the lesions.

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Lesions affecting the cortical shell had a larger effect on the local strains.

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Multiple lesions showed a similar effect to single lesions.

Empowering Women Researchers in the New Century: IADR's Strategic Direction

Gender inequality in science, medicine, and dentistry remains a central concern for the biomedical research workforce today. Although progress in areas of inclusivity and gender diversity was reported, growth has been slow. Women still face multiple challenges in reaching higher ranks and leadership positions while maintaining holistic success in these fields. Within dental research and academia, we might observe trends toward a more balanced pipeline. However, women continue to face barriers in seeking leadership roles and achieving economic equity and scholarship recognition. In an effort to evaluate the status of women in dental research and academia, the authors examined the role of the International Association for Dental Research (IADR), a global research organization, which has improved awareness on gender inequality. The goal of this article is to review five crucial issues of gender inequality in oral health research and academics-workforce pipeline, economic inequality, workplace harassment, gender bias in scholarly productivity, and work-life balance-and to discuss proactive steps that the IADR has taken to promote gender equality. Providing networking and training opportunities through effective mentoring and coaching for women researchers, the IADR has developed a robust pipeline of women leaders while promoting gender equality for women in dental academia through a culture shift. As knowledge gaps remained on the levels of conscious and unconscious bias and sexist culture affecting women advancement in academics, as well as the intersectionality of gender with race, gender identity, ability status, sexual orientation, and cultural backgrounds, the IADR has recognized that further research is warranted.

INCLUSION OF TARGETED SKIN PRODUCTS IN THE PRE-SURGICAL TREATMENT REGIMEN OF PERIPHERAL LYMPHEDEMA & LIPEDEMA

Advanced lymphedema is associated with a number of adverse skin changes including color, thickening of the epidermis, dryness, and hyperkeratosis. These changes are related to prolonged lymph stasis and contribute to an increased risk of infection. Similarly, lipedema is associated with skin thickening and appearance of nodular adipose deposition. Skin care is essential in both conditions. We examined whether inclusion of targeted skin products for 2 weeks to an established pre-surgical conservative treatment program was associated with beneficial effects on the skin condition in 150 patients with lymphedema and lipedema. Patients were randomly assigned to control or one of two treatment groups. All three groups (and for both lymphedema and lipedema) demonstrated a significant reduction in softness. Dimpling/redness was significantly reduced in the targeted skin product groups for both patients with lymphedema or lipedema. Only patients with lipedema demonstrated a significant reduction in dryness/ hyperkeratosis following targeted skin product treatment. This study demonstrates that short-term use of targeted skin products in both patients with lymphedema and lipedema can be of benefit and further studies are needed to replicate these results and explore possible mechanisms.

MULTIPLE LYMPHATIC-VENOUS ANASTOMOSES (MLVA) FOR MICROSURGICAL DRAINAGE OF PRIMARY PENO-SCROTAL LYMPHEDEMA: A CASE REPORT

Single site Multiple Lymphatic-Venous Anastomoses (MLVA) provides optimal functional and cosmetic results with low complication rates in treatment of lower limb lymphedema. However, no evidence exists in literature concerning the use of this technique in treatment of peno-scrotal lymphedema. We report a case of a 44-year-old male patient who developed secondary peno-scrotal lymphedema with severe lymphorrhea, following a laser treatment for scrotal pustolosis, leading to recurrent infections and finally an established peno-scrotal lymphedema. Utilizing MLVA, a complete remission of scrotal lymphedema was achieved with significant volume reduction of the penile lymphedema. The post-operative course was uneventful with clear improvement in lymphatic flow demonstrable on lymphoscintigraphy (6 months) and no recurrence of scrotal lymphedema at 2 years follow-up. This article reports very promising results of a novel application of MLVA in the treatment of genital lymphedema and suggests that MLVA provides the possibility to shunt both superficial and deep lymphatics to improve the lymphatic drainage from the peno-scrotal area using a single surgical site.

2380Mechanisms of myocardial ischemia during exercise in microvascular angina

Background

Coronary microvascular dysfunction (MVD) is defined by impaired flow augmentation in response to a vasodilator, the pathophysiological basis of which is unclear. This study sought to address two major gaps in our understanding of MVD: firstly, whether diminished flow reserve is due to structural changes within the microvasculature or potentially reversible dysfunction and secondly to unravel the mechanism of exercise-induced ischemia in the absence of obstructive disease.

Methods

Simultaneous intracoronary pressure and flow velocity recordings were made in the left anterior descending artery of patients with angina and no obstructive epicardial disease (Fractional Flow Reserve >0.80). Measurements were made at rest, during adenosine-mediated hyperaemia and supine bicycle exercise. Wave intensity analysis was used to quantify waves that accelerate and decelerate coronary blood flow, coronary perfusion efficiency being defined as the proportion of total wave energy that accelerates blood flow. Patients were prospectively classified into MVD (coronary flow reserve <2.5) and controls with researchers blinded to the classification throughout the protocol. Myocardial perfusion and vascular function were assessed by 3T cardiac MRI and venous occlusion plethysmography with forearm blood flow (FBF) assessment during serial infusions of acetylcholine, adenosine and the nitric oxide synthase inhibitor NG-monomethyl-L-arginine (L-NMMA).

Results

78 patients were enrolled (42 patients had MVD and 36 were controls), with no differences in cardiovascular risk factors between groups. The MVD group had elevated coronary blood flow (21.3±6.4 vs. 15.1±4.5cm s–1; p<0.001) and global myocardial perfusion (1.36±0.37 vs. 1.13±0.22ml/min/g; p=0.01) at rest. Maximum coronary and myocardial blood flow during hyperaemia was similar in both groups. During exercise, MVD patients achieved similar peak flow (30.5±10.0 vs. 26.3±7.7cm s–1; p=0.07) despite a higher rate-pressure product (20777±5205 vs. 17450±4710bpm.mmHg; p=0.01). Coronary perfusion efficiency, decreased with exercise in the MVD group (61±11% vs. 44±10% p<0.001) but was unchanged in controls. On MRI, MVD had lower hyperaemic endo-epicardial perfusion ratio than controls (0.94±0.08 vs. 1.04±0.13; p=0.001). Augmentation of FBF with acetylcholine was attenuated in MVD patients compared to controls (p=0.02) but the response to adenosine was similar (p=0.13). Infusion of L-NMMA caused a significantly greater reduction in FBF in MVD patients compared to controls (p<0.001).

Exercise Physiology in MVD

Conclusion

Impaired flow reserve in MVD represents a dysfunctional state, characterised by inappropriately elevated resting flow due to increased nitric-oxide synthase mediated vasodilatation. There is abnormal flow distribution in the myocardium predisposing to subendocardial ischaemia, associated with and exacerbated by impaired cardiac-coronary coupling during exercise. These novel findings may represent distinct therapeutic targets.

Acknowledgement/Funding

British Heart Foundation