Exposure to statin therapy decreases the incidence of venous thromboembolism after trauma

INTRODUCTION

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in trauma patients, despite chemoprophylaxis. Statins have been shown capable of acting upon the endothelium. We hypothesized that statin therapy in the pre- or in-hospital settings leads to a decreased incidence of VTE.

METHODS

We conducted a retrospective cohort study of injured patients who received statin therapy pre- or in-hospital. Adult, highest-level trauma activation patients admitted January 2018 - June 2022 were included. Patients on prehospital anticoagulants, history of inherited bleeding disorder, and who died within the first 24 hours were excluded. Statin users were matched to non-users by statin use indications including age, current heart and cardiovascular conditions and history, hyperlipidemia, injury severity, and body mass index. Time to in-hospital statin initiation and occurrence of VTE and other complications within 60 days were collected. Differences between groups were determined by univariate, multivariable logistic regression, and Cox proportional hazard analyses.

RESULTS

Of 3,062 eligible patients, 79 were statin users that were matched to 79 non-users. There were no differences in admissions demographics, vital signs, injury pattern, transfusion volumes, lengths of stay, or mortality between groups. The overall VTE incidence was 10.8% (17/158). Incidence of VTE in statin users was significantly lower (3%) than non-users (19%; P = 0.003). Differences between statin users and non-users were observed for rates of DVT (0% vs 9%), PE (3% vs 15%), and sepsis (0% vs 5%). Exposure to statins was associated with an 82% decreased risk of developing VTE (hazard ratio = 0.18, 95% CI 0.04 - 0.86; P = 0.033).

CONCLUSIONS

Statin exposure was associated with decline in VTE and lower individual rates of DVT, PE, and sepsis. Our findings indicate that statins should be evaluated further as a possible adjunctive therapy for VTE chemoprophylaxis after traumatic injury.

LEVEL OF EVIDENCE AND STUDY TYPE

Level III, Retrospective Cohort Study.

The Protein S Erlangen Mutation PROS1c.1904T>C (F635S) Suppresses Secretion

BACKGROUND

The recently identified PROS1 mutation Protein S Erlangen c.1904T>C, resulting in amino acid exchange F635S, is associated with severe quantitative protein S (PS) deficiency and clinical thrombosis. It was hypothesized that this deficiency is due to a secretion defect [1]. This report aims to further elucidate the potential secretion defect of PS Erlangen.

METHODS

Coding sequences (CDS) of wild type (WT) PROS1 (encoding PS) and mutated PROS1c.1904T>C (encoding PSF635S) were cloned in front of the CDS of green fluorescent protein (GFP), and the respective plasmids were introduced into HEK293T cells. PROS1-GFP and PROS1c.1904T>C-GFP expressing HEK293T cell lines were analyzed by confocal laser scanning microscopy and western blot for cellular proteins and proteins secreted to the growth medium.

RESULTS

Western blot analysis revealed a significantly reduced secretion of PSF635S compared to WT PS. This observation was confirmed by the detection of mutant PSF635S-GFP fusion exclusively in the endoplasmic reticulum (ER), while PS-GFP passed through the entire secretory pathway, as indicated by the localization within both the ER and Golgi apparatus.

CONCLUSIONS

The Protein S Erlangen mutation results in type I PS deficiency caused by a secretion defect.

SERPINC1 c.1247dupC: a novel SERPINC1 gene mutation associated with familial thrombosis results in a secretion defect and quantitative antithrombin deficiency

BACKGROUND

Antithrombin (AT) is an important anticoagulant in hemostasis. We describe here the characterization of a novel AT mutation associated with clinically relevant thrombosis. A pair of sisters with confirmed type I AT protein deficiency was genetically analyzed on suspicion of an inherited SERPINC1 mutation. A frameshift mutation, c.1247dupC, was identified and the effect of this mutation was examined on the cellular and molecular level.

METHODS

Plasmids for the expression of wild-type (WT) and mutated SERPINC1 coding sequence (CDS) fused to green fluorescent protein (GFP) or hemagglutinin (HA) tag were transfected into HEK293T cells. Subcellular localization and secretion of the respective fusion proteins were analyzed by confocal laser scanning microscopy and Western blot.

RESULTS

The c.1247dupC mutation results in a frameshift in the CDS of the SERPINC1 gene and a subsequently altered amino acid sequence (p.Ser417LysfsTer48). This alteration affects the C-terminus of the AT antigen and results in impaired secretion as confirmed by GFP- and HA-tagged mutant AT analyzed in HEK293T cells.

CONCLUSION

The p.Ser417LysfsTer48 mutation leads to impaired secretion, thus resulting in a quantitative AT deficiency. This is in line with the type I AT deficiency observed in the patients.

Mental health and academic outcomes over the first year at university in international compared to domestic Canadian students

OBJECTIVE

To compare risk factors and associated mental health and academic outcomes between international and domestic students.

PARTICIPANTS

Canadian university undergraduate students.

METHODS

Electronic surveys were completed at university entry and the end of first year. Surveys assessed demographics, risk factors, symptoms of mental disorders, and access to support. Academic outcomes were obtained from university databases.

RESULTS

International students had comparable or lower rates of clinically significant anxiety, depression, and insomnia. Domestic female students reported the highest screening rates for common mental disorders. However, international students were more likely to report having attempted suicide. International students felt less connected to the university community and had lower academic performance. Psychosocial risk factor profiles and proportions accessing mental health services were similar.

CONCLUSIONS

The scope of mental health need appears more similar than different between international and domestic students; however, international students may benefit from targeted academic and social support initiatives.

Implementation frameworks for polypharmacy management within healthcare organisations: a scoping review

BACKGROUND

Several guidelines support polypharmacy management in individual patients. More organisational-level focus is needed on the use of implementation frameworks.

AIM

To characterise the peer reviewed literature on implementation frameworks, focussing on barriers and facilitators to implementation at organisational level in the context of polypharmacy management.

METHOD

A scoping review protocol was devised, supporting retrieval of studies published in English, reporting from any sector of practice. Medline, International Pharmaceutical Abstracts, Cumulative Index of Nursing and Allied Health Literature and Business Source Complete were searched to January 2022 using Medical Subject Headings including: 'polypharmacy', 'deprescriptions', 'strategic planning' and 'organizational innovation'. A narrative approach to data synthesis was applied. Searching, data extraction and synthesis were undertaken independently by two reviewers.

RESULTS

After screening 797 records eight papers remained. Two were descriptive outlining details of specific initiatives, six used qualitative methods to explore determinants for implementation including barriers and enablers. Organisation level barriers included: poor organisational culture with a lack of sense of urgency and national plans, resource availability and communication issues including patient information and at transitions of care. Organisational facilitators included availability of government funding and regulatory environment promoting patient safety, a national emphasis on quality of care for older adults, co-ordinated national efforts and local evidence.

CONCLUSION

Limited literature focusses on the use of implementation frameworks at organisational levels. This review highlights the need for further work on implementation frameworks in this context to help achieve effective organisational change.

Medium supplementation with human, but not fetal calf serum facilitates endocytosis of PLGA nanoparticles by human primary B-lymphocytes via complement opsonization

The "biological identity" of nanoparticles (NPs) is governed by a shell consisting of various biomolecules that is formed upon exposure to biological media, the so-called biomolecule corona. Consequently, supplementation of cell culture media with e.g. different sera is likely to affect interactions between cells and NPs ex-vivo, especially endocytosis. We aimed to investigate the differential impact of human and fetal-bovine serum on the endocytosis of poly (lactic-co-glycolic acid) NPs by human peripheral blood mononuclear cells via flow cytometry. Furthermore, we employed different methods to inhibit endocytosis, providing mechanistic insights. The resulting biomolecule corona was characterized via denaturing gel electrophoresis. We found profound differences between human and fetal bovine serum regarding the endocytosis of fluorescently labeled PLGA nanoparticles by different classes of human leukocytes. Uptake by B-lymphocytes was particularly sensitive. We further present evidence, that these effects are mediated by a biomolecule corona. We demonstrate to our knowledge for the first time that the complement is an important contributor to the endocytosis of non-surface-engineered PLGA-nanoparticles prepared via emulsion solvent evaporation by human immune cells. Our data demonstrates that results obtained with xenogeneic culture supplements such as fetal bovine serum may have to be interpreted with caution.

TNF promotes DECTIN2 family C-type lectin receptor expression in human macrophages

TNF blockade constitutes an effective therapy for inflammatory bowel disease (IBD), yet increases the risk for infection including active tuberculosis. The DECTIN2 family C-type lectin receptors (CLR) MINCLE, MCL and DECTIN2 sense mycobacterial ligands and activate myeloid cells. In mice, upregulation of DECTIN2 family CLR after stimulation with Mycobacterium bovis Bacille Calmette-Guerin (BCG) requires TNF. Here, we investigated whether TNF controls inducible CLR expression in human myeloid cells. Monocyte-derived macrophages (MDM) were stimulated with BCG and the TLR4 ligand LPS, and expression of CLR was analyzed. BCG and LPS strongly upregulated mRNA expression of DECTIN2 family CLR, but not of DECTIN1. BCG and LPS also induced robust production of TNF. Recombinant TNF was sufficient to upregulate expression of DECTIN2 family CLR. Blocking TNF with the TNFR2-Fc fusion protein Etanercept abrogated, as expected, the effect of recombinant TNF, and impaired induction of DECTIN2 family CLR by BCG and LPS. Flow cytometry confirmed upregulation of MCL at the protein level by recombinant TNF and showed inhibition of BCG-induced MCL by Etanercept. To investigate the impact of TNF on CLR expression in vivo, we analyzed PBMC of patients with IBD and observed down-regulation of MINCLE and MCL expression after therapeutic TNF blockade. Together, TNF is sufficient to upregulate DECTIN2 family CLR in human myeloid cells and contributes to this process after encounter with BCG or LPS. Impaired CLR expression in patients receiving TNF blockade may dampen the sensing of microbes and defense against infection.

Systematic review of topical interventions for the management of odour in patients with chronic or malignant fungating wounds

Chronic wounds adversely affect the quality of life of individuals and odour is a well-recognised associated factor. Odour can affect sleep, well-being, social interactions, diet and potentially wound healing. This systematic review aims to examine the effectiveness of topical interventions in the management of odour associated with chronic and malignant fungating wounds. A systematic review guided by PRISMA recommendations of randomised controlled trials where odour intensity/odour is the primary outcome was undertaken. Inclusion criteria were adults (18 years and over) with chronic venous, arterial, diabetic or pressure ulcers or with malignant fungating wounds where odour has been managed through topical application of pharmacological/non-pharmacological agents. Searches were conducted in CENTRAL, CINAHL, EMBASE, MEDLINE, Scopus, and Web of Science. Eligibility screening, risk of bias assessment and data extraction was completed by authors working independently. Searches retrieved 171 titles and abstracts (157 post de-duplication). Thirteen studies were retained for full text review of which five (n = 137 individuals) examining the following treatments remained: metronidazole (n = 4), silver (n = 1). Meta-analysis was not possible but individual studies suggest improved outcomes (i.e., reduced odour) using metronidazole. Treatment options to manage wound odour are limited and hampered by lack of clinical trials, small sample sizes, and absence of standardised outcomes and consistent measurement. Whereas metronidazole and silver may have a role in controlling wound odour, robust and well-designed interventions with rigorous procedures and standardised odour outcomes are necessary to evaluate their contribution.

Registered clinical trials investigating ketamine and esketamine for treatment-resistant depression: A systematic review

Background and Aims

Ketamine and esketamine have garnered interest in both psychiatric research and clinical practice for treatment-resistant depression (TRD). In this review, we examined registered trials investigating the therapeutic use of ketamine or esketamine for TRD, with the aim of characterizing emerging trends and knowledge gaps.

Methods

The ClinicalTrials.gov electronic registry and results database was queried from inception to February 5, 2022, adhering to elements of the PRISMA guideline, we evaluated trial eligibility in the qualitative synthesis. Data regarding study design, drug regimens, and measures were subsequently abstracted and descriptively analyzed.

Results

The search returned 86 records, of which 56 trials were included in the final review. The number of trials investigating ketamine and esketamine for TRD increased since 2008, with higher peaks observed in 2015 (n = 9) and 2021 (n = 9). Most trials were Phase 2 (13, 23.2%) or Phase 3 (11, 19.6%), gathering preliminary data on efficacy and/or further data on safety and efficacy with variant dosing and pharmacological approaches. By and large, trials examined ketamine and esketamine as individual versus combination treatments (45% and 25%, respectively). The Montgomery-Asberg Depression Rating Scale (MADRS) was most commonly used to assess clinical outcomes (75%).

Conclusions

There are increasingly large-scale and late-phase trials of esketamine over ketamine for TRD, coupled with efforts to centralize evidence on these medications. Yet several trials do not assess patient characteristics that may affect treatment response, such as age, sex, and race. By understanding these design limitations, scientists and clinicians can avoid research waste and funding bodies can judiciously direct support towards high priority research.

Characterization of the impact of immune checkpoint inhibitors on platelet activation and aggregation

Immune checkpoint inhibitors (ICIs) are effective oncological drugs which block cellular check-point receptors typically targeted by tumor immune evasion strategies. Despite their benefits, clinicians have reported treatment-associated thromboembolism during ICI therapy in recent years. Though several theories on this ICI-associated pathogenesis exist, the direct effects of ICIs on platelets remains unknown. We therefore investigated the potential direct and indirect effect of PD-1, PD-L1 and CTLA-4-targeting ICIs on platelet functionality in multifaceted in vitro experiments. Interestingly, we could not observe a clear effect of ICI on platelet aggregation and primary hemostasis in whole blood and platelet concentrate-based assays. Furthermore, the presence of ICIs in toll-like receptor stimulation had no significant impact on platelet surface marker expression. In a second approach, we investigated the indirect immunological impact of ICIs on platelet activation by exposing platelets to supernatants from ICI- and Staphylococcal enterotoxin B-exposed PBMCs. Whereas ICIs affected IL-2 levels in supernatants, we could not detect clear differences in the secretion of pro-thrombogenic factors and platelet responses. The obtained data suggest that the direct influence of ICIs on platelet activation or the influence of altered T cell function on platelet activation cannot be considered a major factor in the development of thrombotic events.

The development of a derelict crab trap removal incentive program for commercial shrimpers

Due to fishery-tailored gear, shrimpers are often affected by benthic marine debris, specifically derelict crab traps. To alleviate the impacts on the commercial shrimping industry in the Mississippi Sound, a team of natural resource professionals and stakeholders developed a derelict crab trap removal incentive program for commercial shrimpers. In three years, this program led to the removal of 2904 derelict crab traps from the north-central Gulf of Mexico at a total average cost of $35,595 per year to implement the program, or $53 per derelict crab trap. Results from this study showed the cost of the program could further be reduced while covering the same shrimping area, through the inclusion of fewer disposal locations and targeting active and engaged shrimpers. This program led to the removal of crab traps by non-registered shrimpers, indicating that the existence of the program and associated outreach could lead to improved environmental stewardship without an incentive.

Interprofessional education during experiential learning placements for student pharmacists in Scotland. Exploring current support provision and stakeholder views

Introduction

Increasing global awareness that interprofessional team working is essential within modern healthcare systems has led to regulatory bodies mandating the inclusion of interprofessional education (IPE) within undergraduate curricula. The General Pharmaceutical Council specifies in the 2021 initial education and training standards the requirement for an interprofessional learning plan in which “IPE must mirror practice”.1 Pharmacy educators are intensifying their efforts to ensure student pharmacists are presented with opportunities to develop collaborative competencies. Curricular development and implementation initiatives must explore structures and processes to ensure that experiential learning (EL) environments are conducive to supporting student pharmacists’ interprofessional learning.

Aim

To explore structures and processes needed to support effective planned and unplanned IPE during EL placements for student pharmacists.

Methods

A mixed methods approach underpinned by the Biggs 3P theoretical framework was adopted.2 This included (1) A document analysis reviewing resources including student pharmacist/EL facilitator university handbooks and NHS Education for Scotland Preparation for Facilitating Experiential Learning (PFEL) training - a mandatory requirement for all EL facilitators hosting student pharmacists on placement in Scotland. (2) A pre-piloted online survey distributed to EL facilitators. Survey development, guided by the Interprofessional Facilitation Scale, aimed to encourage EL facilitators to self-evaluate their own IPE facilitation skills.3 The final survey tool included ten items with responses rated on a 4-point Likert scale (Poor, Fair, Good and Excellent) and a demographic section (3) Online semi-structured focus groups/dyadic interviews conducted with six EL facilitators, four practice educators and two academic staff were recorded and transcribed. Descriptive statistics were employed for quantitative data generated from the survey tool; for qualitative data content analysis was applied to develop emerging themes. Ethical approval was granted (S292) from the School of Pharmacy and Life Sciences Ethics Review Committee at Robert Gordon University.

Results

(1) The document analysis concluded that although the resources reviewed could not be specifically classed as training to support IPE, data collected provided context to EL placements and the training and pre-activities that student pharmacists and EL facilitators complete. Three main themes emerged: “Lack of specific IPE training focus”, “Varied terminology”, “Lack of IPE pre-learning activities”. (2) The survey was completed by ninety EL facilitators working in various practice settings: hospital 41.1% (n=37); primary care 25.6% (n=23); community 21.1% (n=19); academia 2.2% (n=2); other 8.9% (n=8). Survey responses indicated that 51.1% (n=46) and 42.2% (n=38) of respondents rated their ability to role model positive interactions with other healthcare professionals as good and excellent. However, responses to items relating more specifically to IPE facilitation skills indicated a lower confidence level. (3) Initial themes emerging from focus groups/dyadic interviews include “Profession-related perceptions of IPE”, “Factors influencing IPE delivery and student learning”, “Factors influencing future developments”.

Discussion/Conclusion

This exploratory study has provided valuable insight into multifactorial aspects affecting IPE during EL placements; this will be used to guide future development of IPE initiatives. One limitation is that student pharmacists were not included in this study; the next phase of this research programme will explore student pharmacists’ perceptions of IPE in EL.

References

1. General Pharmaceutical Council. Standards for the initial education and training of pharmacists. [homepage on the Internet]. London: GPhC; 2021. Available from: https://www.pharmacyregulation.org/sites/default/files/document/standards-for-the-initial-education-and-training-of-pharmacists-january-2021.pdf

2. Biggs, J.B. From Theory to Practice: A Cognitive Systems Approach. High Educ Res Dev, 1993, 12(1), 73-85

3. Sargeant J., Hill T., Breau L. Development and testing of a scale to assess interprofessional education (IPE) facilitation skills. J Cont Educ Health Prof, 2010, 30(2), 126-131

Biomimetic Magnetic Particles for the Removal of Gram-Positive Bacteria and Lipoteichoic Acid

Gram⁺ bacteria are very common in clinical medicine and responsible for a large number of infectious diseases. For example, Gram⁺ bacteria play a major role in causing bloodstream infections and sepsis. Therefore, the detection of Gram⁺ bacteria is of great importance for the diagnosis and treatment of infectious diseases. Furthermore, these bacteria are often present in biofilms that cover implants. Recent research work has mainly focused on the biologic activity and removal of Gram-negative bacteria or bacterial components such as lipopolysaccharides (LPS). In contrast, the effects of lipoteichoic acid (LTA) have been less well studied so the relevance of their removal from body fluids is possibly underestimated. To address this topic, we evaluated superparamagnetic iron oxide particles (SPION) carrying different peptides derived from the innate immune receptor (GP-340) for their ability to bind and remove Gram⁺ bacteria and LTA from different media. Our results show that, beyond S. aureus, effective agglutinating and removing of S. pneumoniae was possible. Furthermore, we were able to show for the first time that this was possible with LTA alone and that the magnetic removal of bacteria was also efficient under flow conditions. We also found that this method was able to capture Stapyhylococcus aureus from platelet concentrates, which can help to enhance the sensitivity of microbiological diagnostics, quality control measures, and blood product safety.

Case-mix and outcome variability in people with diabetic foot complications in England and Scotland

Background

We assessed the difference in survival rates for people with diabetes experiencing LEA in England and Scotland, using large databases held by the Royal College of General Practitioners (RCGP) and the Scottish Diabetes Register (SCI-DC).

Methods

Observational retrospective study of T2D adults 18+ years with LEA between 1/1/2008-1/1/2018 from 1,800 general practices in England (7.4%) and all primary, secondary care units in Scotland. Significance tests were carried out using univariate odds ratios within each database.

Results

On 1/1/2018, N = 127,100 people with T2D were registered alive in RCGP, with N = 1,052 (832 per 100,000) experiencing prior LEA, vs N = 2,200 (783 per 100,000) out of 280,908 in SCI-DC. Among them, England recorded N = 405 patients (72.5%) with prior DFU diagnosis vs N = 993 in Scotland (74.3%), with a median time DFU to LEA of 2.0 vs 2.4 years. The median time spent with LEA was 3.4 years in England vs 3.9 years in Scotland. After including those dying earlier, different univariate patterns were found for England and Scotland. In both networks, increased risk was found for those aged 50+ at first LEA, with prior history of acute myocardial infarction, peripheral arterial disease, ischemic heart disease, cerebrovascular event, higher glomerular filtration rate and major LEA first. In England, reduced risks were found for males (OR = 0.77, 95%CI: 0.64-0.93) and people with retinopathy (0.69; 0.57-0.82), while higher risk were found for hypertension (1.29; 1.09-1.54). In Scotland, lower risks were found for obese (0.59; 0.52-0.66) and those with DFU after LEA (0.74; 0.62-0.89), vs higher rates among those of non-white ethnicity (1.63; 1.19-2.23) and dyalisis (2.31; 1.75-3.07).

Conclusions

Notable differences were found between England and Scotland in terms of characteristics associated with different outcomes following LEA among T2D adults. Multivariate analyses of aggregate patterns are currently ongoing to adjust for potential confounding.

Key messages

• Routine datasets from England and Scotland showed a differential impact of case-mix characteristics on lower extremity amputations among adults with Type 2 diabetes.

• Information available from different clinical networks can be mapped against the available standard sets to compare health care outcomes of people with different complex conditions.

The feasibility and effectiveness of a novel online mental health literacy course in supporting university student mental health: a pilot study

BACKGROUND

There is a need for effective universal approaches to promote and support university student mental health that are scalable and sustainable. In this pilot study we assess the feasibility and acceptability of a fully-digitalized, comprehensive mental health literacy course co-created with and tailored to the needs of undergraduate students. We also explore preliminary associations with mental health and positive behaviour change.

METHODS

An accredited online mental health literacy course was developed using state-of-the-art pedagogical principles and a reverse mentorship approach. The course was offered as an interdisciplinary undergraduate elective. Students completed an online survey before and after the 12-week course that collected demographic information and assessed mental health knowledge, emotional self-awareness, mental health, stigma, and health-related behaviors using validated measures. Dependent group t-tests were used to compare pre- and post-course levels of knowledge, mental health, sleep quality and substance use. Mental health outcomes of students who completed the course were compared to an age and sex-matched sample of students not enrolled in the course and who completed the same survey measures over the same academic year. Multivariable linear regression was used to examine the effect of course participation on outcomes at follow-up.

RESULTS

The course had good uptake and was positively reviewed by participants. Specifically, students found the course engaging, relevant, and applicable, and agreed they would recommend it to their peers. Among course participants there was improvement in mental health knowledge (p < 0.001) and emotional self-awareness (p = 0.02) at course completion. Compared to the matched comparison group, taking the course was associated with reduced alcohol (β = - 0.41, p = 0.01) and cannabis use (β = - 0.35, p = 0.03), and improved sleep quality (β = 1.56, p = 0.09) at the end of the term.

CONCLUSIONS

Findings suggest that delivering mental health literacy as an online accredited course may be an acceptable and effective way of promoting university student mental health through improved knowledge, emotional self-awareness, and healthy lifestyle choices. As the course is expanded to larger and more diverse student cohorts we will be able to further examine the short and long-term effectiveness of the course in supporting student mental health and the underlying mechanisms.

Subclinical Doses of Combined Fumonisins and Deoxynivalenol Predispose Clostridium perfringens–Inoculated Broilers to Necrotic Enteritis

Fumonisins (FB) and deoxynivalenol (DON) are mycotoxins which may predispose broiler chickens to necrotic enteritis (NE). The objective of this study was to identify the effects of subclinical doses of combined FB and DON on NE. A total of 480 day-old male broiler chicks were divided into four treatment groups; 1) control group (basal diet + Clostridium perfringens); 2) necrotic enteritis group (basal diet + Eimeria maxima + C. perfringens); 3) FB + DON group (basal diet + 3 mg/kg FB + 4 mg/kg DON + C. perfringens); and 4) FB + DON + NE group (basal diet + 3 mg/kg FB + 4 mg/kg DON + E. maxima + C. perfringens). Birds in NE and FB + DON + NE groups received 2.5 × 10³E. maxima on day 14. All birds were inoculated with C. perfringens on days 19, 20, and 21. On day 35, birds in the NE, FB + DON, and FB + DON + NE groups had 242, 84, and 339 g lower BWG and a 19-, 2-, and 22-point increase in FCR respectively, than in the control group. Subclinical doses of FB + DON increased (p < 0.05) the NE lesion scores compared to the control group on day 21. On day 21, birds in the NE, FB + DON, and FB + DON + NE groups had increased (p < 0.05) serum FITC-D, lower (p < 0.05) jejunal tight junction protein mRNA, and increased (p < 0.05) cecal tonsil IL-1 mRNA compared to control group. On day 21, birds in the NE group had decreased (p < 0.05) villi height to crypt depth ratio compared to the control group and the presence of FB + DON in NE-induced birds further decreased the villi height to crypt depth ratio. Birds in the NE, FB + DON, and FB + DON + NE groups had increased (p < 0.05) C. perfringens, lower (p < 0.05) Lactobacillus loads in the cecal content, and a lower (p < 0.05) CD8⁺: CD4⁺ cell ratio in the cecal tonsils compared to the control group. It can be concluded that subclinical doses of combined FB and DON predispose C. perfringens-inoculated birds to NE, and the presence of FB + DON in NE-induced birds exacerbated the severity of NE.

Exploring determinants of antimicrobial prescribing behaviour: a qualitative study using the Theoretical Domains Framework

Introduction

Few qualitative studies have explored determinants of antimicrobial prescribing behaviour in hospitals, and none has made reference to behavioural theories. An understanding of these determinants is required for the successful development and implementation of behaviour change interventions (BCIs) in this area.

Aim

To explore the determinants of clinicians’ antimicrobial prescribing behaviour, using the Theoretical Domains Framework (TDF; a framework of behavioural theories).

Methods

This work was part of a multi-phase explanatory, sequential mixed methods PhD programme of research. This qualitative part involved semi-structured, online (video) interviews via a videoconferencing software programme (Zoom) with clinicians (doctors and pharmacists) based in 12 Hamad Medical Corporation hospitals in Qatar. Clinicians were sampled purposively in strata of gender, profession, years of experience and area of practice. The interview schedule was developed based on a review of published literature (1), previous findings of quantitative research (2) and the TDF to ensure comprehensive coverage of key determinants (including barriers and facilitators) related to clinicians’ antimicrobial prescribing behaviour. Interviews were conducted from December 2020 to February 2021, audio-recorded, transcribed and independently analysed by two research team members using the TDF as an initial coding framework.

Results

Data saturation was achieved after interviewing eight doctors and eight pharmacists from a range of areas of practices and with a variety of experiences. A number of themes, linked to ten TDF domains, were identified as determinants of antimicrobial prescribing behaviour and these determinants were interrelated. In-depth analysis identified several barriers and facilitators that may contribute to inappropriate or appropriate antimicrobial prescribing. Main barriers identified were around hospital guidelines and electronic system deficiencies (environmental context and resources), gaps in the knowledge in relation to guidelines and appropriate prescribing (knowledge), restricted roles/responsibilities of microbiologists and pharmacists (professional role and identity), uncomfortable antimicrobial prescribing decisions (memory, attention and decision processes), as well as professional hierarchies and poor multidisciplinary teamworking/relationships (social influences). “Sometimes, the barrier would be the ego of senior doctors who refuse our evidence-based recommendation and depend on their clinical judgement or experience” (Pharmacist 470, Cardiology). Key facilitators highlighted included guidelines compliance goals and intentions, and the beliefs of consequences of appropriate or inappropriate prescribing. Further education and training sessions, and some changes to guidelines, including accessibility were also considered essential. “We need to seriously consider getting an antibiotic guidelines app which is downloaded to clinicians’ mobile phones. The mobile app is handy, you can access it anytime even at the patient’s bedside” (Doctor 514, Microbiology).

Conclusion

This qualitative study, using a theoretically based approach, has identified that antimicrobial prescribing in hospitals is a complex process influenced by a broad range of behavioural determinants that described specific barriers and facilitators. The in-depth understanding of this complexity provided by this phase of the research may contribute to the design and development of theoretically based BCIs to improve clinicians’ antimicrobial prescribing. Limitations include data collected with online interviews due to the Covid-19 restrictions. This may have excluded some clinicians who did not feel comfortable with or have access to the technology required.

References

(1) Talkhan H, Stewart D, Mcintosh T, Ziglam H, Abdulrouf P, Al-Hail M et al. The use of theory in the development and evaluation of behaviour change interventions to improve antimicrobial prescribing: a systematic review. Journal of Antimicrobial Chemotherapy. 2020;75(9):2394-2410.

(2) Talkhan H, Stewart D, McIntosh T, Ziglam H, Abdulrouf P, Al-Hail M et al. Using the Theoretical Domains Framework to investigate clinicians’ behavioural determinants of antimicrobial prescribing in Qatar. International Journal of Pharmacy Practice. 2021;29(1):i20-i22.

Views and perceptions on the designated prescribing practitioner role, barriers, and facilitators for its implementation in community pharmacy: a theory-based quantitative study

Introduction

Scottish Government aims to increase numbers of pharmacist independent prescribers (IP) in community to improve healthcare access. This includes utilising qualified IPs as Designated Prescribing Practitioners (DPP) to increase capacity to supervise pharmacists on IP courses.

Aim

To investigate views and perceptions of practice-based stakeholders and identify potential influences on DPP implementation for Scottish community pharmacists (CP)

Methods

A theory-based cross-sectional online survey of stakeholders involved in DPP role implementation (e.g. Directors of Pharmacy, Prescribing Leads, IP qualified CPs) was employed. Participation invites were shared with Scottish health boards and CP organisations via email and social media. Snowball sampling was used so no key individual was omitted. The questionnaire was informed by Royal Pharmaceutical Society (RPS) DPP Framework (1) and Consolidated Framework for Implementation Research (2). It examined views and awareness of DPP role, implementation drivers, and obstacles. The tool was reviewed for credibility and dependability then piloted. Data were analysed descriptively.

Results

Ninety-nine responses were received (NB: Since this was a national survey of multiple stakeholders without a defined sample list, response rate was indeterminate). Two-fifths (n=39, 40.2%) were community pharmacists with majority qualified for more than 10 years (n=76, 76.8%). Only 18 had previous involvement with IP courses. The table shows awareness and views of the role based on RPS framework. Respondents had positive attitudes to DPP implementation with the majority supporting it (72, 73.5%) and believing that its advantages outweigh any disadvantages (74, 75.5%). Facilitators of successful implementation were having clearly defined leadership roles (89, 90.9%), piloting (85, 87.6%), and incentives (65, 88.8%). Drivers for uptake of role included improving patient care (94, 96%) and the profession (91, 92.8%), self-development (91, 92.8%), developing individual pharmacists (89, 90.8%), payment (77, 79.4%), and being recognised by peers/employers (73, 75.2%).

Conclusion

There was positivity regarding DPP role, its acceptability in, and advantages for CP. Resource-related concerns were expressed that need further consideration to ensure effective implementation. This is the first study internationally to explore views on DPP role. Given the Scottish focus, findings may lack generalisability. Future research should focus on theory-based evaluation of structures and processes of implementation.

References

(1) Royal Pharmaceutical Society. Designated Prescribing Practitioner Competency Framework [internet]. London: Royal Pharmaceutical Society; 2019 [Cited 28/09/2021]. Available from: https://www.rpharms.com/resources/frameworks/designated-prescribing-practitioner-competency-framework

(2) Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50.

Development and implementation of strategic frameworks for polypharmacy management in healthcare organisations: a scoping review

Introduction

‘Polypharmacy management’ (PM) guidelines exist (1) but there are challenges to implementation and WHO recommends theory-based organisational change strategies to address this (2).

Aim

To identify current evidence base around the development and implementation of strategic frameworks for polypharmacy management in healthcare organisations.

Methods

The Arksey and O’Malley framework and the PRISMA Scoping Reviews extension were used. Databases (Medline, IPA, CINAHL and Business Source Complete) were searched to December 2020. After title and abstract screening full text articles were reviewed. Search, data extraction and eligibility criteria were defined (table). Included studies were charted to collate extracted information and a descriptive narrative approach to data synthesis was taken. All steps involved independent checks by two team members with disagreement mediation by a third.

Results

Initially 702 records were identified after removal of duplicates, 632 of these were excluded after screening leaving 70 papers. A further 63 of these 70 papers were excluded after full text review. The seven papers remaining met the eligibility criteria fully and showed: despite wide availability of polypharmacy guidelines in the West, particularly the UK and European Union, there is limited evidence on the strategic development and implementation of PM frameworks. The main characteristics of strategic approaches used included: Kotter’s eight step process for organisational change, theoretical domains framework to identify individual behavioural determinants, and a community-based medication management intervention. Reported barriers were: lack of data to create a sense of urgency, lack of a national plan for implementation, monitoring and evaluation, poor coordination of care, lack of time for staff, unclear allocation of tasks and responsibilities and lack of training. Organisational level facilitators included: government funding streams and strict regulatory environment, national emphasis on quality and presence of contextual evidence.

Conclusion

Despite PM guidance this review shows limited evidence on development of theory based strategic frameworks for organisational change. Evidence was from Western contexts only. A strength of this work is that it searched internationally but was limited by exclusion of grey literature. Further work is required on theory based strategic organisational change in PM particularly in contexts out with the Western world.

References

(1) Mair A, Fernandez-Llimos F, Alonso A, Harrison C, Hurding S, Kempen T, Kinnear M, Michael N, McIntosh J, Wilson M, the SIMPATHY Consortium. Polypharmacy Management by 2030: a patient safety challenge. 2nd edition. Coimbra: SIMPATHY Consortium; 2017.

(2) World Health Organization. Medication safety in polypharmacy: technical report. Geneva: World Health Organization; 2019.

Scavenging of bacteria or bacterial products by magnetic particles functionalized with a broad-spectrum pathogen recognition receptor motif offers diagnostic and therapeutic applications

Sepsis is a dysregulated host response of severe bloodstream infections, and given its frequency of occurrence and high mortality rate, therapeutic improvements are imperative. A reliable biomimetic strategy for the targeting and separation of bacterial pathogens in bloodstream infections involves the use of the broad-spectrum binding motif of human GP-340, a pattern-recognition receptor of the scavenger receptor cysteine rich (SRCR) superfamily that is expressed on epithelial surfaces but not found in blood. Here we show that these peptides, when conjugated to superparamagnetic iron oxide nanoparticles (SPIONs), can separate various bacterial endotoxins and intact microbes (E. coli, S. aureus, P. aeruginosa and S. marcescens) with high efficiency, especially at low and thus clinically relevant concentrations. This is accompanied by a subsequent strong depletion in cytokine release (TNF, IL-6, IL-1β, Il-10 and IFN-γ), which could have a direct therapeutic impact since escalating immune responses complicates severe bloodstream infections and sepsis courses. SPIONs are coated with aminoalkylsilane and capture peptides are orthogonally ligated to this surface. The particles behave fully cyto- and hemocompatible and do not interfere with host structures. Thus, this approach additionally aims to dramatically reduce diagnostic times for patients with suspected bloodstream infections and accelerate targeted antibiotic therapy. STATEMENT OF SIGNIFICANCE: Sepsis is often associated with excessive release of cytokines. This aspect and slow diagnostic procedures are the major therapeutic obstacles. The use of magnetic particles conjugated with small peptides derived from the binding motif of a broad-spectrum mucosal pathogen recognition protein GP-340 provides a highly efficient scavenging platform. These peptides are not found in blood and therefore are not subject to inhibitory mechanisms like in other concepts (mannose binding lectine, aptamers, antibodies). In this work, data are shown on the broad bacterial binding spectrum, highly efficient toxin depletion, which directly reduces the release of cytokines. Host cells are not affected and antibiotics not adsorbed. The particle bound microbes can be recultured without restriction and thus be used directly for diagnostics.

An innovative General Practice based Pharmacy Longitudinal Clerkship: using theory to characterise its development, implementation and initial evaluation

BACKGROUND

Longitudinal Integrated Clerkships exist in undergraduate medicine courses. A pilot Pharmacy Longitudinal Clerkship (pPLC) was funded to investigate delivery of this model of clinical education for student pharmacists.

OBJECTIVE(S)

To investigate the development, implementation and initial evaluation of a pPLC.

METHODS

The 11-week pPLC was delivered to two students in two GP practices in Scotland. Mixed theory-based methods were used to gather information on the pPLC structures and processes required and qualitative semi-structured Theoretical Domains Framework (TDF) based interviews explored outcomes with key stakeholders. Informed written consent was obtained. Interviews were audio-recorded, transcribed verbatim and analysed thematically. University Ethics approval was granted.

RESULTS

Data were generated on resources and processes required for a pPLC including funds budgeted for and actually spent on staffing, student travel/subsistence and student clinical 'Kit Bags', learning outcomes, curriculum and training timetable, GP Practice/University contracts. Interviews were completed with the two students, three linked GP clinical supervisors and two Regional Tutors involved. The seven themes were identified and mapped to seven TDF domains including: increased levels of student confidence, and increased student enthusiasm for a career in pharmacy, need for definition of the role of the Regional Tutor for the PLC and GP positivity towards the expected outcomes of clerkship model versus traditional placements.

CONCLUSION

Findings are limited by the small number of participants and settings, but evaluation was positive and the work garnered information on requirements for resources and processes. This will inform 'roll out' of the PLC.

COVID-19 mental health impact among children with early brain injury and associated conditions

This study describes the impact of COVID-19 among a clinical research sample of children with early brain injury and associated conditions. Between March 2020 and March 2021, 64 children and their parents participated. Children ranged in age between 3 and 14 years (M = 6 years, 3 months; SD = 2 years, 4 months) with a range of diagnoses (i.e., neonatal stroke, hypoxic ischemic encephalopathy (HIE), congenital heart disease (CHD) and preterm birth (<32 weeks)). The abbreviated CoRonavIrus Health Impact Survey (CRISIS) was completed by parents as part of their child's routine intake for neuropsychological services. Questions included COVID-19 specific ratings of child mental health impact, child, and parent stressors, with open-ended questions regarding negative and positive COVID-19 related changes. Over 40% of parents described moderate to extreme influence of COVID-19 on their child's mental health. Common child stressors reported included restrictions on leaving the home and social isolation. Among parents, the most common stress reported was caring for their child's education and daily activities. Children's mental health impact was associated with social isolation, parent mental health, COVID-19 economic concern, and number of siblings in the home. Child's age, sex, brain injury severity, or intellectual functioning were not associated with reported COVID-19 mental health impact. Some COVID-19 positives were identified, namely increased quality family time. Findings reflect the significant pandemic mental health impact among neurologically at-risk children and their families. Implications to future clinical needs and considerations for neuropsychological practice are discussed.

Rapid generation of monocyte-derived antigen-presenting cells with dendritic cell-like properties

BACKGROUND

One of the major challenges in cellular therapy is the establishment and validation of simple and fast production protocols meeting good manufacturing practice (GMP) requirements. Dendritic cells (DCs) are of particular therapeutic interest, due to their critical role in T cell response initiation and regulation. Conventional wisdom states that DC generation from monocytes is a time-consuming protocol, taking up to 7-9 days.

STUDY DESIGN AND METHODS

This study systematically screened and validated numerous culture components and conditions to identify the minimal requirements, which can give rise to functional monocyte-derived antigen-presenting cells (MoAPCs) in less than 48 h (36 h MoAPC). A total of 36 h MoAPCs were evaluated in terms of surface marker expression, endocytic capability, and induction of antigen-specific T cell expansion via flow cytometry.

RESULTS

Screening of media compositions, glucose concentrations, and surface marker kinetics, particularly DC-SIGN as a DC-specific marker, allowed the generation of DC-like APCs in 36 h (36 h MoAPCs). A total of 36 h MoAPCs displayed a similar phenotype to 48 h MoAPC and standard 7 d MoDCs in terms of HLA-DP,DQ,DR, CD83, and DC-SIGN expression, while CD1a was preferentially expressed in standard MoDCs. Functional evaluation revealed that 36 h MoAPCs displayed reduced endocytosis capabilities and IL-12p70 production. However, 36 h MoAPCs were able to induce T cell expansion both in an allogenic and antigen-specific setting.

CONCLUSION

Our results indicate that mature 36 h MoAPCs possess DC-like capabilities by inducing antigen-specific T cell responses. This study has important implications for the generation of DC-based cellular therapies, allowing a more cost and time-efficient generation of APCs.

Using the Theoretical Domains Framework to investigate clinicians’ behavioural determinants of antimicrobial prescribing in Qatar

Introduction

A recent systematic review by Talkhan et al demonstrated the need for theoretically based behaviour change interventions in this area. [1] For development of such complex interventions, emphasis should be placed on using theory to systematically identify behavioural determinants of antimicrobial prescribing.

Aim

To identify and quantify clinicians’ behavioural determinants of antimicrobial prescribing in Qatar.

Methods

This cross-sectional survey is part of a multi-phase explanatory, sequential mixed methods PhD project in Qatar. Questionnaires were distributed (online and paper based) to all doctors (~4,000) and pharmacists (~400) within Hamad Medical Corporation (HMC, the main healthcare provider). The questionnaire was developed with reference to the Determinants of Implementation Behaviour Questionnaire (a generic questionnaire derived from the 14 theoretical domains of the Theoretical Domains Framework, TDF). [2] Each item was presented as a 5-point Likert scale (scored 5=Strongly agree to 1=Strongly disagree). Personal and practice demographics were also collected for data contextualisation. The draft questionnaire was reviewed for face/content validity by an expert panel of six researchers in Qatar and the UK with experience in the use of the TDF, followed by ‘Think aloud’ testing and piloting. Analysis investigated the behavioural determinants and influential factors through descriptive, principal component analysis (PCA) and inferential analysis. Ethics approval was granted from a UK university and HMC.

Results

In total, 535 responses were received, 339 (63.4%) from doctors and 196 (36.6%) from pharmacists. Respondents were predominantly male, 346 (64.7%). Just over half (n=285, 53.3%) had ≤ 5 years’ experience as health professionals. PCA showed a three component (C) solution with components incorporating a number of questionnaire items labelled: ‘Guidelines compliance’ (C1 with 8 items), ‘Influences on prescribing’ (C2 with 7 items) and ‘Self-efficacy’ (C3 with 5 items) in prescribing/recommendation activity. A scale score for each respondent was calculated through summation of Likert scores for the relevant questionnaire items within each component. These scales had high internal reliability (Cronbach’s alpha all &gt;0.7) showing consistency in response between component items indicating statistical appropriateness for developing scales. The median score (possible scale range, midpoint) for each scale was C1, 32 (8 to 40, 24), C2, 26 (7 to 35, 21) and C3, 20, (5 to 25, 15). By way of example Table 1 shows levels of agreement for items in C2. This shows lower levels of agreement than C1 scale with the median scale score (26) closer to the midpoint (21) indicating that respondents had less positive views. Inferential analysis using these scale scores and free text analysis is in progress.

Conclusion

A theoretical basis was used throughout providing insights to behavioural determinants for the development of a theory-based behaviour change intervention. Preliminary results suggest that social influences, staff development and quality monitoring may be useful targets for behaviour change interventions to improve antimicrobial prescribing practice. Limitations include potential social desirability bias and focus on one healthcare organisation/country in the Middle East which may limit generalisability of findings. More in-depth exploration is required to select and test appropriate linked theory-based behaviour change techniques.

References

1. Talkhan H, Stewart D, McIntosh T, Ziglam H Palli Valapila, A; Moza Sulaiman H, Diab M, Cunningham S. The use of theory in the development and evalu​ation of behaviour change interventions to improve antimicrobial prescribing: a systematic review. J Antimicrob Chemother. 2020;75(9):2394–2410, Available from https://doi.org/10.1093/jac/dkaa154 [Accessed 12 Oct 2020].

2. Huijg JM, Gebhardt WA, Dusseldorp E, Verheijden MW, van der Zouwe N, Middelkoop BJ, Crone MR. Measuring determinants of implementation behaviour: psychometric properties of a questionnaire based on the Theoretical Domains Framework. Implement. Sci. 2014;9(1):33.

A qualitative exploration of pharmacist prescribing for patients with Chronic Kidney Disease in the United Kingdom

Introduction

Chronic Kidney Disease (CKD) has a high risk of mortality, frequent hospitalisation and reduced life expectancy. Clinical pharmacy services have potential to contribute significantly to the multidisciplinary team. In the UK Government policies prioritise development of pharmacist prescribing and the GPhC highlight changing health services that increasingly use pharmacist prescribers.

Aim

To explore the development, implementation and evaluation of pharmacist prescribing for patients with Chronic Kidney Disease (CKD) in the UK.

Method

This phase of a doctoral research programme used a phenomenological qualitative semi-structured interview approach. It involved 48 pharmacist prescriber members of the UK Renal Pharmacy Group (UKRPG) who had agreed to further research after an online survey. The development of the theory based semi-structured interview tool followed a rigorous iterative process using findings from a systematic review in the first phase [1] and results from a survey in the second phase.[2] The tool was designed using the Consolidated Framework for Implementation Research (CFIR) and reviewed independently for face and content validity by an expert panel. Think aloud testing and piloting completed the development process. A date / time for an audio-recorded telephone interview was arranged following receipt of signed consent. All interviews were transcribed verbatim naturalistically. NVivo® 11 was used for data management and analysis. Interview data were analysed thematically, guided by the CFIR, initially by two team members independently. The Francis method of checking for data saturation was used. Ethical approval was granted by RGU School of Pharmacy & Life Sciences Ethics committee.

Results

Fourteen pharmacists of the 48 agreed to participate. Demographic details included: 11 female, 7 had &gt;16 year experience in profession, all had secondary care as main practice setting and 8 had &gt; 11years as a prescriber. The interviewees were generally very positive about their prescribing practice and they articulated that they were prescribing in a variety of settings. They used mainly independent prescribing in both inpatient and/or outpatient settings and prescribing in clinic settings for CKD associated anaemia / epoetin clinics. CFIR helped identify themes related to facilitators and barriers to advancing prescribing practice (Table 1). There was enthusiasm for the future development of prescribing practice including further establishment of clinics and taking responsibility for groups of patients. Interviewees indicated awareness of systems for evaluating their prescribing activity.

Conclusion

This work provides valuable information relating to the current status of and needs for the development of pharmacist prescribing practice in the UK. It fills a gap shown from previous work [1] around availability of information on structures, process and monitoring of outcomes of this specific growing aspect of clinical pharmacy practice. Main strengths include consideration of aspects of trustworthiness throughout the research process aided by theoretical underpinning with CFIR and the focus on specialist pharmacist prescribers. Major limitations include low number of participants with consequent potential for recruitment and social desirability biases and lack of transferability of findings. Further ‘deep dive’ case study work will help explore the practice of leading edge advanced and consultant level practitioners to learn even more about practice development.

References

1. Al Raiisi F, Stewart D, Fernandez-Llimos F, Salgado TM, Fahmy Mohamed M, Cunningham S. 2019. Clinical pharmacy practice in the care of Chronic Kidney Disease patients: a systematic review. Int J Clin Pharm. 2019 41(3):630–666. doi: 10.1007/s11096-019-00816-4.

2. Al Raiisi F, Stewart D, Ashley C, Fahmy M, Alnaamani H, Cunningham S. A theoretically based cross-sectional survey on the behaviors and experiences of clinical pharmacists caring for patients with chronic kidney disease. Res Social Adm Pharm. 2020 May. In press, https://doi.org/10.1016/j.sapharm.2020.05.005

Exploration of inter-professional learning in experiential Learning for student pharmacists in Scotland: A qualitative study

Introduction

Additional Cost of Teaching for Pharmacy (ACTp) funding from Scottish Government supports the development of experiential learning (EL) placements for student pharmacists [1]. Interprofessional learning (IPL) has been built into initial education for many healthcare professionals [2]. In 2019, a National Pharmacy EL Stakeholder event recommended exploring the further development of IPL within EL for the MPharm.

Aim

To scope existing IPL in EL and explore the feasibility for further development within the MPharm in Scotland

Methods

Online qualitative interviews were conducted with key stakeholders from Schools of Pharmacy, NHS Education for Scotland, EL sites, and Scottish health boards. All were involved in the development/delivery of these activities. The interview schedule was developed by the research team, reviewed for face and content validity, piloted prior to use, and modified based on early interviews. All interviews were audio-recorded, transcribed, and independently thematically analysed by two researchers. Interviews continued until data saturation and good representation from all settings were achieved. All ethical approvals were sought prior to the interviews.

Results

Twenty interviews were conducted with three key themes emerging; (1)current IPL within EL activities, (2)future developments, and (3)perceptions of enablers and barriers to developing/delivering IPL within EL. There were limited examples of existing IPL within EL activities including: a pilot pharmacy longitudinal clerkship and hospital-based pharmacy/medical student IPL week. Some stakeholders indicated that current IPL involves mainly campus-based activities but other EL based initiatives were planned but not yet implemented. Respondents indicated that future developments should be carefully planned in collaboration with other stakeholders and tailored to students’ stage of study to ensure their success. There was significant support for incorporating IPL within EL initiatives as part of the MPharm course to complement traditional ways of teaching.

“I think if we don't do it, we're missing a big trick… Doing something in a classroom or doing something within a small tutorial is a very false way of learning, whereas in practice, where they're going to end up working together, it seems ideal.”

Many enablers were highlighted mainly relating to the expected benefits of such activities on students, facilitators, patients, and the healthcare system. Logistics and planning difficulties were perceived to be barriers to implementation of IPL within EL.

“We've tried to do it, it was with the medical school and they were receptive to it, but the logistics just didn't work out… when you've got two very different timetables to try and bring together, it is very, very difficult to do.”

Conclusion

Pharmacy stakeholders highlighted that the majority of IPL currently undertaken in Scotland is not based in EL settings but they supported developing it. Enablers and barriers articulated highlight the need for careful planning of these activities. A strength of this study is it involved a broad range of key stakeholders from across Scotland ensuring representativeness of views and ideas. A limitation may be that, given the Scottish focus, findings may lack direct transferability to other countries. Future research should focus on designing a framework for developing and implementing IPL within EL in Scotland.

References

1. NHS Education for Scotland, 2020. Experiential learning for student pharmacists in Scotland. [online]. Edinburgh: NHS Education for Scotland. Available from: https://www.nes.scot.nhs.uk/our-work/experiential-learning-for-student-pharmacists-in-scotland/ [Accessed 07/10/2020].

2. Barr H. Interprofessional Education-The Genesis of Global Movement. 2015. https://www.caipe.org/resources/publications/barr-h-2015-interprofessional-education-genesis-global-movement. [Accessed 4 Aug 2020]

The international literature underpinning collaborative practice within practice based experiential learning for the initial education of student pharmacists: a scoping review

Introduction

Interprofessional team working within healthcare [1] enables the use of complementary areas of expertise. Collaborative practice (CP) builds on this and enhances recognition and respect for such expertise which facilitates professional synergy. Development of CP needs to be built into initial education programmes and there is global progress. [2] Further, a WHO Framework highlighted the importance of courses developing CP in experiential learning (EL) environments. [1] There is need to develop both CP and EL within pharmacy courses to meet governmental and regulatory aspirations around the clinical and prescribing roles of pharmacists.

Aim

The aim of this part of a scoping review was to describe the different characteristics of the international literature around the development, implementation and evaluation of CP within practice based EL for initial education of student pharmacists.

Methods

The six-stage Arksey and O’Malley framework and the PRISMA extension for Scoping Reviews for reporting were followed. Eligibility criteria were defined (Table 1) and electronic searches of relevant databases (Medline, IPA, CINAHL and Google Scholar) conducted from inception to April 2020. MeSH terms and other relevant subject headings and text words were used. First stage involved screening titles / abstracts and second stage involved review of full text articles. A charting tool was developed and used to extract data on: country, study design, methods of evaluation, sector of practice, stage of students, professional groups involved, monitoring and assessment and scope for development. Findings were presented as a descriptive narrative summary. All steps involved independent checks by two of the review team.

Results

Twenty-eight papers were included with most from the USA (16 papers), with the remainder from Australia (5 papers), UK (5 Papers), Canada and the Netherlands (1 paper each). The majority of papers described quantitative methods using a wide variety of published (some validated) scales (20 scales including RIPLS, SPICE, CPAT) and a number of bespoke survey tools. The main focus was at ‘Kirkpatrick model of educational evaluation’ level 3 – with 13 papers focussing on changes to professional behaviours. Papers focussed on either hospital (12 papers) or primary care initiatives (12 papers) with the remaining four describing cross-sectoral settings. Only 6 papers stated that they focussed on specific healthcare specialities and the remainder were in general medical facilities. The nature of initiatives and activities varied with a predominance of focus to include later years of study. Only 3 papers included only pharmacy and medicine students.. Detailed information was lacking on methods of student assessment: some reported this involved reflection, with limited reporting of tools to assess competencies. A wide array of further research proposals was articulated.

Conclusion

This scoping review highlights the range of work already carried out. The diversity highlights the need for consideration of commonality in the nature of activity and tools to evaluate outcomes to ensure transferability to practice. There are many challenges influencing further development and implementation of CP. Facilitating matters by using the evidence base to add to existing placements without restructuring curricula across courses / institutions has been proposed by some authors.

References

1. Framework [Framework for Action on Interprofessional Education & Collaborative Practice (WHO/HRH/HPN/10.3). World Health Organization 2010, Geneva 27, Switzerland, Available at http://www.who.int/hrh/nursing_midwifery/en/ [Accessed 4 Aug 2020]

2. Barr H. Interprofessional Education-The Genesis of Global Movement. 2015. https://www.caipe.org/resources/publications/barr-h-2015-interprofessional-education-genesis-global-movement. [Accessed 4 Aug 2020]

Case Report: Unexpected Remission From Extreme and Enduring Bulimia Nervosa With Repeated Ketamine Assisted Psychotherapy

Background: Bulimia nervosa is a disabling psychiatric disorder that considerably impairs physical health, disrupts psychosocial functioning, and reduces overall quality of life. Despite available treatment, less than half of sufferers achieve recovery and approximately a third become chronically ill. Extreme and enduring cases are particularly resistant to first-line treatment, namely antidepressants and cognitive behavioral therapy, and have the highest rate of premature mortality. Here, we demonstrate that in such cases, repeated sessions of ketamine assisted psychotherapy (KAP) is an effective treatment alternative for improving symptoms. Case Presentation: A 21-year-old woman presented with extreme and enduring bulimia nervosa. She reported recurrent binge-eating and purging by self-induced vomiting 40 episodes per day, which proved refractory to both pharmacological and behavioral treatment at the outpatient, residential, and inpatient level. Provided this, her physician recommended repeated KAP as an exploratory and off-label intervention for her eating disorder. The patient underwent three courses of KAP over 3 months, with each course consisting of six sessions scheduled twice weekly. She showed dramatic reductions in binge-eating and purging following the first course of treatment that continued with the second and third. Complete cessation of behavioral symptoms was achieved 3 months post-treatment. Her remission has sustained for over 1 year to date. Conclusions: To our knowledge, this is the first report of repeated KAP used to treat bulimia nervosa that led to complete and sustained remission, a rare outcome for severe and enduring cases, let alone extreme ones. Additionally, it highlights the degree to which KAP can be tailored at the individual level based on symptom severity and treatment response. While its mechanism of action is unclear, repeated KAP is a promising intervention for bulimia nervosa that warrants future research and clinical practice consideration.

The Lullaby Project: A Musical Intervention for Pregnant Women

Background: This pilot study investigated the impact of a musical intervention on maternal/fetal attachment, psychiatric symptoms, and perceived stress in two centers.

Materials and Methods: Forty-four pregnant women participated from the Virginia Commonwealth University in Richmond, VA, and Jacobi Medical Center in Bronx, NY. Participants were assigned to a lullaby intervention or control group. The Maternal Fetal Attachment Scale, Perceived Stress Scale (PSS), and Symptom Checklist (SCL-27) were completed at baseline and follow-up.

Results: Although no significant differences were found in maternal/fetal attachment between control and intervention groups, there were within-group differences in both groups from baseline to follow-up. No statistically significant differences in change from baseline occurred on the SCL-27 and PSS.

Conclusions: Exposure to a lullaby intervention was not statistically associated with maternal/fetal attachment, mental health, and perceived stress in this pilot study. Future studies with larger samples and different outcomes are suggested.

Validation of a SARS-CoV-2 RNA RT-PCR assay for high-throughput testing in blood of COVID-19 convalescent plasma donors and patients

BACKGROUND

The frequency of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNAemia in blood donors is uncertain. Thus, assays for SARS-CoV-2 RNA detection in blood, validated on commercially available polymerase chain reaction (PCR) systems, are required to allow a good comparability of data.

STUDY DESIGN AND METHODS

The cobas SARS-CoV-2 dual-target reverse transcriptase PCR (RT-PCR) assay, licensed for respiratory swab SARS-CoV-2 RNA testing, was validated for detection of viral RNA in blood. For the validation panel, SARS-CoV-2-positive plasma samples were prepared by spiking SARS-CoV-2-positive respiratory specimens in negative human plasma. The 95% limit of detection (LOD95) was determined by probit analysis. For clinical validation, coronavirus disease 2019 (COVID-19) convalescent plasma (CCP) donors and patients with COVID-19 with a severe disease course treated in an intensive care unit (ICU) were included.

RESULTS

The validation of the SARS-CoV-2 RT-PCR assay for blood demonstrated high sensitivity and specificity and intra- and inter-assay precision and efficiency. The LOD95 for SARS-CoV-2 RNA was 5.0 genome copies/mL (95% confidence interval [CI], 3.3-12 copies/mL) for target 1 and 4.3 genome copies/mL (95% CI, 2.9-10 copies/mL) for target 2. In a cohort of 39 CCP donors with 66 CCP donations no SARS-CoV-2 RNA in plasma was detected. Screening of 25 blood samples of 19 ICU patients with COVID-19 showed six positive results for SARS-CoV-2 RNA in at least one target of the assay.

CONCLUSION

The SARS-CoV-2 RNA assay, only licensed for respiratory swabs, performed on a PCR system for high-throughput testing, showed a good assay performance for blood testing.

Recent Advances in Good Manufacturing Practice-Grade Generation of Dendritic Cells

Dendritic cells (DCs) are pivotal regulators of immune responses, specialized in antigen presentation and bridging the gap between the innate and adaptive immune system. Due to these key features, DCs have become a pillar of the continuously growing field of cellular therapies. Here we review recent advances in good manufacturing practice strategies and their individual specificities in relation to DC production for clinical applications. These take into account both small-scale experimental approaches as well as automated systems for patient care.

A Prospective Study of Exposure to Gender-Based Violence and Risk of Sexually Transmitted Infection Acquisition in the Women's Interagency HIV Study, 1995-2018

Background: Our objectives were to estimate the association of gender-based violence (GBV) experience with the risk of sexually transmitted infection (STI) acquisition in HIV-seropositive and HIV-seronegative women, to compare the STI risks associated with recent and lifetime GBV exposures, and to quantify whether these associations differ by HIV status. Methods: We conducted a multicenter, prospective cohort study in the Women's Interagency HIV Study, 1994-2018. Poisson models were fitted using generalized estimating equations to estimate the association of past 6-month GBV experience (physical, sexual, or intimate partner psychological violence) with subsequent self-reported STI diagnosis (gonorrhea, syphilis, chlamydia, pelvic inflammatory disease, or trichomoniasis). Results: Data from 2868 women who reported recent sexual activity comprised 12,069 person-years. Higher STI risk was observed among HIV-seropositive women (incidence rate [IR] 5.5 per 100 person-years) compared with HIV-seronegative women (IR 4.3 per 100 person-years). Recent GBV experience was associated with a 1.28-fold (95% confidence interval [CI] 0.99, 1.65) risk after adjustment for HIV status and relevant demographic, socioeconomic, and sexual risk variables. Other important risk factors for STI acquisition included unstable housing (adjusted incidence rate ratio [AIRR] 1.81, 95% CI 1.32-2.46), unemployment (AIRR 1.42, 95% CI 1.14-1.76), transactional sex (AIRR 2.06, 95% CI 1.52-2.80), and drug use (AIRR 1.44, 95% CI 1.19-1.75). Recent physical violence contributed the highest risk of STI acquisition among HIV-seronegative women (AIRR 2.27, 95% CI 1.18-4.35), whereas lifetime GBV experience contributed the highest risk among HIV-seropositive women (AIRR 1.59, 95% CI 1.20-2.10). Conclusions: GBV prevention remains an important public health goal with direct relevance to women's sexual health.

The effect of organizational arrangements on people with type 2 diabetes and foot ulcers in Scotland

Background

A recent meta-analysis showed that specific organizational arrangements may decrease the risk of lower extremity amputations among subjects with type 2 diabetes (T2D) affected by foot ulcers (DFU). We aim to translate these results into algorithms to extract cohorts from routine data from the Scottish Diabetes Register (SCI-Diabetes). We used models to estimate the actual effectiveness of different practices and discuss transferability of the approach to other contexts e.g. the English database of general practitioners.

Methods

A multidisciplinary team mapped the Scottish database to the outputs of meta-analysis, adopting the standard set for diabetes of the International Consortium for Health Outcomes Measurement. Algorithms extracted a standardized retrospective cohort for 2016-2019. Records up to 5 years before first entry into the cohort were used for case-mix. Proportional hazards were used for multivariate modelling. Results were expressed in terms of hazard ratios with 95% confidence intervals.

Results

In 2016-2019, a total of 275,386 adults with T2D were registered in SCI-diabetes. Among them, 1,843 (0.66%) had an amputation, of which 777(42%) had a previous DFU diagnosis. We applied the criteria derived from meta-analysis and the definitions of the diabetes standard set to calculate columns included in the case-mix for predictive modelling. The refinement of multivariate models is still in progress and all adjusted hazard ratios will be included in the revised version of this abstract to be presented at the Conference.

Conclusions

Epidemiological evidence on diabetes care can be directly translated into algorithms for extracting dynamic cohorts from high quality diabetes registers. Results can be generalised to different types of national databases, adjusting for the heterogeneous dataset structures.

Key messages

Sets of criteria and definitions adopted for the conduction of meta-analyses can be translated into algorithms to extract cohorts and test models of real-world evidence from routine national databases. The Scottish Diabetes Register was successfully used to confirm the effectiveness of organizational arrangements in diabetes in normal practice.

Prevalence of amputations amongst people with type 2 diabetes enrolled in primary care in England

Background

Different patterns of co-morbidities observed among people with type 2 diabetes (T2D) and lower extremity amputations (LEA) compared with those without may provide insights into the quality of care provided by general practitioners in England. We analysed routinely recorded clinical data to build predictive models for benchmarking and continuous improvement.

Methods

A cross-sectional computerized data extraction of clinical records from the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) database of people with T2D in England. Key target cases were defined as adults with T2D and a record of major/minor LEA between 2008-2019 vs all subjects with T2D without amputation. Quality of care was assessed in terms of percentage of patients treated with optimal medical therapy and diagnostic procedures and referred to specialized care according to their clinical profile. The association between quality of care and outcomes was explored using a logistic regression model, adjusting for case-mix.

Results

During the last decade, in a sample covering approximately 7.4% of all general practitioners in England, a total of 1,052 subjects out of 127,100 adults with T2D had a LEA (832 per 100,000). The median time since amputation was 3.4 years. Only 410 (38%) patients had a recorded DFU diagnosis prior to the amputation, with a median of 2 years from diagnosis to amputation. Major LEA was recorded in 280 (27%) cases. People with a record of retinopathy, peripheral arterial disease, renal disease, neuropathy and DFU had a higher risk of amputations. Quality of care was heterogeneous between patients with and without LEA.

Conclusions

People with T2D and LEA have a distinct pattern of co-morbidities some of which may be sensitive to improved primary care management, and differential quality of care. Models built using this national database can routinely monitor amputations in England. Variation in treatment should be properly investigated.

Key messages

The automated extraction of clinical cases from a national database may help shed light on clinical patterns among people with diabetes at high risk of amputations, based on evidence-based criteria. Variation in treatment and quality of care among amputated vs non-amputated subjects can be rapidly explored using a cross-sectional analysis of current records.

A theoretically based cross-sectional survey on the behaviors and experiences of clinical pharmacists caring for patients with chronic kidney disease

The literature shows a lack of evidence on pharmacists contributing to chronic kidney disease services. The aim was to determine pharmacists' behaviors and experiences and perceptions of barriers and facilitators to implementation of models of care. A theoretically informed survey was developed and sent to pharmacist members of the United Kingdom renal pharmacy group. Sections included: demographics, clinical practice and prescribing practice. Questions were of various types; closed type and some open for comments. Attitudinal items on clinical/prescribing used 5-point Likert scale. Development/implementation items were derived from the Consolidated Framework for Implementation Research (CFIR). Analysis used descriptive statistics and open comments were analysed thematically. Ethical approval was granted by an academic institution. Response rate; 50% (n = 71), seven were incomplete and excluded. Respondents provided; inpatient general pharmaceutical care (n = 56, 87.5%), to those receiving dialysis (n = 54, 84.4%) and transplantation. Non-clinical roles; audits (n = 46, 71.9%), patient education (n = 31, 48.4%), only 7.8% (n = 5) doing academic research. For barrier/facilitators most strongly agreed/agreed with most CFIR items relating to clinical practice. A majority (n = 44, 68.7%) disagreed that they had sufficient time to practice clinically and 44 (68.7%) disagreed there was sufficient cover for services. For prescribing roles, 90.5% (n = 48) were currently actively prescribing. Although prescribing related CFIR items were largely positive, 39.6% (n = 19) disagreed about sufficient time to practice and 18.7% (n = 9) were neutral. Two thirds (n = 33, 68.7%) disagreed that there was sufficient cover for the prescribing. The majority of respondents provided general pharmaceutical care to dialysis and transplant patients, were confident in their abilities and tried new ways of working including independent prescribing. Many expressed that lack of resources was the main barrier to providing more advanced care. Further work is needed to explore these matters in more depth.

Predictors of mental health and academic outcomes in first-year university students: Identifying prevention and early-intervention targets

BACKGROUND

Although there is growing interest in mental health problems in university students there is limited understanding of the scope of need and determinants to inform intervention efforts.

AIMS

To longitudinally examine the extent and persistence of mental health symptoms and the importance of psychosocial and lifestyle factors for student mental health and academic outcomes.

METHOD

Undergraduates at a Canadian university were invited to complete electronic surveys at entry and completion of their first year. The baseline survey measured important distal and proximal risk factors and the follow-up assessed mental health and well-being. Surveys were linked to academic grades. Multivariable models of risk factors and mental health and academic outcomes were fit and adjusted for confounders.

RESULTS

In 1530 students surveyed at entry to university 28% and 33% screened positive for clinically significant depressive and anxiety symptoms respectively, which increased to 36% and 39% at the completion of first year. Over the academic year, 14% of students reported suicidal thoughts and 1.6% suicide attempts. Moreover, there was persistence and overlap in these mental health outcomes. Modifiable psychosocial and lifestyle factors at entry were associated with positive screens for mental health outcomes at completion of first year, while anxiety and depressive symptoms were associated with lower grades and university well-being.

CONCLUSIONS

Clinically significant mental health symptoms are common and persistent among first-year university students and have a negative impact on academic performance and well-being. A comprehensive mental health strategy that includes a whole university approach to prevention and targeted early-intervention measures and associated research is justified.

Use of Normalization Process Theory to explore key stakeholders' perceptions of the facilitators and barriers to implementing electronic systems for medicines management in hospital settings

BACKGROUND

Limited data exist on the facilitators and barriers to implementing electronic systems for medicines management in hospitals. Whilst numerous studies advocate system use in improved patient safety and efficiency within the health service, their rate of adoption in practice has been slow.

OBJECTIVE

To explore the perceptions of key stakeholders towards the facilitators and barriers to implementing electronic prescribing systems, robotic pharmacy systems, and automated medication storage and retrieval systems in public hospital settings using Normalization Process Theory as a theoretical framework.

METHODS

Individual face-to-face semi-structured interviews were conducted in three public hospitals in Ireland with 23 consenting participants: nine nurses; four pharmacists; two pharmacy technicians; six doctors; and two Information Technology managers.

RESULTS

Enhanced patient safety and efficiency in healthcare delivery emerged as key facilitators to system implementation, as well as the need to have clinical champions and a multi-disciplinary implementation team to promote engagement and cognitive participation. Key barriers included inadequate training and organisational support, and the need for ease and confidence in system use to achieve collective action.

CONCLUSIONS

Many themes that are potentially transferable to other national settings have been identified and extend the evidence base. This will assist organisations around the world to better plan for implementation of medication-related eHealth systems.

Influence of interpregnancy interval on uterine rupture

OBJECTIVE

This study aims to assess the independent influence of interpregnancy interval (IPI) on uterine rupture using a population-based cohort of all Ohio births, regardless of prior cesarean (PCS) or trial of labor (TOL) status.

STUDY DESIGN

Population-based retrospective cohort study of all live births in Ohio (2006-2012). Frequency of uterine rupture was quantified and stratified by number of prior cesarean deliveries and IPI. The relative and adjusted risk of IPI on uterine rupture was calculated using multivariate logistic regression.

RESULTS

Of 1,034,522 live births recorded during the 7-year study period, 249 cases of uterine rupture were identified for analysis. Two-thirds of uterine rupture cases (n = 158) occurred in women with one or more PCS and one-third (n = 91) had no prior cesarean. IPI 24-59 months had the lowest frequency of uterine rupture and was used as the referent group. IPI 12-23 and IPI ≥ 60 months were not significantly associated with risk of uterine rupture, p = .847, .540 respectively. In women with PCS, IPI < 12 months was associated with greater than two-fold increased risk of uterine rupture (aRR 2.4, CI 1.5-3.8). No association between IPI < 12 months and uterine rupture was observed in women with no PCS, p = .696.

CONCLUSION

IPI < 12 months is independently associated with uterine rupture in women with prior cesarean, but does not appear to influence risk in women with an unscarred uterus.

Plasmacytoid dendritic cell depletion modifies FoxP3+ T cell homeostasis and the clinical course of bacterial pneumonia in mice

Plasmacytoid dendritic cells (pDC) are critical to antiviral defense because of their high production of type I IFNs; less is known regarding their functions in bacterial infection. Moreover, pDC are involved in immunomodulation. A stable pool of regulatory T cells (Treg) is crucial for maintaining immune homeostasis. However, interactions between pDC and Treg regarding the regulation of Treg homeostasis are understudied. By using BDCA2-DTR mice as a systemic pDC depletion model, we identified increased steady-state numbers of FoxP3⁺ T cells with an effector Treg-like phenotype in lungs, liver, and spleen tissues. During sublethal, pulmonary Klebsiella pneumoniae infection, pDC deficiency also elevated respiratory FoxP3⁺ T cell numbers. Additionally, the improvement in acute pneumonia survival until day 5 post infection was accompanied by impaired proinflammatory cytokine production. In contrast, pDC-depleted mice exhibited a delayed clinical recovery during the post-acute phase. Therefore, we assume that pDC act as immunomodulators supporting the rapid onset of immune response in a proinflammatory manner and regulate inflammation or tissue regeneration in the post-acute phase. In summary, pDC assist in FoxP3⁺ T cell homeostasis and the regulation of Klebsiella-pneumonia progression.

Protocol for the cost-consequence and equity impact analyses of a cluster randomised controlled trial comparing three variants of a nutrition-sensitive agricultural extension intervention to improve maternal and child dietary diversity and nutritional status in rural Odisha, India (UPAVAN trial)

Background

Undernutrition causes around 3.1 million child deaths annually, around 45% of all child deaths. India has one of the highest proportions of maternal and child undernutrition globally. To accelerate reductions in undernutrition, nutrition-specific interventions need to be coupled with nutrition-sensitive programmes that tackle the underlying causes of undernutrition. This paper describes the planned economic evaluation of the UPAVAN trial, a four-arm, cluster randomised controlled trial that tests the nutritional and agricultural impacts of an innovative agriculture extension platform of women’s groups viewing videos on nutrition-sensitive agriculture practices, coupled with a nutrition-specific behaviour-change intervention of videos on nutrition, and a participatory learning and action approach.

Methods

The economic evaluation of the UPAVAN interventions will be conducted from a societal perspective, taking into account all costs incurred by the implementing agency (programme costs), community and health care providers, and participants and their households, and all measurable outcomes associated with the interventions. All direct and indirect costs, including time costs and donated goods, will be estimated. The economic evaluation will take the form of a cost-consequence analysis, comparing incremental costs and incremental changes in the outcomes of the interventions, compared with the status quo. Robustness of the results will be assessed through a series of sensitivity analyses. In addition, an analysis of the equity impact of the interventions will be conducted.

Discussion

Evidence on the cost and cost-effectiveness of nutrition-sensitive agriculture interventions is scarce. This limits understanding of the costs of rolling out or scaling up programs. The findings of this economic evaluation will provide useful information for different multisectoral stakeholders involved in the planning and implementation of nutrition-sensitive agriculture programmes.

Trial registration

ISRCTN65922679. Registered on 21 December 2016

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3388-2) contains supplementary material, which is available to authorized users.

Developing and Testing the Agency for Healthcare Research and Quality's National Guideline Clearinghouse Extent of Adherence to Trustworthy Standards (NEATS) Instrument

In 2011, the Institute of Medicine (IOM) (now the National Academy of Medicine) published standards for trustworthy guidelines and recommended that the National Guideline Clearinghouse (NGC) of the Agency for Healthcare Research and Quality clearly indicate the extent to which guidelines adhere to these standards. To accomplish this, the authors developed and tested the NGC Extent of Adherence to Trustworthy Standards (NEATS) instrument. The standards were operationalized as an instrument containing 15 items that cover disclosure of the funding source; disclosure and management of conflicts of interest; multidisciplinary input; incorporation of patient perspectives; rigorous systematic review; recommendations accompanied by rationale, assessment of benefits and harms, clear linkage to the evidence, and assessment of strength of evidence and strength of recommendation; clear articulation of recommendations; external review by diverse stakeholders; and plans for updating. After multiple rounds of feedback from experts on clinical practice guideline development, the external validity and interrater reliability of the instrument were evaluated. For each item, 80% to 100% of survey respondents judged it to be a good measure of the IOM standards. All external stakeholders stated that NEATS was suitable for its intended goal. Interrater reliability for the final NEATS instrument had a weighted κ of 0.73. The NEATS instrument is a focused tool that provides a concise evaluation of a guideline's adherence to the IOM standards for trustworthy guidelines. It has good external validity among guideline developers and good interrater reliability across trained reviewers.