Distribution of normalized pulmonary transit time per pathology in a population of routine CMR examinations

Pulmonary transit time (PTT), defined as the time taken for a contrast agent bolus to pass from the right ventricle to the left ventricle, is a surrogate for non-invasive assessment of preload. It is used in several imaging modalities: pulmonary angiography, echocardiography and cardiac magnetic resonance (CMR). Many recent studies have highlighted the prognostic value of PTT. Therefore, we sought to evaluate PTT in a consecutive cohort of patients undergoing CMR. We retrospectively evaluated PTT normalised for heart rate in 278 patients (66% male, mean age 58 ± 11 years) who underwent CMR between August 2017 and November 2021 with a diagnosis of dilated cardiomyopathy, infarct, hypertrophy, valvular, myocarditis, other pathology or no pathology ("normal"). Normalised pulmonary transit time (nPTT) was higher in men than in women (8.4 ± 1.3 beats vs 7.5 ± 1.1 beats, p = 0.002) in the "normal" group. nPTT was moderately correlated with left ventricular end-diastolic volume (LVEDV) (r2 = 0.19; p < 0.001), left ventricular end-systolic volume (LVESV) (r2 = 0.34; p < 0.001) and left ventricular ejection fraction (LVEF) (r2 = 0.29; p < 0.001). nPTT was significantly higher in patients with dilated cardiomyopathy (11.3 ± 5.4 beats; p < 0.001), infarct (9.5 ± 2.9 beats; p < 0.001) or valvular heart disease (9.5 ± 3.1 beats; p = 0.006) than in patients included in the "normal" group (7.9 ± 1.3 beats). The nPTT is an important marker of pathology. Its value depends on sex and type of pathology, but it is not specific for any type of pathology.

Battling professional self-sabotage: Embracing standard of care as the future of pharmacy regulation

Laws and regulations are intended to protect the public; however, overregulation of the profession can block initiatives focused on patient safety and public health. This article discusses the 3 main regulatory approaches to pharmacy practice: standard of care (SOC), bright line, and right touch. An SOC regulatory model supports practitioners delivering patient care within their scope of practice and clinical training. Patient safety is maintained by measuring care against other practitioners within the same practice setting while supporting practitioners practicing at the top of their clinical ability. Compared with bright line and right touch approaches, the SOC regulatory model provides the adaptability needed to respond to different practice scenarios and settings, thus increasing access to health care and opportunities for innovation. To have a lasting impact on the profession and support patients, all pharmacy professionals must be fluent in regulatory approaches and advocate for states to transition to SOC regulatory models.

229 NEW STROKE EARLY SUPPORTED DISCHARGE SERVICE PROVIDES ALTERNATIVE REHAB PATHWAY AND IMPROVES PATIENT AND ORGANISATIONAL OUTCOMES

Background

Early Supported Discharge (ESD) for stroke is an international model of best care for stroke patients. ESD improves patient outcomes while facilitating a faster hospital discharge through providing stroke specific rehabilitation at home. ESD can be expected to improve disability outcomes and quality of life and reduce length of hospital stay. A pilot ESD service was introduced to this model 3 hospital in 2021 which encompasses a large geographical rural area that historically had an absence of Stroke rehabilitation services.

Methods

A retrospective review of routine data extracted from 57 patients accepted to the ESD service in 2021 was completed. This initial examination explored the effectiveness of ESD with the population in this rural area. Service Objectives as follows: (1) Improve patient’s functioning as measured by Functional Independence Measure (FIM) and Functional Assessment Measures (FAM); (2) Demonstrate a reduction in disability outcomes as evidenced on the Modified Rankin Scale (MRS); (3) Increase number of early supported discharges directly home for patients; and (4) Reduce length of hospital stay for patients post-stroke.

Results

Implementation of an ESD service over a 12-month period achieved the following: (1) 8.1% improvement in total FIM/FAM scores indicating positive functional outcomes and enhanced independence when discharged home with ESD; (2) A decrease in the average MRS score indicating improved disability outcomes; (3) 25% of all stroke patients in 2021 were discharged with ESD rehabilitation; (4) An increase of 12% in total number of discharges home post stroke from 2020 to 2021; (5) 244 bed saving days.

Conclusion

The introduction of an ESD service resulted in patient and organisational benefits. Participation in ESD rehabilitation had a positive impact on reduction of disability scores captured using MRS and improvements in functional outcome measure scores captured using the FIM/FAM.

69 BUILDING TOWARDS COMPREHENSIVE GERIATRIC ASSESSMENT (C.G.A.) – A STEP-BY-STEP CPD PROGRAM

Background

The National Clinical Programme for the Older Person (2016) advises Comprehensive Geriatric Assessment (CGA) as the gold standard for the management of frailty in older people. Over the past three years the Medicine for the Elderly (MedEl) OT service have introduced a number of key quality initiatives as part of a wider Continuous Professional Development (CPD) program to support adherence to the CGA guidelines. These initiatives have focused on implementing staff development and training, and clinical processes to provide OTs with the necessary knowledge, skills and structures to carry out CGA

Methods

An audit of OT initial assessments was completed in which data pertinent to CGA was collected, this identified poor compliance and led to the re-design of the OT MedEl Staff Grade competencies in line with CGA guidelines. The team In-services and staff grade peer support were also re-designed into cycles based on the key performance domains within CGA such as upper limb and cognition. It was hoped that a more coordinated approach to CPD, beginning with the structures in place would result in improved knowledge and skills to carry out CGA.

Results

An audit of OT initial assessments was completed in which data pertinent to CGA was collected pre and post in-service cycles. This demonstrated an average increase of 21% across the 9 performance domains. Staff also self-rated their knowledge, skills and confidence in relation to the key performance domains within CGA which demonstrated an average improvement of 12.5%.

Conclusion

As part of an ongoing iterative testing cycle, a further re-audit of the OT Initial Assessment tool will be completed in the next quarter to ascertain the long-term impact of a coordinated, cohesive CPD program to support sustained implementation of CGA within our service.

84 A PROSPECTIVE AUDIT OF THE MANAGEMENT OF POSTOPERATIVE ANAEMIA IN PATIENTS AFTER OPERATIVE MANAGEMENT OF NECK OF FEMUR FRACTURES

Background

There is limited evidence available to guide the diagnosis and management of anaemia and iron deficiency in post operative patients. Numerous guidelines from professional associations exist for the management of pre-operative anaemia. We identified an international consensus statement that provided guidance on patient care with respect to postoperative anaemia and iron deficiency. Our aim was to determine if our practice was consistent with the best practice recommendations of this document.

Methods

We conducted a prospective audit on a convenience sample of patients over the age of 60 with neck of femur fractures who underwent operative management between January and April 2022. We collected data on pre and post operative haematological indices including haemoglobin, serum iron, ferritin and transferrin saturation as well as data on patients who received IV iron and red cell transfusions.

Results

We included 50 patients with neck of femur fractures who underwent hip replacement. All patients had post-op haemoglobin levels performed. Fifteen (30%) patients fulfilled the criteria for diagnosis of postoperative iron deficiency. Only 4/15 of these patients received IV iron postoperatively. Four patients who did not fulfil criteria for post-op iron deficiency received IV iron. Two patients had a post-op haemoglobin between 7-8g/dL and appropriately received red cell transfusions. Four patients received red cell transfusions despite having post-op haemoglobin levels &gt;8g/dL.

Conclusion

Our findings indicated approximately 1/3 of patients fulfilled criteria for post operative iron deficiency while only a small proportion were treated for this. More data is required to establish the impact of post-op anaemia management strategies on functional recovery and quality of life as well as laboratory and interventional endpoints. A local protocol for the management of post operative iron deficiency with and without anaemia will be developed.

The impact of a fasting mimicking diet on the metabolic health of a prospective cohort of patients with prostate cancer: a pilot implementation study

BACKGROUND

This pilot prospective study investigated the effect of a periodic fasting mimicking diet (FMD) on metabolic health factors in patients with Prostate Cancer (PC). There is a well-documented association between PC and metabolic health. Impaired metabolic health is a significant risk factor for the development of PC, and a metabolic syndrome can be induced by hormonal therapies commonly required for its management. (ClinicalTrials.gov Identifier: NCT04292041).

METHODS

We introduced a periodic 5-day FMD -low in calories, sugars, and proteins but high in unsaturated fats -to a cohort of PC patients and features of metabolic syndrome. 29/35 patients completed 3-monthly cycles of the 5-consecutive day packaged FMD. We compared the subjects' baseline weight, abdominal circumference (AC), blood pressure (BP) and selected laboratory results to the same measurements 3-months after completing the FMD cycles.

RESULTS

Several important metabolic factors showed improvements post-intervention. On average patients' weights dropped by 3.79 kg (95% CI: -5.61, -1.97, p = 0.0002). AC was reduced on average by 4.57 cm, (95% CI: -2.27, -6.87, p = 0.0003). There was also a decrease in systolic and diastolic BP by 9.52 mmHg (95% CI: -16.16, -2.88, p = 0.0066) and 4.48 mmHg (95% CI: -8.85, -0.43, p = 0.0316) respectively. A sub-analysis indicates that FMD had more relevant effects in 'at-risk' patients than those with normal values of risk factors for metabolic syndrome. For example, subjects with baseline levels of systolic BP > 130 mmHg experienced a greater reduction in BP(-16.04 mmHg, p = 0.0001) than those with baseline systolic BP < 130 mmHg (-0.78 mmHg, p = 0.89).

CONCLUSIONS

The FMD cycles were safely introduced to this small cohort of PC patients with little or no observed toxicity, and a high overall compliance of 83%. Analysis of the metabolic variables showed an overall decrease in weight, AC, and BP. Larger clinical trials focused on metabolic risk factors, PC quality of life and progression free survival are needed to assess the effect of the FMD on prostate cancer patients.

Musculoskeletal Injury in Referees That Officiate Over Ladies Gaelic Football and Camogie

Aim Ladies Gaelic football and Camogie are leading female sports in Ireland. Referees are essential to the game, however, no research has examined injury in referees that officiate over female Gaelic games to date. Therefore, this study aims to retrospectively examine the musculoskeletal injury profile and injury prevention practices of referees that officiate over female Gaelic games. Methods A retrospective anonymous questionnaire examined injuries that occurred in the previous 12 months in currently active Ladies Gaelic football and Camogie referees (n=170). Incidence and repeat incidence proportions were calculated along with descriptive statistics. Results In 2019, 42.9% (n=73) of referees sampled sustained an injury with 27.4% (n=20) sustaining two or more. Injuries primarily occurred to the lower extremity (79.6%,n=78), particularly the lower leg (20.4%,n=20) and knee (18.4%,18). Muscle strains and cramps (55.1%,n=54) were most frequent and injuries predominantly occurred during games (71.4%,n=70). Referees largely completed a warm-up but just 30.6% (n=52) conducted a cool-down. Over half had undertaken injury prevention education but only 37.6% (n=64) incorporated injury prevention elements into their training. Conclusion Just over two in five referees that officiate female Gaelic games became injured in the previous year, however their utilisation of injury prevention strategies, beyond completing a warm-up, is lacking. Thus, a referee specific injury prevention programme should be developed and if found to be effective, incorporated into a comprehensive injury prevention strategy by the governing bodies.

Redefining 'advanced': Supporting and promoting practice change through community advanced pharmacy practice experiences

INTRODUCTION

Community pharmacy practice in the United States (US) has faced several external pressures, threatening traditional practice models. Schools and colleges of pharmacy (S/COP), particularly through experiential rotations, are perfectly poised to help these practices create new sustainable business models. The purpose of this article is to highlight demonstrated, reproducible successes of community advanced pharmacy practice experience (APPE) advancement initiatives.

PERSPECTIVE

Despite community pharmacists being highly-trained health care providers with roughly equivalent educational backgrounds, community-based practices in the US are not all the same. Student pharmacists can contribute to the design and implementation of revenue-generating services helping individual pharmacies elevate their practice. Doing so involves new models for staffing, workflow, billing, and documentation. Students can help support practice change by focusing on implementation and sustainability. Example APPE integrations focused on community pharmacy practice transformation are described in detail from the University of Arkansas for Medical Sciences College of Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, and Idaho State University.

IMPLICATIONS

Establishing intentional connections that focus on new sustainable community business models is a responsibility for S/COP. The examples provided serve to demonstrate the feasibility of these partnerships. Training students on innovative practice models and utilizing them is critical in moving community practice forward. As academicians, we must prepare students to be agents of change for the profession and intentionally integrate them into a systematic plan to help promote and change practice activities wherever possible, but especially in community practice.

155 CHARACTERISTICS AND PREDICTORS OF INPATIENT FALLS IN A GERIATRIC REHABILITATION UNIT

Background

Falls are one of the most frequent complications on geriatric rehabilitation wards. In addition to having adverse consequences for patients, falls also result in prolonged hospitalisation and increased healthcare costs. Therefore, identification of risk factors and development of successful falls prevention strategies targeted at this population are essential. The aim of this study is to identify predisposing or situational risk factors contributing to falls in older adults completing post-acute inpatient rehabilitation.

Methods

Retrospective review of all inpatient falls on two geriatric rehabilitation units over a one year period identified from incident forms. Chi-squared test was used to calculate differences between fallers and non-fallers.

Results

One in five patients admitted to the unit suffered a fall (average age 81, 52% male) with a total of 95 falls involving 56 patients. Of these, only 77% (n = 43) were identified as high risk on falls screening. 61% (n = 34) had one fall and 39% (n = 22) had two or more falls. Nearly one in three (n = 15) falls resulted in injury. More falls occurred in the single bedded unit (14.8 per 1,000 bed-days) as compared to the multi-bedded unit (6.8 per 1,000 bed days). Use of a Zimmer frame or rollator was associated with more falls than use of other mobility aids. Fallers tended to have a previous history of falls (75%, n = 42) and polypharmacy (average 10 medications). Delirium and dementia were present in one third of fallers. Falls were associated with a higher risk of discharge to long-term care, with 70% of fallers discharged home compared to 89% of non-fallers (p = 0.0006).

Conclusion

Previous falls, single room occupancy, polypharmacy and a medium level of dependency when mobilizing were identified as predictors of falls in our review. Nearly a quarter of fallers were not identified as high falls risk on screening further questioning the utility of falls risk screening assessments.

Common mental disorders among Irish jockeys: prevalence and risk factors

OBJECTIVE

Jockeys compete in a sport, horseracing, renowned for its physical and psychological demands. Previous research has identified that common mental disorders (CMDs) may be prevalent among this unique population of athletes. The aim of the present study was to further explore the prevalence of CMDs among jockeys and to test for associations with potential risk factors.

METHODS

An anonymous survey was distributed to professional jockey online. Self-report screening tools for four CMDs (psychological distress, depression, generalized anxiety, and adverse alcohol use) were included alongside predictor variables from questionnaires assessing for burnout, career satisfaction, social support, and the contemplation of retirement. Binary logistic regression was used to explore associations between CMDs (present versus not present) and risk factors. Eighty-four professional jockeys completed the questionnaire (response rate = 52%).

RESULTS

In total, 79% of jockeys met the threshold for at least one CMD. Prevalence (%) of CMD varied as follows: adverse alcohol (61%), depression (35%), generalized anxiety (27%), and psychological distress (19%). Burnout, career (dis)satisfaction, lower levels of social support, and the contemplation of retirement increased the odds of meeting the criteria for CMDs.

CONCLUSION

The findings indicate that jockeys report CMD symptoms at comparable rates to athletes in other sports. The study was the first to highlight potential risk factors as predictors of CMDs among jockeys, including burnout, career satisfaction, and the current contemplation of retirement. Screening tools for the risk factors demonstrated may, therefore, provide useful in the early identification of CMDs among jockeys. The development of jockey-specific assessment tools, education programmes, and interventions may help better understand and support the mental health of jockeys.

Implementation and assessment of a pilot module on billing for pharmacist-provided healthcare services in a doctor of pharmacy program

BACKGROUND AND PURPOSE

To describe the implementation and assessment of a pilot module on billing to inform future comprehensive curricular integration of billing for pharmacist-provided healthcare services.

EDUCATIONAL ACTIVITY AND SETTING

A module (two-hour didactic session and two-hour lab), developed by a faculty member and pharmacy billing specialist, was piloted to teach second-year pharmacy students how to bill the medical insurance benefit for provided services. Web-based pre- and post-surveys and performance on knowledge assessment questions were used to evaluate the pilot module.

FINDINGS

Students' perceptions of their abilities and knowledge to provide and bill for healthcare services improved as a result of participation in the pilot module.

SUMMARY

This pilot module on billing was successful in improving students' knowledge and perceptions of abilities to provide and bill for healthcare services. However, further efforts to integrate billing education within individual institutions and the entire pharmacy academy will help better prepare pharmacists to provide sustainable clinical services.

Direct patient care services by community and ambulatory care pharmacists in Idaho

Background Pharmacists are one of the most accessible but unoptimized healthcare providers in the community. They are medication experts and have authority to independently prescribe in Idaho. Through the provision of direct patient care services (i.e., those distinct from traditional prescription dispensing functions), pharmacists have a greater opportunity to impact chronic disease prevention and management across the state. This can be done by filling gaps in community care (e.g., prescribing recommended therapy) and directly managing and preventing chronic diseases. However, current practices surrounding pharmacist-provided direct patient care services are unknown. Objective To characterize direct patient care services provided by Idaho community and ambulatory care pharmacists as well as to assess individual pharmacists' and their work sites' capacity and barriers in providing and expanding services. Setting Community and ambulatory care pharmacists' work sites in Idaho. Method We administered a cross-sectional, electronic, 20-min survey to Idaho community and ambulatory care pharmacists. Main outcome measure The survey focused on collecting data on current practices, capacity, and barriers related to pharmacist-provided direct patient care services. Results The survey was completed by 280 eligible community and ambulatory care pharmacists with the majority of respondents (n = 250) offering pharmacist-provided direct patient care services. Pharmacists most often prescribed therapy for tobacco cessation (nicotine replacement, bupropion, varenicline), naloxone, and devices for patients with diabetes. Top barriers to individual pharmacists providing services were dispensing load and workload while top barriers to work sites (e.g., environment) were reimbursement/billing, number of available staff, and workflow. Conclusion Idaho community and ambulatory care pharmacists currently offer direct patient care services to patients across the state, but face barriers in providing and increasing services offered.

A-28 Updated Baselines Show Improvement, Even When Athletes Sustain A Concussion Between Assessments

Objective

To explore change across repeated baseline assessments using raw scores and percentile scores, for athletes sustaining and not sustaining a concussion between baselines.

Method

Athletes (12–23 years) completed two valid, baseline neurocognitive test sessions using ImPACT. Participants were divided into independent groups based on having sustained a concussion between annual baselines (CONCUSSION; N = 269) or no concussion (NO CONCUSSION; N = 270) between baselines. Raw change scores were calculated between the first and follow-up baseline for both groups by subtracting the first baseline score from the updated baseline score on the four ImPACT composite scores. Age- and gender-based percentile scores were then applied for all participants, and percentile change scores were calculated in the same manner. Raw change scores and percentile change scores between groups were compared using 4 ANOVAs with a Bonferroni-corrected p-value of (p &lt; .0125).

Results

Using raw scores ANOVAs revealed that athletes in the CONCUSSION group showed significantly greater improvement on follow-up testing than athletes in the NO CONCUSSION group on Verbal Memory (p &lt; .001) and Visual Motor Speed (p = .001), but not on Visual Memory (p = .41) and Reaction Time (p = .04). Using percentile ranks, ANOVAs revealed significantly greater improvement in CONCUSSION group on Verbal Memory (p &lt; .001), but not on Visual Memory (p = .34), Visual Motor Speed (p = .03), or Reaction Time (p = .014).

Conclusions

Athletes sustaining a concussion between annual baseline assessments show increases on Verbal Memory and Visual Motor Speed follow-up testing when using raw composite scores, but only on Verbal Memory when using age- and gender-based percentile ranks.

Community Pharmacy Enhanced Dispensing Model to Improve Medication Access for Rural Patients Living with HIV

Objective:

To demonstrate the utility of a community pharmacy-centric workflow for improving access to medications for high-risk, rural persons living with HIV (PLWH) in partnership with a Federally Qualified Health Center (FQHC).

Setting:

University-sponsored independent community pharmacy and rural FQHC providing care to PLWH.

Practice Description:

Patient-centered Pharmacy Program is a service designed to improve access to HIV medications for PLWH in rural Idaho. The service is delivered in partnership with a 340B-covered entity (FQHC).

Practice innovation:

The workflow for the service in the community pharmacy is described in detail, including time assessments and descriptions of tools and forms developed for rollout.

Evaluation:

Quality improvement initiatives over three years are described.

Results:

This service ensures medication access for rural PLWH and is sustainable for the community pharmacy. Expansion of services is feasible for the future.

Conclusion:

This partnership may be one that could be implemented at other rural, independent community pharmacies seeking to have outreach to rural patients with chronic medication needs.

Exposure to Serial Post-Concussion Neurocognitive Testing Does not Affect Future “Updated” Baseline Neurocognitive Performance in Adolescent Athletes

Purpose

We investigated a dose response for serial post-concussion neurocognitive testing exposure on updated post-concussion baseline testing performance.

Methods

Athletes (13-18 yrs) that completed two, valid baseline neurocognitive testing (ImPACT) sessions approximately 1-3 years apart participated in this study. A sub-sample of athletes that sustained a SRC between baseline sessions were categorized into dose-response groups based on the number of serial, post-concussion neurocognitive tests completed following SRC: ONE (n=76), TWO (n=99), and THREE OR MORE (n=111). Athletes that did not sustain a SRC comprised the ZERO group (n=289). Change scores between the first to the second baseline were calculated for the ImPACT Composite and Symptom Scores and compared between the dose-response groups and controls with 5 ANOVAs, with a Bonferroni-corrected p-value of (p<.01). Baseline testing was administered using ImPACT stimuli within the “Baseline” administration, and all post-concussion ImPACT testing was administered using alternate-form associated with that specific post-injury assessment (Post-Injury1, Post-Injury2, etc).

Results

ANOVAs revealed no effect of number of post-concussion assessments (0, 1, 2, or 3+) on magnitude of the change between first and final baselines, for Verbal Memory (p=.08), Visual Memory (p=.96), Visual Motor Speed (p=.47), Reaction Time (p=.91), or Total Symptom Scores (p=.86).

Conclusion

Repeated exposure to neurocognitive testing has revealed improvements in Visual Motor Speed among normal controls, across test-retest intervals of 1-month, 1-year, and 2-years. However, in this study, exposure to post-concussion, serial neurocognitive testing had no effect on future performance on post-concussion baseline neurocognitive testing.

Vaginoscopy Against Standard Treatment: a randomised controlled trial

OBJECTIVE

To evaluate whether vaginoscopy or standard hysteroscopy was more successful in the outpatient setting.

DESIGN

Randomised controlled multicentre trial.

SETTING

Outpatient hysteroscopy clinics at two UK hospitals.

POPULATION

1597 women aged 16 or older undergoing an outpatient hysteroscopy.

METHODS

Women were allocated to vaginoscopy or standard hysteroscopy using third party randomisation stratified by menopausal status with no blinding of participants or clinicians.

MAIN OUTCOME MEASURES

The primary outcome was 'success', a composite endpoint defined as: a complete procedure, no complications, a level of pain acceptable to the patient, and no sign of genitourinary tract infection 2 weeks after the procedure.

RESULTS

Vaginoscopy was significantly more successful than standard hysteroscopy [647/726 (89%) versus 621/734 (85%), respectively; relative risk (RR) 1.05, 95% CI 1.01-1.10; P = 0.01]. The median time taken to complete vaginoscopy was 2 minutes compared with 3 minutes for standard hysteroscopy (P < 0.001). The mean pain score was 42.7 for vaginoscopy, which was significantly less than standard hysteroscopy 46.4 (P = 0.02). Operative complications occurred in five women receiving vaginoscopy and 19 women receiving standard hysteroscopy (RR 0.26, 95% CI 0.10-0.69).

CONCLUSIONS

Vaginoscopy is quicker to perform, less painful, and more successful than standard hysteroscopy and therefore should be considered the technique of choice for outpatient hysteroscopy.

TWEETABLE ABSTRACT

Vaginoscopy is quicker to perform, less painful, and more successful than standard hysteroscopy.

European recommendations and quality assurance for cytogenomic analysis of haematological neoplasms

Cytogenomic investigations of haematological neoplasms, including chromosome banding analysis, fluorescence in situ hybridisation (FISH) and microarray analyses have become increasingly important in the clinical management of patients with haematological neoplasms. The widespread implementation of these techniques in genetic diagnostics has highlighted the need for guidance on the essential criteria to follow when providing cytogenomic testing, regardless of choice of methodology. These recommendations provide an updated, practical and easily available document that will assist laboratories in the choice of testing and methodology enabling them to operate within acceptable standards and maintain a quality service.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Complex history of dog (Canis familiaris) origins and translocations in the Pacific revealed by ancient mitogenomes

Archaeological evidence suggests that dogs were introduced to the islands of Oceania via Island Southeast Asia around 3,300 years ago, and reached the eastern islands of Polynesia by the fourteenth century AD. This dispersal is intimately tied to human expansion, but the involvement of dogs in Pacific migrations is not well understood. Our analyses of seven new complete ancient mitogenomes and five partial mtDNA sequences from archaeological dog specimens from Mainland and Island Southeast Asia and the Pacific suggests at least three dog dispersal events into the region, in addition to the introduction of dingoes to Australia. We see an early introduction of dogs to Island Southeast Asia, which does not appear to extend into the islands of Oceania. A shared haplogroup identified between Iron Age Taiwanese dogs, terminal-Lapita and post-Lapita dogs suggests that at least one dog lineage was introduced to Near Oceania by or as the result of interactions with Austronesian language speakers associated with the Lapita Cultural Complex. We did not find any evidence that these dogs were successfully transported beyond New Guinea. Finally, we identify a widespread dog clade found across the Pacific, including the islands of Polynesia, which likely suggests a post-Lapita dog introduction from southern Island Southeast Asia.

Psychological Factors Influence the Success of Coronary Artery Surgery

Thirty-six patients with angina were investigated by treadmill exercise testing and coronary angiography prior to coronary artery surgery. Severity of angina was judged by interview and self-assessment visual analogue scale and all patients were psychiatrically assessed. Further physical and psychiatric assessments were made at 3 and 6 months postoperatively. Eleven patients (31%) had significant psychiatric morbidity preoperatively and these had worse symptom scores and exercise tolerance compared with non-psychiatric cases, despite equivalent coronary angiographic findings and left ventricular function. Postoperatively, exercise tolerance improved equally in both groups but psychiatric cases remained significantly more symptomatic. Psychiatric morbidity remained unchanged throughout the study.

We conclude that almost one third of patients with severe angina have psychiatric morbidity which is associated with a poor symptomatic response to coronary artery surgery, despite objective improvement in exercise tolerance. Ways of improving the symptomatic response to surgery in patients with coexisting psychiatric morbidity should be studied.

Effects of a dynamic core stability program on the biomechanics of cutting maneuvers: A randomized controlled trial

Deficits in trunk control predict ACL injuries which frequently occur during high-risk activities such as cutting. However, no existing trunk control/core stability program has been found to positively affect trunk kinematics during cutting activities. This study investigated the effectiveness of a 6-week dynamic core stability program (DCS) on the biomechanics of anticipated and unanticipated side and crossover cutting maneuvers. Thirty-one male, varsity footballers participated in this randomized controlled trial. Three-dimensional trunk and lower limb biomechanics were captured in a motion analysis laboratory during the weight acceptance phase of anticipated and unanticipated side and crossover cutting maneuvers at baseline and 6-week follow-up. The DCS group performed a DCS program three times weekly for 6 weeks in a university rehabilitation room. Both the DCS and control groups concurrently completed their regular practice and match play. Statistical parametric mapping and repeated measures analysis of variance were used to determine any group (DCS vs control) by time (pre vs post) interactions. The DCS resulted in greater internal hip extensor (P=.017, η² =0.079), smaller internal knee valgus (P=.026, η² =0.076), and smaller internal knee external rotator moments (P=.041, η² =0.066) during anticipated side cutting compared with the control group. It also led to reduced posterior ground reaction forces for all cutting activities (P=.015-.030, η² =0.074-0.105). A 6-week DCS program did not affect trunk kinematics, but it did reduce a small number of biomechanical risk factors for ACL injury, predominantly during anticipated side cutting. A DCS program could play a role in multimodal ACL injury prevention programs.

Electrospun API-loaded mixed matrix membranes for controlled release

The development of biocompatible membrane materials capable of delivering active pharmaceutical ingredients (APIs) over a fixed time period offers significant advantages to the pharmaceutical and biomedical industries alike.

Compassionate access anti-tumour necrosis factor-α therapy for ulcerative colitis in Australia: the benefits to patients

BACKGROUND

The efficacy of infliximab has been demonstrated in patients with both acute severe and moderate-severe ulcerative colitis (UC). However, there is a need for 'real-life data' to ensure that conclusions from trial settings are applicable in usual care. We therefore examined the national experience of anti-tumour necrosis factor-α (TNF-α) therapy in UC.

METHODS

Case notes review of patients with UC who had received compassionate access (CA) anti-TNF-α therapy from prospectively maintained inflammatory bowel disease databases of six Australian adult teaching hospitals.

RESULTS

Patients either received drug for acute severe UC (ASUC) failing steroids (n = 29) or for medically refractory UC (MRUC) (n = 35). In ASUC, the treating physicians judged that anti-TNF-α therapy was successful in 20/29 patients (69%); in these cases, anti-TNF-α was able to be discontinued (after 1-3 infusions in 19/20 responders) as clinical remission was achieved. Consistent with this perceived benefit, only 7/29 (24%) subsequently underwent colectomy during a median follow up of 12 months (interquartile range (IQR) 5-16). Eight of the 35 patients with MRUC (23%) required colectomy during a median follow up of 28 months (IQR 11-43). The majority of these patients (20/35 or 57%) had anti-TNF-α therapy for ≥4 months, whereas, 27/29 (93%) of ASUC patients had CA for ≤3 months.

CONCLUSIONS

These data show an excellent overall benefit for anti-TNF-α therapy in both ASUC and MRUC. In particular, only short-duration anti-TNF-α was required in ASUC. These real-life data thus support the clinical trial data and should lead to broader use of this therapy in UC.

Epidemiology of Injury in Gaelic Handball

The initial step in developing injury prevention strategies is to establish the epidemiology of injury. However there has been no published research on injury in Gaelic handball. This study describes the epidemiology of injury in 75 Gaelic handball players utilising a retrospective questionnaire. 88% of participants reported one or more injuries. Injuries to the upper limb were prevalent (52.9%), followed by the lower limb (30.3%). The shoulder (17.6%), finger (10.5%) and ankle (9.8%) were the primary sites of injury. Injuries occurred most frequently in December (9.7%), January (9.7%), February (9.7%) and November (8.7%). Injuries predominantly occurred during games (82.4%). Injuries were primarily severe (54.7%), with 14.6% of participants admitted to hospital due to injury. Given that this is the only study on Gaelic handball to date, prospective epidemiological studies and further research on injury prevention strategies are necessary.

Impact of delirium and suture-less securement on accidental vascular catheter removal in the ICU

The objectives were to describe the incidence of accidental vascular catheter removal (AVCR) in an Australian Intensive Care Unit (ICU) and evaluate whether the fixation method or patient delirium increased the risk of AVCR. This prospective observational study was based in a tertiary level ICU between April 2011 and October 2012. All vascular catheters were secured either by sutures or by a suture-less securement device (STATLOCK(™), Bard Medical, Covington, GA, USA) as per the treating clinician. Data were obtained from bedside nursing staff, with daily screening for delirium completed by the ICU medical team using the Confusion Assessment Method-ICU. 2361 patients were admitted during this period with 1032 patients screened and data available for 322 patients (452 vascular catheters). AVCR occurred in 15 patients (16 vascular catheters) (5.0%) with an incidence of AVCR of 2.77 per 100 catheter-days. Delirious patients were 13-fold more likely to have an AVCR event (odds ratio=13.3; 95% confidence interval 4.36, 40.52; P <0.0001). There was a non-significant trend to an increase in AVCR when using the suture-less securement device (odds ratio=2.6; 95% confidence interval 0.87, 7.8; P=0.09) but delirious patients were no more likely to have an AVCR episode when a suture-less securement device was used (P=0.95). In this study the use of suture-less securement did not seem to increase the risk of AVCR. However, there was a non-significant trend towards increased AVCR when using suture-less securement devices, which may reflect a ß error.

A multicentre programme of clinical and public health research in support of the National Suicide Prevention Strategy for England

Objectives

To carry out a programme of linked research studies aimed at improving the management of self-harm, reducing the incidence of suicide and providing reliable data to evaluate the impact of theNational Suicide Prevention Strategy for England(2002).

Methods

There were four research streams: (1) we studied inquest records from 12 coroners and Ministry of Justice data to assess the accuracy of official suicide statistics; (2) we used Office for National Statistics mortality statistics, data from the Multicentre Study of Self-harm in England, national liver unit data, prescription data and patient interviews to assess (a) the impact of paracetamol (acetaminophen) pack size restrictions (1998), (b) the impact of withdrawal of co-proxamol in 2007 and (c) the relative toxicity in overdose of commonly used antidepressants; (3) we carried out 3-month audits of self-harm management in 32 hospitals to investigate variations between hospitals and the impact of management on repeat self-harm; and (4) we developed and piloted letter-based contact interventions aimed at reducing self-harm.

Key findings

(1) Between 1990 and 2005, the proportion of researcher-defined suicides given a verdict of suicide by the 12 coroners studied decreased by almost 7%, largely because of the increased use of misadventure/accident verdicts for deaths thought, on clinical review, to be suicides. Use of narrative verdicts increased markedly. Coroners who gave more narrative verdicts also gave fewer suicide verdicts, and geographical variations in the use of narrative verdicts appeared to distort reliable assessment of small-area differences in suicide rates. 2(a) UK legislation to reduce pack sizes of paracetamol was followed by a 43% reduction in number of deaths and a 61% reduction in registrations for liver transplantation over the next 11 years. Paracetamol overdoses were often impulsive and some were influenced by media (including the internet); sales outlets appeared mostly to be adhering to sales guidance. Smaller pack sizes of paracetamol for sale in Ireland compared with England did not result in a smaller number of tablets being taken in overdose. There was no clear evidence of an effect of the legislation on prescribing of non-steroidal anti-inflammatory drugs, nor on resulting gastrointestinal bleeds. 2(b) Withdrawal of co-proxamol from use in the UK resulted in approximately 600 fewer deaths than predicted between 2005 and 2010 based on previous trends, with no evidence of substitution by poisoning with other analgesics. 2(c) Of the tricyclic antidepressants, dosulepin and doxepin had the greatest toxicity. Citalopram was more toxic than other selective serotonin reuptake inhibitors. (3) There was marked variation between hospitals in the management of self-harm; effects of this variation on patient outcomes were unclear, although psychosocial assessment may have been associated with reduced repetition. Levels of specialist assessment remained static between 2001–2 and 2010–11, but service quality appeared to improve. (4) Findings of two pilot randomised controlled trials suggested that, although it would be feasible to scale up these interventions to full trials, these interventions might have low generalisability and be of limited benefit to patients.

Conclusion

Within the context of the strengths and limitations of the individual studies, this research programme has made significant additions to the evidence base related to suicide and self-harm prevention in the UK.

Study registration

A pilot study of a contact and information based intervention to reduce repeat self-harm; ISRCTN65171515.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.