PRO-FIT-CARE study: the feasibility assessment of a pilot online exercise intervention for persons living with obesity and female infertility

Introduction

Moderate-to-high physical activity participation is associated with a reduced risk of infertility. Yet, exercise interventions that target cardiorespiratory fitness, independent of weight loss, are lacking in obesity and female fertility research.

Purpose

The primary objective of the PRO-FIT-CARE (PROmoting FITness for CArdiometabolic & REproductive Health) study was to assess the feasibility of a moderate-to-high-intensity online exercise program for persons with obesity and female infertility.

Methods

Feasibility, safety, acceptability, and efficacy were assessed by examining: (1) recruitment and consent rate, (2) study retention, (3) adverse events, (4) participant satisfaction, (5) adherence, and (6) cardiorespiratory fitness.

Results

Eleven of thirty-two women contacted agreed to participate in the program (34.4% consent rate). Eight participants (72.7%) completed the study. One musculoskeletal injury was reported. There was a 30% adherence rate based on prescribed exercise intensity (60%-80% of heart rate maximum). One of eleven participants attended 80% of the exercise intervention. Based on a weekly satisfaction survey, the program had an overall high level of satisfaction. Compared to sex and age normative data, post-intervention, two of eight participants improved their cardiorespiratory fitness percentile rank.

Conclusion

The study highlights challenges with adherence to an online exercise program. While the program was safe and participants reported high levels of program satisfaction, approaches to improve adherence must be incorporated.

Soft Skills: The Work of Communication and Persuasion Among Nurse Navigators in Hospital at Home Programs

OBJECTIVE

To assess the role of soft skills in the work of Hospital at Home (HaH) nurse navigators.

BACKGROUND

In HaH programs that employ them, nurse navigators are often responsible for identifying, assessing, referring, and educating potential HaH patients. The experiences of these navigators have gone understudied.

METHODS

Researchers conducted semistructured interviews and observations with nurse navigators (n = 7) who collectively cover 14 North Carolina-based HaH sites. Navigators were asked to keep diaries of responses to directed questions.

RESULTS

In their capacity as navigators, interviewees said they served several roles: intermediaries between hospital and HaH staff, interpreters of clinical knowledge for patients, and champions of, and educators for, the home-based program. The navigators noted that the interpersonal soft skills of building rapport, clear communication, and gentle persuasion were of the utmost importance in this work.

CONCLUSIONS

The job descriptions of nurse navigators in HaH programs should fully reflect the breadth of their responsibilities, including time performing soft skilled labor. Also, training for these roles should include techniques to develop and refine these skills.

A scoping review of person-centred care strategies used in diagnostic Nuclear Medicine

INTRODUCTION

Person-centred care (PCC) emphasises the need for the health care professional to prioritise individual patient needs, thereby fostering a collaborative and emphatic environment that empowers patients to actively participate in their own care. This article will explore the purpose of PCC in Nuclear Medicine (NM), while discussing strategies that may be used to implement PCC during diagnostic NM examinations performed on adult patients.

METHODS

The scoping review was conducted in accordance with the Joanna Briggs Institute methodology. The search was performed on PubMed, Embase and Cinhal in June 2023 and included studies in English, Spanish, Portuguese and Italian. The research equation combined keywords and Medical Subject Heading terms (MeSH) related to person-centred care (PCC), for all types of nuclear medicine diagnostic examinations performed. Three independent review authors screened all abstracts and titles, and all eligible full-text publications were included in this scoping review.

RESULTS

Fifty-three articles, published between 1993 and 2022, met the inclusion criteria for this scoping review. Seven articles were published in 2015 while 56.6 % of all included studies were performed in Europe. Most studies (n = 39/53) focused on the patients only, with the identified patient benefits being: improve patient experience (67.9 %), increase patient comfort (13.2 %), increase patient knowledge (5.7 %), reduction of patient anxiety (9.4 %) and reduction of waiting/scan time (3.8 %).

CONCLUSION

The scoping review identified a lack of research investigating the use of person-centred care strategies in NM. Future research will focus on using an international survey to explore this topic in nuclear medicine departments overseas.

IMPLICATIONS FOR PRACTICE

By applying PCC principles, the NM professional can improve the patient care pathway and increase patient satisfaction, leading to enhanced clinical outcomes.

Emergency department presentations with suicide and self-harm ideation: a missed opportunity for intervention?

AIMS

Suicidal ideation constitutes a central element of most theories of suicide and is the defining facet separating suicide from other causes of death such as accidents. However, despite a high worldwide prevalence, most research has focused on suicidal behaviours, such as completed suicide and suicide attempts, while the greater proportion who experienced ideation, which frequently precedes suicidal behaviour, have received much less attention. This study aims to examine the characteristics of those presenting to EDs with suicidal ideation and quantify the associated risk of suicide and other causes of death.

METHODS

Retrospective cohort study was performed based on population-wide health administration data linked to data from the Northern Ireland Registry of Self-Harm and centrally held mortality records from April 2012 to December 2019. Mortality data, coded as suicide, all-external causes and all-cause mortality were analysed using Cox proportional hazards. Additional cause-specific analyses included accidental deaths, deaths from natural causes and drug and alcohol-related causes.

RESULTS

There were 1,662,118 individuals aged over 10 years, of whom 15,267 presented to the ED with ideation during the study period. Individuals with ideation had a 10-fold increased risk of death from suicide (hazard ratio [HR_adj] = 10.84, 95% confidence interval [CI] 9.18, 12.80) and from all-external causes (HR_adj = 10.65, 95% CI 9.66, 11.74) and a threefold risk of death from all-causes (HR_adj = 3.01, 95% CI 2.84, 3.20). Further cause-specific analyses indicated that risk of accidental death (HR_adj = 8.24, 95% CI 6.29, 10.81), drug-related (HR_adj = 15.17, 95% CI 11.36, 20.26) and alcohol-related (HR_adj = 10.57, 95% CI 9.07, 12.31) has also significantly increased. There were few socio-demographic and economic characteristics that would identify which of these patients are most at risk of suicide or other causes of death.

CONCLUSIONS

Identifying people with suicidal ideation is recognized to be both important but difficult in practice; this study shows that presentations to EDs with self-harm or suicide ideation represent an important potential intervention point for this hard-to-reach vulnerable population. However, and unlike individuals presenting with self-harm, clinical guidelines for the management and recommended best practice and care of these individuals are lacking. Whilst suicide prevention may be the primary focus of interventions aimed at those experiencing self-harm and suicide ideation, death from other preventable causes, especially substance misuse, should also be a cause of concern.

Outcomes with Endovascular Treatment of Patients with M2 Segment MCA Occlusion in the Late Time Window

BACKGROUND AND PURPOSE

Randomized trials in the late window have demonstrated the efficacy and safety of endovascular thrombectomy in large-vessel occlusions. Patients with M2-segment MCA occlusions were excluded from these trials. We compared outcomes with endovascular thrombectomy in patients with M2-versus-M1 occlusions presenting 6-24 hours after symptom onset.

MATERIALS AND METHODS

Analyses were on pooled data from studies enrolling patients with stroke treated with endovascular thrombectomy 6-24 hours after symptom onset. We compared 90-day functional independence (mRS ≤ 2), mortality, symptomatic intracranial hemorrhage, and successful reperfusion (expanded TICI = 2b-3) between patients with M2 and M1 occlusions. The benefit of successful reperfusion was then assessed among patients with M2 occlusion.

RESULTS

Of 461 patients, 367 (79.6%) had M1 occlusions and 94 (20.4%) had M2 occlusions. Patients with M2 occlusions were older and had lower median baseline NIHSS scores. Patients with M2 occlusion were more likely to achieve 90-day functional independence than those with M1 occlusion (adjusted OR = 2.13; 95% CI, 1.25-3.65). There were no significant differences in the proportion of successful reperfusion (82.9% versus 81.1%) or mortality (11.2% versus 17.2%). Symptomatic intracranial hemorrhage risk was lower in patients with M2-versus-M1 occlusions (4.3% versus 12.2%, P = .03). Successful reperfusion was independently associated with functional independence among patients with M2 occlusions (adjusted OR = 2.84; 95% CI, 1.11-7.29).

CONCLUSIONS

In the late time window, patients with M2 occlusions treated with endovascular thrombectomy achieved better clinical outcomes, similar reperfusion, and lower symptomatic intracranial hemorrhage rates compared with patients with M1 occlusion. These results support the safety and benefit of endovascular thrombectomy in patients with M2 occlusions in the late window.

Evaluating Racial/Ethnic Differences in Care Escalation Among COVID-19 Patients in a Home-Based Hospital

The novel coronavirus disease 2019 (COVID-19) has infected over 414 million people worldwide with 5.8 million deaths, as of February 2022. Telemedicine-based interventions to expand healthcare systems' capacity and reduce infection risk have rapidly increased during the pandemic, despite concerns regarding equitable access. Atrium Health Hospital at Home (AH-HaH) is a home-based program that provides advanced, hospital-level medical care and monitoring for patients who would otherwise be hospitalized in a traditional setting. Our retrospective cohort study of positive COVID-19 patients who were admitted to AH-HaH aims to investigate whether the rate of care escalation from AH-HaH to traditional hospitalization differed based on patients' racial/ethnic backgrounds. Logistic regression was used to examine the association between care escalation within 14 days from index AH-HaH admission and race/ethnicity. We found approximately one in five patients receiving care for COVID-19 in AH-HaH required care escalation within 14 days. Odds of care escalation were not significantly different for Hispanic or non-Hispanic Blacks compared to non-Hispanic Whites. However, secondary analyses showed that both Hispanic and non-Hispanic Black patients were younger and with fewer comorbidities than non-Hispanic Whites. The study highlights the need for new care models to vigilantly monitor for disparities, so that timely and tailored adaptations can be implemented for vulnerable populations.

A qualitative analysis of radiography students' reflective essays regarding their experience of clinical placement during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic significantly impacted healthcare services and clinical placement for healthcare students. There is a paucity of qualitative research into radiography students' experiences of clinical placement during the pandemic.

METHOD

Students in stages three and four of a 4-year BSc Radiography degree in Ireland wrote reflective essays regarding their experience of clinical placement during the COVID-19 healthcare crisis. Permission was granted by 108 radiography students and recent graduates for their reflections to be analysed as part of this study. A thematic approach to data analysis was used, allowing themes to emerge from the reflective essays. Two researchers independently coded each reflective essay using the Braun and Clarke model.

RESULTS

Four themes were highlighted; 1) Challenges associated with undertaking clinical placement during the pandemic, such as reduced patient throughput and PPE-related communication barriers; 2) Benefits of clinical placement during the pandemic, in terms of personal and professional development and completing degree requirements to graduate without delay; 3) Emotional impact and 4) Supporting students in clinical practice. Students recognised their resilience and felt proud of their contribution during this healthcare crisis but feared transmitting COVID-19 to family. Educational and emotional support provided by tutors, clinical staff and the university was deemed essential by students during this placement.

CONCLUSIONS

Despite the pressure hospitals were under during the pandemic, students had positive clinical placement experiences and perceived these experiences to have contributed to their professional and personal growth.

IMPLICATIONS FOR PRACTICE

This study supports the argument for clinical placements to continue throughout healthcare crisis periods, albeit with additional learning and emotional support in place. Clinical placement experiences during the pandemic prompted a deep sense of pride amongst radiography students in their profession and contributed to the development of professional identity.

Nucleus of the solitary tract A2 neurons control feeding behaviors via projections to the paraventricular hypothalamus

Hindbrain NTS neurons are highly attuned to internal physiological and external environmental factors that contribute to the control of food intake but the relevant neural phenotypes and pathways remain elusive. Here, we investigated the role of NTS A2 neurons and their projections in the control of feeding behaviors. In male TH Cre rats, we first confirmed selective targeting of NTS A2 neurons and showed that chemogenetic stimulation of these neurons significantly suppressed dark cycle food intake, deprivation re-feed and high fat diet intake. Despite reducing intake, activation of NTS A2 neurons had no effect on food approach, anxiety-like behaviors, locomotor activity, blood glucose levels nor did it induce nausea/malaise, thus revealing a selective role for these neurons in the consummatory aspect of food intake control. Pathway-specific mapping and manipulation of NTS A2 neurons showed that these effects were mediated by NTS A2 neurons projecting to the paraventricular nucleus of the hypothalamus (PVH) because chemogenetic activation of these projections, but not projections to bed nucleus of the stria terminalis (BNST), reduced food intake. Cell-type specific analyses demonstrated that activation of NTS A2 neurons recruited both PVH oxytocin (OT)- and corticotropin-releasing factor (CRF)-expressing neurons, and plasma analyses showed increased plasma corticosterone following NTS A2 stimulation. While we also showed that chemogenetic inhibition of NTS A2 neurons attenuated the intake inhibitory effects of CCK, the specificity of transgene expression was low. Together, these findings showed that NTS A2 neurons are sufficient to control the consummatory aspects of feeding, regardless of energy status or food palatability and identified their projections to PVH, but not BNST, in food intake control.

Personalized Liquid Biopsy May Predict Relapse in Aggressive Endometrial Cancer

Introduction/Objective

High-grade endometrial cancer (EC) recurs in 50% of patients following surgery and first-line chemotherapy. There are no established blood-based biomarkers with sufficient specificity and sensitivity to monitor EC patients for residual disease and recurrence. The ability to detect and monitor EC currently relies on serial imaging based approaches. Liquid biopsies via blood-based tests for cell-free circulating tumor DNA (ctDNA) are becoming increasingly popular, but none have been FDA approved for EC and current approaches have not been validated in patients with uncommon tumor mutations. We hypothesized that personalized testing panels based on tumor-specific chromosomal rearrangements would allow ctDNA to be monitored and that ctDNA presence correlates with other clinical indicators of recurrence.

Methods/Case Report

Twelve patients with FIGO Stage I-IV and biopsy confirmed high-grade EC were prospectively enrolled and underwent primary tumor resection. DNA was isolated from tumor tissue and sequenced on Illumina NGS platforms [San Diego, CA]. BIMA algorithm and SVAtools identified junctions of somatic chromosomal rearrangements and 4-5 junctions were chosen per patient, based primarily on copy number/amplification level. Blood was collected before surgery, and longitudinally between 1 and 7 timepoints. Total cell-free DNA (cfDNA) was extracted from platelet poor plasma with the Qiagen CNA kit [Germany]. Personalized ctDNA qPCR Taqman [IDT, Coralville, Iowa] probe assays were developed with pooled pre-amplification to maximize sensitivity for the multiple junctions and normalized to input.

Results (if a Case Study enter NA)

ctDNA was detected in 9/12 and 5/12 cases pre- and post-surgery, respectively. The detection or absence of measurable ctDNA following surgery showed high correlation with cancer recurrence as detected by CT or MRI scans.

Conclusion

The detection of ctDNA in high-grade EC using personalized junction panels shows promise for a blood-based assay that may help physicians better monitor and treat patients.

25 EVALUATION OF PATIENTS PRESENTING WITH TIA IN THE AMAU AND TIA FAST ASSESSMENT CLINICS - ARE WE MEETING ESO GUIDELINES?

Background

The European Stroke Organisation published guidelines on the management of Transient Ischaemic Attack (TIA) in 2021. Specialist review of suspected TIA is recommended within 24-hours of symptom onset in a TIA clinic. They suggest using CT or MR angiogram for additional confirmation of large artery stenosis of >50%. They advise against the use of prediction tools alone e.g. ABCD2 score when identifying high-risk patients. Dual antiplatelet therapy is recommended short-term in high risk, non cardio-embolic TIA patients. This audit evaluates if these guidelines are being followed in our institution.

Methods

We evaluated all patients attending the TIA clinic and the Acute Medical Assessment Unit (AMAU) with suspected TIA over a three-week period in 2021 in a single tertiary referral centre. Retrospective data was collected based on chart review.

Results

Twenty patients underwent review in the TIA clinic and eight in the AMAU with suspected TIA in the chosen time period. One patient (3.5%) was seen within 24 hours from symptom onset, 2 were seen within 24-36 hours (7.1%), 4 patients (14.2%) were seen within 36-72 hours, 21 patients (75%) were seen >72 hours after symptom onset. In all patients who had a doppler US showing >50% carotid stenosis, a CT angiogram was performed. ABCD2 scores were recorded but used in combination with clinical judgment. All patients with high-risk, non-cardioembolic TIA received early, short-term dual antiplatelet therapy.

Conclusion

The diagnostic methods and treatment strategies in place for patients attending the TIA clinic or AMAU with TIA were in keeping with the recently published ESO guidelines. However, there was a time delay from symptom onset to time of review in many patients. Further studies are indicated to identify the potential mechanisms behind these delays. Interventions to ensure that we are meeting this ‘time-to-review’ target in patients could be implemented, ensuring high quality, evidence-based care.

Evaluating Palin Stammering Therapy for School Children (Palin STSC 8–14): protocol for a feasibility randomised controlled trial comparing Palin STSC(8–14) with usual treatment

Background

Having a stammer can have a significant effect on a child’s social, emotional and educational development. With approximately 66,000 children in the UK having a stammer, there is a need to establish an adequate evidence base to inform clinical practice. We describe a feasibility trial to explore the effectiveness of a new therapy programme for children aged 8–14: Palin Stammering Therapy for School Children (Palin STSC(8–14)). Preliminary data from the Michael Palin Centre, where the programme was developed, indicate that Palin STSC(8–14) is effective in reducing stammering frequency and impact for children, with beneficial effects for parents too. We will investigate the feasibility of the methods required for a definitive randomised controlled trial to investigate the application of this therapy by NHS speech and language therapists (SLTs), compared with ‘treatment as usual’ (TAU), beyond the specialist context in which it was developed.

Methods

This is a two-arm feasibility cluster-randomised controlled trial of Palin STSC(8–14) with TAU control arm, and randomisation at the level of the SLT. Quantitative and qualitative data will be collected to examine the following: the recruitment and retention of therapists and families, the acceptability of the research processes and the therapeutic intervention and the appropriateness of the therapy outcome measures. Assessments will be completed by children and parents at baseline and 6 months later, including measures of stammering severity; the impact of child’s stammering on both children and parents; child temperament, behaviour and peer relations, anxiety; quality of life; and economic outcomes. There will also be a qualitative process evaluation, including interviews with parents, children, SLTs and SLT managers to explore the acceptability of both the research and therapy methods. Treatment fidelity will be examined through analysis of therapy session records and recordings.

Discussion

The findings of this feasibility trial will inform the decision as to whether to progress to a full-scale randomised controlled trial to explore the effectiveness of Palin STSC(8–14) when compared to Treatment as Usual in NHS SLT services. There is a strong need for an evidence-based intervention for school age children who stammer.

Trial registration

ISRCTN. ISRCTN17058884. Registered on 18 December 2019.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Evolving strategy for an evolving virus: development of real-time PCR assays for detecting all SARS-CoV-2 variants of concern

In order to detect the SARS-CoV-2 variants of concern (VOCs), five real-time reverse transcriptase PCR (rRT-PCR) assays were designed to target the critical discriminatory mutations responsible for the following amino acid changes in the spike protein: two Δ69–70 + N501Y + E gene triplexes (one optimized for Alpha [B.1.1.7] and one optimized for Omicron [B.1.1.529]), a K417N + 242–244 wild-type duplex, a K417T + E484K duplex, and a L452R + P681 + E484Q triplex. Depending on the assay, sensitivity was 98.97–100% for the detection of known VOC-positive samples, specificity was 97.2–100%, limit of detection was 2–116 copies/reaction, intra- and interassay variability was less than 5%, and no cross-reactivity with common respiratory pathogens was observed with any assay. A subset of rRT-PCR- positive VOC samples were further characterized by genome sequencing. A comparison of the lineage designation by the VOC rRT-PCR assays and genome sequencing for the detection of the Alpha, Beta, Gamma, Delta and Omicron variants showed clinical sensitivities of 99.97–100 %, clinical specificities of 99.6–100 %, positive predictive values of 99.8–100%, and negative predictive values of 99.98–100 %. We have implemented these rRT-PCR assays targeting discriminatory single nucleotide polymorphisms for ongoing VOC screening of SARS-CoV-2 positive samples for surveillance purposes. This has proven extremely useful in providing close to real-time molecular surveillance to monitor the emergence of Alpha, the replacement of Alpha by Delta, and the replacement of Delta by Omicron. While the design, validation and implementation of the variant specific PCR targets is an ever-evolving approach, we find the turn-around-time, high throughput and sensitivity to be a useful complementary approach for SARS-CoV-2 genome sequencing for surveillance purposes in the province of Alberta, Canada.

Paramedics' Perceptions of Their Role in End of Life Care

Aims Critical decisions made in the field by paramedics influence where patients die if their end of life (EOL) wishes are upheld and how appropriately health-care resources are used. The aim was to gauge perceptions as to the current and future role of paramedics in EOL care. Methods A qualitative approach collated data from two focus group interviews (group 1 n=7, group 2 n=8). Focus groups were audio recorded, transcribed, and analysed using Attride-Stirling's framework for thematic network analysis. Results The global theme 'Paramedics' Perceptions of Their Role in End of Life Care' emerged from five organising themes: 1. education and training; 2. current clinical practice guidelines; 3. communication; 4. environment and 5. staff support. Poor communication between those involved in patient care, lack of support from current clinical practice guidelines, limited training in managing EOL scenarios and inadequate staff supports were highlighted by participants. The clinical environment also effected how challenging practitioners found the call. Conclusion The pathway to improving EOL care must include an emphasis on improvements in practitioner education and training, enhanced communication between all those involved in a patient's care and offering non didactic practice guidelines that are practitioner driven and patient-focused. It must also include increased psychological supports for paramedics dealing with EOL patients.

Selective Androgen Receptor Modulator Induced Hepatotoxicity

Selective androgen receptor modulators (SARMs) have been developed as an alternate to traditional anabolic steroids due to their favorable effects on the bones and muscles without androgenic side effects. They are very popular among athletes and bodybuilders and are available online or over the counter. The FDA has warned of their side effects including liver injury. Here we present the case of a 29-year-old patient who presented with jaundice, fatigue, and elevated liver function tests after starting SARM supplements. His symptoms improved and eventually resolved with stopping the supplements. The purpose of this case report is to raise awareness and educate clinicians of the potential side effect of hepatotoxicity of these supplements that can help in its early identification and management.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

Investigating the association between COVID-19 vaccination and care home outbreak frequency and duration

OBJECTIVES

At the end of 2020, many countries commenced a vaccination programme against SARS-CoV-2. Public health authorities aim to prevent and interrupt outbreaks of infectious disease in social care settings. We aimed to investigate the association between the introduction of the vaccination programme and the frequency and duration of COVID-19 outbreaks in Northern Ireland (NI).

STUDY DESIGN

We undertook an ecological study using routinely available national data.

METHODS

We used Poisson regression to measure the relationship between the number of RT-PCR confirmed COVID-19 outbreaks in care homes, and as a measure of community COVID-19 prevalence, the Office for National Statistics COVID-19 Infection Survey estimated the number of people testing positive for COVID-19 in NI. We estimated the change in this relationship and estimated the expected number of care home outbreaks in the absence of the vaccination programme. A Cox proportional hazards model estimated the hazard ratio of a confirmed COVID-19 care home outbreak closure.

RESULTS

Care home outbreaks reduced by two-thirds compared to expected following the introduction of the vaccination programme, from a projected 1625 COVID-19 outbreaks (95% prediction interval 1553-1694) between 7 December 2020 and 28 October 2021 to an observed 501. We estimated an adjusted hazard ratio of 2.53 of the outbreak closure assuming a 21-day lag for immunity.

CONCLUSIONS

These findings describe the association of the vaccination with a reduction in outbreak frequency and duration across NI care homes. This indicates probable reduced harm and disruption from COVID-19 in social care settings following vaccination. Future research using individual level data from care home residents will be needed to investigate the effectiveness of the vaccines and the duration of their effects.

209 NEURO-MEDICAL COMPLICATIONS OF STROKE—TRENDS OVER THE DECADES IN AN ACUTE STROKE UNIT

Background

Neuro-medical complications post-stroke are common and often serious [1]. We first described complications in our stroke cohort in 1998 and sought to assess whether the severity and the nature of neuro-medical complications may have changed over time due to changes in presentation and the processes of care [2].

Methods

Analysis of stroke service database, which captures all neuro-medical complications as part of its portal for the Irish National Audit of Stroke (INAS), was completed. The frequency of each of the 19 complications was expressed as the percentage of patients that developed each complication over a certain year and over 5 years. Historical comparison was made with dataset from 1998, which captured six complications.

Results

Data on 1,283 patients presenting over 5 years between 2015–2019 was collected. The median age of all patients was 71 years (Range 21–101). In all, 19 different post-stroke complications were recorded; 48% (n = 622) had post-stroke pain, while 23.85% (n = 306) had cognitive decline. Data on 100 patients from 1998 was compared for a number of common metrics including; 21.82% (n = 275) of patients developed an LRTI in the 2015–2019 cohort compared with 14%(n = 14) in the 1998 cohort (p = 0.09) while 16.29% (n = 209) of patients developed a swallow disorder compared to 21% (n = 21) in 1998 (p = 0.22).

Conclusion

There are high levels of neuro-medical complications in stroke patients. Twenty years has seen extensive investment in hyperacute stroke care yet post-acute care complications did not appear to reduce significantly between this time, albeit with low numbers. Direction of future funding may consider the full spectrum of stroke care.

241 IMPLEMENTATION OF AN INTRACEREBRAL CEREBRAL HAEMORRHAGE CARE BUNDLE

Background

Mortality for Intracerebral haemorrhage (ICH) is 31% (Irish National Audit Stroke, 2019). An ICH care bundle focusing on acute anticoagulation reversal, blood pressure lowering, and a neurosurgical care pathway was associated with improved survival. Translating evidence-based medicine into clinical practice is challenging. The aim of this study was to determine feasibility and outcomes of implementation of a care bundle.

Methods

An ICH care bundle was developed using an iterative process involving expert stakeholder review of the evidence-based literature. A pre-and-post quasi-experimental research design was employed to evaluate this intervention. Baseline data were collected before implementation (January 2016-June 2018). Implementation took place in a staged manner in a single university teaching hospital with multiple ‘Plan Do Study Act cycles’ (June 2018 to January 2021). Data on compliance, process measures and outcomes were collected.

Results

Systolic blood pressure (first 24-hours) and anticoagulant reversal were significantly better controlled post-implementation (χ2 (1, N = 91) = 5.34, P = 0.02), (χ2 (1, N = 25) = 5.85, P = 0.016), respectively. DNAR orders were significantly lower in the post-implementation group (χ2 (1, N = 25) = 5.85, P = 0.029). However, ‘Do Not Actively Resuscitate’ status did not significantly differ when accounting for low GCS as a surrogate measure for poor prognosis (χ2 (1, N = 34) = 0.00, P = 0.966). Modified Rankin Scale on discharge did not differ significantly pre-and-post-implementation (z = −0.075, P = 0.94). A greater proportion of patients survived in the post-implementation group; however, this was not statistically significant (χ2 (1, N = 133) = 0.77, P = 0.38). Length of stay significantly increased post implementation.

Conclusion

An ICH care bundle was developed based on expert stakeholder feedback. The feasibility of implementing this bundle of care was demonstrated in a real-world clinical practice setting. A cluster-randomized trial or a large registry study is the next step to evaluate the overall impact of this care bundle on patient outcomes.

Acute arterial events across all vascular territories in the FOURIER trial

Background

In the FOURIER (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Patients With Elevated Risk) trial, adding the PCSK9 inhibitor evolocumab to statin therapy reduced low-density lipoprotein cholesterol (LDL-C) and cardiovascular risk. Although atherosclerotic coronary, cerebrovascular, and peripheral vascular events share a related pathobiology, the effect of aggressive LDL-C lowering with PCSK9 inhibition on the risk of acute arterial events across all three vascular beds is not well-described.

Purpose

To assess the efficacy of evolocumab on acute arterial events in all vascular territories including coronary, cerebral, and peripheral vascular beds.

Methods

In the FOURIER trial, patients (n=27,564) with stable atherosclerotic cardiovascular disease and LDL-C ≥70 mg/dL on a statin were randomly assigned to evolocumab versus placebo and followed for a median of 2.2 years (1.8–2.5). Acute arterial events were defined as a composite of coronary (coronary heart disease [CHD] death, myocardial infarction [MI], or urgent coronary revascularization), cerebrovascular (ischemic stroke, transient ischemic attack [TIA], or urgent cerebral revascularization), or peripheral vascular (acute limb ischemia, major amputation, or urgent peripheral revascularization) events. Cox proportional-hazard models were used to assess the efficacy of evolocumab on these outcomes. Landmark and total event analyses were also done.

Results

Of the 2,210 first acute arterial events occurring during follow-up, 74% were coronary, 22% were cerebrovascular, and 4% were peripheral vascular. Evolocumab reduced the risk of a first acute arterial event by 19% (HR 0.81, 95% CI 0.74–0.88; P<0.001), with significant individual reductions in acute coronary (HR 0.83; 95% CI 0.75–0.91; P<0.001), acute cerebrovascular (HR 0.77; 95% CI 0.65–0.92; P=0.004), and acute peripheral vascular (HR 0.58; 95% CI 0.38–0.88; P=0.01) events (Figure, top). The magnitude of the risk reduction with evolocumab tended to increase over time, with a 16% reduction (HR 0.84; 95% CI 0.75–0.96) in the first year followed by a 24% reduction (HR 0.76; 95% CI 0.67–0.85) thereafter (Figure, bottom). There were 3,780 total acute arterial events (first plus recurrent), with a 22% reduction with evolocumab (incidence rate ratio [RR] 0.78; 95% CI 0.70–0.87). Evolocumab prevented 496 total acute arterial events as compared to 222 first events.

Conclusions

The addition of the PCSK9 inhibitor evolocumab to statin therapy reduced the risk of acute arterial events across all vascular territories with a robust effect over time. These findings indicate a pan-vascular impact of aggressive lipid-lowering therapy on these acute and clinically meaningful events.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The FOURIER trial was supported by Amgen.

Reducing Severe Tracheal Intubation Events Through an Individualized Airway Bundle

BACKGROUND

Neonatal tracheal intubation (TI) is a high-risk procedure associated with adverse safety events. In our newborn and infant ICU, we measure adverse tracheal intubation-associated events (TIAEs) as part of our participation in National Emergency Airway Registry for Neonates, a neonatal airway registry. We aimed to decrease overall TIAEs by 10% in 12 months.

METHODS

A quality improvement team developed an individualized approach to intubation using an Airway Bundle (AB) for patients at risk for TI. Plan-do-study-act cycles included AB creation, simulation, unit roll out, interprofessional education, team competitions, and adjusting AB location. Outcome measure was monthly rate of TIAEs (overall and severe). Process measures were AB initiation, AB use at intubation, video laryngoscope (VL) use, and paralytic use. Balancing measure was inadvertent administration of TI premedication. We used statistical process control charts.

RESULTS

Data collection from November 2016 to August 2020 included 1182 intubations. Monthly intubations ranged from 12 to 41. Initial overall TIAE rate was 0.093 per intubation encounter, increased to 0.172, and then decreased to 0.089. System stability improved over time. Severe TIAE rate decreased from 0.047 to 0.016 in June 2019. AB initiation improved from 70% to 90%, and AB use at intubation improved from 18% to 55%. VL use improved from 86% to 97%. Paralytic use was 83% and did not change. The balancing measure of inadvertent TI medication administration occurred once.

CONCLUSIONS

We demonstrated a significant decrease in the rate of severe TIAEs through the implementation of an AB. Next steps include increasing use of AB at intubation.

Effect of a Multicomponent Sepsis Transition and Recovery Program on Mortality and Readmissions After Sepsis: The Improving Morbidity During Post-Acute Care Transitions for Sepsis Randomized Clinical Trial

OBJECTIVES

To evaluate whether a nurse navigator-led, multicomponent Sepsis Transition And Recovery program improves 30-day mortality and readmission outcomes after sepsis hospitalization.

DESIGN

Multisite pragmatic randomized clinical trial.

SETTING

Three hospitals in North Carolina from January 2019 to March 2020.

PATIENTS

Eligible patients hospitalized for suspected sepsis and deemed high-risk for mortality or readmission by validated internal risk models.

INTERVENTIONS

Patients were randomized to receive usual care alone (i.e., routine transition support, outpatient care; n = 342) or additional Sepsis Transition And Recovery support (n = 349). The 30-day intervention involved a multicomponent transition service led by a nurse navigator through telephone and electronic health record communication to facilitate best practice postsepsis care strategies during and after hospitalization including: postdischarge medication review, evaluation for new impairments or symptoms, monitoring comorbidities, and palliative care approach when appropriate. Clinical oversight was provided by a Hospital Medicine Transition Services team.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was a composite of mortality or hospital readmission at 30 days. Logistic regression models were constructed to evaluate marginal and conditional odds ratios (adjusted for prognostic covariates: age, comorbidity, and organ dysfunction at enrollment). Among 691 randomized patients (mean age = 63.7 ± 15.1 yr; 52% female), a lower percentage of patients in the Sepsis Transition And Recovery group experienced the primary outcome compared with the usual care group (28.7% vs 33.3%; risk difference, 4.7%; odds ratio, 0.80; 95% CI, 0.58-1.11; adjusted odds ratio, 0.80; 95% CI, 0.64-0.98). There were 74 deaths (Sepsis Transition And Recovery: 33 [9.5%] vs usual care: 41 [12.0%]) and 155 rehospitalizations (Sepsis Transition And Recovery: 71 [20.3%] vs usual care: 84 [24.6%]).

CONCLUSIONS

In a multisite randomized clinical trial of patients hospitalized with sepsis, patients provided with a 30-day program using a nurse navigator to provide best practices for postsepsis care experienced a lower proportion of either mortality or rehospitalization within 30 days after discharge. Further research is needed to understand the contextual factors associated with successful implementation.

A Study of GP Workload and Satisfaction

Aims In this novel study in the Irish setting, we quantified the number items managed per General Practitioner (GP) consult, how each item is managed, and impact on a GP's job satisfaction. Methods Participating GPs at two surgeries completed a questionnaire - integrated into the practice management software - after each consultation that satisfied the inclusion criteria during a four-week period. Results Due to feasibility constraints, 500 of 857 (58.3%) completed questionnaires were randomly selected for our sample. GPs manage an average of 1.76 items per consultation. Older patients presented with more items. Greater number of presenting items led to less being managed on the day 71% (n=5) for 5 items vs. 95.2% (n= 246) for 1 item, longer consultation duration (mean = 14.63 minutes (4-45) and decreased GP satisfaction, mean 8/10 (2-10). Conclusion Increasing the number of items in a GP consultation has a statistically significant effect on duration of consultation, how each item is managed, and even GP satisfaction.

Zonisamide safety in pregnancy: Data from the UK and Ireland epilepsy and pregnancy register

BACKGROUND

Animal data suggest teratogenic effects with zonisamide use and risk of pregnancy losses. Human data following zonisamide exposure are presently limited, but suggest low risk of malformation with elevated risk of low birth weight.

OBJECTIVE

To calculate the major congenital malformation (MCM) rate of zonisamide in human pregnancy and assess for a signal of any specific malformation pattern and associations with birth weight.

METHODS AND MATERIALS

Data were obtained from the UK and Ireland Epilepsy and Pregnancy register (UKIEPR) which is an observational, registration, and follow up study from December 1996 to July 2020. Eligibility criteria were use of zonisamide and to have been referred to the UKIEPR before the outcome of the pregnancy was known. Primary outcome was evidence of MCM.

RESULTS

From December 1996 through July 2020 there were 112 cases of first trimester exposure to zonisamide, including 26 monotherapy cases. There were 3 MCM for monotherapy cases (MCM rate 13.0% (95% confidence interval 4.5-32.1)), and 5 MCM for polytherapy cases (MCM rate 6.9% (95% confidence interval 3.0-15.2)). While the median birth weight was on 71st and 44th centile for monotherapy and polytherapy cases respectively, there was a high rate of infants born small for gestational age (21% for both).

CONCLUSION

These data raise concerns about a signal for potential teratogenicity with zonisamide in human pregnancy. Given the low numbers reported, further data will be required to adequately counsel women who use zonisamide in pregnancy.

505 INTERLEUKIN-6, C-REACTIVE PROTEIN, FIBRINOGEN, AND RISK OF RECURRENCE AFTER ISCHEMIC STROKE: SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Recent randomised trials showed benefit for anti-inflammatory therapies in coronary disease but excluded stroke. The prognostic value of blood inflammatory markers after stroke is uncertain and guidelines do not recommend their routine measurement for risk stratification.

Methods

We performed a systematic review and meta-analysis of studies investigating the association of C-reactive protein (CRP), interleukin-6 (IL-6) and fibrinogen and risk of recurrent stroke or major vascular events (MVEs). We searched EMBASE and Ovid Medline until 10/1/19. Random-effects meta-analysis was performed for studies reporting comparable effect measures.

Results

Of 2,515 reports identified, 39 met eligibility criteria (IL-6, n = 10; CRP, n = 33; fibrinogen, n = 16). An association with recurrent stroke was reported in 12/26 studies (CRP), 2/11 (fibrinogen) and 3/6 (IL-6). On random-effects meta-analysis of comparable studies, CRP was associated with an increased risk of recurrent stroke [pooled hazard ratio (HR) per 1 standard-deviation (SD) increase in loge-CRP (1.14, 95% CI 1.06-1.22, p < 0.01)] and MVEs (pooled HR 1.21, CI 1.10-1.34, p < 0.01). Fibrinogen was also associated with recurrent stroke (HR 1.26, CI 1.07-1.47, p < 0.01) and MVEs (HR 1.31, 95% CI 1.15-1.49, p < 0.01). Trends were identified for IL-6 for recurrent stroke (HR per 1-SD increase 1.17, CI 0.97-1.41, p = 0.10) and MVEs (HR 1.22, CI 0.96-1.55, p = 0.10).

Conclusion

Despite evidence suggesting an association between inflammatory markers and post-stroke vascular recurrence, substantial methodological heterogeneity was apparent between studies. Individual-patient pooled analysis and standardisation of methods are needed to determine the prognostic role of blood inflammatory markers and to improve patient selection for randomised trials of inflammatory therapies.

Protocol for a two-arm pragmatic stepped-wedge hybrid effectiveness-implementation trial evaluating Engagement and Collaborative Management to Proactively Advance Sepsis Survivorship (ENCOMPASS)

BACKGROUND

Sepsis survivors experience high morbidity and mortality, and healthcare systems lack effective strategies to address patient needs after hospital discharge. The Sepsis Transition and Recovery (STAR) program is a navigator-led, telehealth-based multicomponent strategy to provide proactive care coordination and monitoring of high-risk patients using evidence-driven, post-sepsis care tasks. The purpose of this study is to evaluate the effectiveness of STAR to improve outcomes for sepsis patients and to examine contextual factors that influence STAR implementation.

METHODS

This study uses a hybrid type I effectiveness-implementation design to concurrently test clinical effectiveness and gather implementation data. The effectiveness evaluation is a two-arm, pragmatic, stepped-wedge cluster randomized controlled trial at eight hospitals in North Carolina comparing clinical outcomes between sepsis survivors who receive Usual Care versus care delivered through STAR. Each hospital begins in a Usual Care control phase and transitions to STAR in a randomly assigned sequence (one every 4 months). During months that a hospital is allocated to Usual Care, all eligible patients will receive usual care. Once a hospital transitions to STAR, all eligible patients will receive STAR during their hospitalization and extending through 90 days from discharge. STAR includes centrally located nurse navigators using telephonic counseling and electronic health record-based support to facilitate best-practice post-sepsis care strategies including post-discharge review of medications, evaluation for new impairments or symptoms, monitoring existing comorbidities, and palliative care referral when appropriate. Adults admitted with suspected sepsis, defined by clinical criteria for infection and organ failure, are included. Planned enrollment is 4032 patients during a 36-month period. The primary effectiveness outcome is the composite of all-cause hospital readmission or mortality within 90 days of discharge. A mixed-methods implementation evaluation will be conducted before, during, and after STAR implementation.

DISCUSSION

This pragmatic evaluation will test the effectiveness of STAR to reduce combined hospital readmissions and mortality, while identifying key implementation factors. Results will provide practical information to advance understanding of how to integrate post-sepsis management across care settings and facilitate implementation, dissemination, and sustained utilization of best-practice post-sepsis management strategies in other heterogeneous healthcare delivery systems.

TRIAL REGISTRATION

NCT04495946 . Submitted July 7, 2020; Posted August 3, 2020.

Inflammatory cytokines, high-sensitivity C-reactive protein, and risk of one-year vascular events, death, and poor functional outcome after stroke and transient ischemic attack

Background

Inflammation driven by pro-inflammatory cytokines is a new therapeutic target in coronary disease. Few data exist on the association of key upstream cytokines and post-stroke recurrence. In a prospective cohort study, we investigated the association between pivotal cytokines, high-sensitivity C-reactive protein (hsCRP) and one-year outcomes.

Methods

BIO-STROKETIA is a multi-center prospective cohort study of non-severe ischemic stroke (modified Rankin score ≤ 3) and transient ischemic attack. Controls were patients with transient symptoms attending transient ischemic attack clinics with non-ischemic final diagnosis. Exclusion criteria were severe stroke, infection, and other pro-inflammatory disease; hsCRP and cytokines (interleukin (IL) 6, IL-1β, IL-8, IL-10, IL-12, interferon-γ (IFN-γ), tumor-necrosis factor-α (TNF-α)) were measured. The primary outcome was one-year recurrent stroke/coronary events (fatal and non-fatal).

Results

In this study, 680 patients (439 stroke, 241 transient ischemic attack) and 68 controls were included. IL-6, IL-1β, IL-8, IFN-γ, TNF-α, and hsCRP were higher in stroke/transient ischemic attack cases (p ≤ 0.01 for all). On multivariable Cox regression, IL-6, IL-8, and hsCRP independently predicted one-year recurrent vascular events (adjusted hazard ratios (aHR) per-quartile increase IL-6 1.31, confidence interval (CI) 1.02–1.68, p = 0.03; IL-8 1.47, CI 1.15–1.89, p = 0.002; hsCRP 1.28, CI 1.01–1.62, p = 0.04). IL-6 (aHR 1.98, CI 1.26–3.14, p = 0.003) and hsCRP (aHR 1.81, CI 1.20–2.74, p = 0.005) independently predicted one-year fatality. IL-6 and hsCRP (adjusted odds ratio per-unit increase 1.02, CI 1.01–1.04) predicted poor functional outcome, with a trend for IL-1β (p = 0.054).

Conclusion

Baseline inflammatory cytokines independently predicted late recurrence, supporting a rationale for randomized trials of anti-inflammatory agents for prevention after stroke and suggesting that targeted therapy to high-risk patients with high baseline inflammation may be beneficial.

Patient navigation plus hospital at home to improve COVID-19 outcomes for cancer patients

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Background: Reports suggested cancer patients were at greater risk for increased morbidity and mortality from COVID-19. A process to mitigate these risks was established at Levine Cancer Institute (LCI) in partnership with Atrium Health’s (AH) Hospital at Home (HAH) initiative. This virtual health navigation process employed expertise from the departments of Hematologic Oncology and Blood Disorders, Oncology, and Supportive Oncology, including a specialized nurse navigation team, to rapidly identify COVID-19 positive LCI patients, monitor them under physician supervision, and escalate care as needed with AH HAH program. Methods: AH Information Services created an automated list of LCI COVID-19 positive patients with a daily database. Each patient was reviewed by a nurse navigator. Review included hematologic or oncologic diagnosis, outpatient or inpatient status, and any COVID-19 symptoms. Once a malignant diagnosis was confirmed, a diagnosis-specific navigator contacted and screened the patient with a COVID assessment tool. Documentation was forwarded to the primary oncologist/hematologist. The tool scored patients for surveillance and treatment needs. A score of 0-2 prompted phone assessment every 48-72 hours, and score of 3-5 required every 24-48 hour calls with physician involvement when appropriate. If score of ≥6, care was escalated to LCI nurse/physician for admission to AH acute care HAH or conventional inpatient admission. Results: From inception on 3/20/2020 to data review date of 12/2/2020, 974 LCI patients were identified as COVID-19 positive and reviewed for nurse navigation (Table). Of the 974, 488 were navigated. Given limited resources, patients with benign conditions were not assigned a navigator, though a similar process was created for sickle cell disease. Of the 974, 75 are now deceased. Only 25 are deceased among the 488 navigated. Conclusions: The COVID-19 pandemic presented unprecedented circumstances to our patients and their clinicians. LCI expeditiously put policies and procedures in place to mitigate the intersection of COVID-19 and cancer. The multidisciplinary response strategy liaising between AH HAH and LCI followed, assessed, and assisted LCI COVID-19 positive patients. With our embedded nurse navigation team’s specialized attention along with enhanced physician oversight and close collaboration with AH HAH, opportunities for care escalation or adjustments in cancer-focused care were promptly identified. Analysis is ongoing to elucidate the lower mortality rate observed among navigated patients.[Table: see text]

P10: LYMPH NODE YIELD IS NOT A RELIABLE PROGNOSTIC MARKER IN ANTERIOR RESECTION AND ABDOMINOPERINEAL RESECTION FOLLOWING NEOADJUVANT THERAPY FOR RECTAL CANCER

Introduction

International guidelines recommend a minimum lymph node yield (LNY) of ≥12 for oncological resection in colorectal cancer (CRC). Neoadjuvant chemoradiotherapy (NACRT) decreases LNY, which questions its ability to provide accurate prognostic information. The consensus of this significance remains undetermined. This study aimed to investigate the significance of LNY on recurrence and survival following anterior resection and abdominoperineal resection with or without NACRT for rectal cancer.

Method

Prospectively collected data on patients diagnosed with rectal cancer in a tertiary referral centre was interrogated retrospectively. Patients were divided into primary surgery and NACRT groups. Univariable analysis was performed using Fisher's exact test, t-test, and x2 test, while multivariable analysis utilised a multiple regression model. Disease recurrence and survival was analysed with logrank test for Kaplan-Meier curves.

Result

148 patients were included [56.1% (n=83) receiving NACRT]. The median LNY of the primary surgery group was 14 [interquartile range (IQR) 11-19] and for the NACRT group was 12 (IQR 8-14) (p <0.001). Disease recurrence was similar in both primary surgery and NACRT groups. There was a significant decrease in overall mortality in NACRT patients (p = 0.03), but there was no significant difference observed in recurrence or mortality amongst LNYs of <8, 8-11, and ≥12.

Conclusion

LNY less than 12 was not a negative prognostic indicator following NACRT and surgery for rectal cancer.

Take-home message

A lymph node yield of less than 12 is not a negative prognostic indicator in rectal cancer patients who receive neoadjuvant chemotherapy.

Non-melanoma skin cancer activity during the COVID-19 pandemic- A single UK tertiary centre experience

The pandemic caused by SARS-CoV-2 virus, also known as COVID-19, has generated shockwaves in medical and surgical practice. It has necessitated re-deployment of staff and resources to cater for the unpredictable increase in footfall and demand on healthcare systems. This study aimed to investigate how the restructuring of our service altered the triage and management of non-melanoma skin cancer (NMSC) during the pandemic's first wave rise and peak. We retrospectively analysed all patients who underwent a skin excision under local anaesthetic which revealed the presence of a basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) on histopathological analysis between 1st February 2020 - 31st May 2020 compared with the same period in 2019. There was a 158% increase in patients with excision of lesions confirmed on histopathological analysis as a NMSC during the COVID-19 period (168 vs. 65). In 2020, more excisions were performed by consultants (42.9% v 21.5%, p = 0.002) with a lower proportion of excisions with a close margin (27.7% v 17.8%, p = 0.096) and an involved margin (3.1% v 1.8%, p = 0.62). Five of these patients had their further management altered due to service constraints at this time The resource constraints secondary to the pandemic have yielded beneficial service adaptations with the incorporation of a more efficient model for the NMSC service. The sustainability of this model and its impact on training will require further examination when non-urgent and benign elective workload is slowly reinstated and plastic surgery trainees return to their original posts.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

A new clinical presentation: breast implant pneumocapsule and pneumothorax following penetrating chest wall trauma

Pneumothorax resulting from traumatic thoracic injury is a potentially life-threatening emergency requiring prompt recognition and management with an intercostal drain. A 34-year-old woman was brought into the emergency department after sustaining a stab injury to the right upper outer quadrant of the right breast. She described noticing a jelly-like substance from her wound, on the background of a prior cosmetic breast augmentation. On examination, it was noted that the right breast was significantly swollen. Computed tomography demonstrated a large right sided pneumothorax with associated punctured right breast implant, a 'pneumocapsule' and extensive subcutaneous emphysema of the breast. This case highlights that the fibrous tissue capsule around a breast implant can function as an anatomical space in continuity with the thoracic cavity, masking the diagnosis of pneumothorax in penetrating trauma.

Retinal microvascular parameters are not significantly associated with mild cognitive impairment in the Northern Ireland Cohort for the Longitudinal Study of Ageing

BACKGROUND

The retinal and cerebral microvasculature share similar embryological origins and physiological characteristics. Improved imaging technologies provide opportunistic non-invasive assessment of retinal microvascular parameters (RMPs) against cognitive outcomes. We evaluated baseline measures for associations between RMPs and mild cognitive impairment (MCI) from participants of the Northern Ireland Cohort for the Longitudinal Study of Ageing (NICOLA).

METHODS

RMPs (central retinal arteriolar / venular equivalents, arteriole to venular ratio, fractal dimension and tortuosity) were measured from optic disc centred fundus images and analysed using semi-automated software. Associations between RMPs and MCI were assessed by multivariable logistic regression with adjustment for potential confounders including age, sex, alcohol consumption, smoking status, educational attainment, physical activity, cardiovascular disease (CVD), hypertension, mean arterial blood pressure, triglycerides, diabetes, body mass index, and high density lipoprotein levels. P < 0.05 was considered statistically significant.

RESULTS

Data were available for 1431 participants, of which 156 (10.9%) were classified with MCI defined by a Montreal Cognitive Assessment (MoCA) score ≤ 26, with subjective cognitive decline, in the absence of depression or problems with activities of daily living. Participants had a mean age of 62.4 ± 8.5 yrs. and 52% were female. As expected, individuals with MCI had a lower MoCA score than those without (23.5 ± 2.6 versus 26.3 ± 2.7, respectively), were more likely to be female, have a lower level of educational attainment, be less physically active, more likely to have CVD, have higher levels of triglycerides and lower levels of high density lipoprotein. No significant associations between RMPs and MCI were detected in unadjusted, minimally adjusted or fully adjusted regression models or subsequent sensitivity analyses.

CONCLUSION

Previous studies have reported both increased retinal venular calibre and reduced fractal dimension in association with mild cognitive impairment. Our study failed to detect any associations between RMPs and those individuals at an early stage of cognitive loss in an older community-based cohort.

Asymmetric cell division promotes therapeutic resistance in glioblastoma stem cells

Asymmetric cell division (ACD) enables the maintenance of a stem cell population while simultaneously generating differentiated progeny. Cancer stem cells (CSCs) undergo multiple modes of cell division during tumor expansion and in response to therapy, yet the functional consequences of these division modes remain to be determined. Using a fluorescent reporter for cell surface receptor distribution during mitosis, we found that ACD generated a daughter cell with enhanced therapeutic resistance and increased coenrichment of EGFR and neurotrophin receptor (p75NTR) from a glioblastoma CSC. Stimulation of both receptors antagonized differentiation induction and promoted self-renewal capacity. p75NTR knockdown enhanced the therapeutic efficacy of EGFR inhibition, indicating that coinheritance of p75NTR and EGFR promotes resistance to EGFR inhibition through a redundant mechanism. These data demonstrate that ACD produces progeny with coenriched growth factor receptors, which contributes to the generation of a more therapeutically resistant CSC population.

Insights From Rapid Deployment of a "Virtual Hospital" as Standard Care During the COVID-19 Pandemic

BACKGROUND

Pandemics disrupt traditional health care operations by overwhelming system resource capacity but also create opportunities for care innovation.

OBJECTIVE

To describe the development and rapid deployment of a virtual hospital program, Atrium Health hospital at home (AH-HaH), within a large health care system.

DESIGN

Prospective case series.

SETTING

Atrium Health, a large integrated health care organization in the southeastern United States.

PATIENTS

1477 patients diagnosed with coronavirus disease 2019 (COVID-19) from 23 March to 7 May 2020 who received care via AH-HaH.

INTERVENTION

A virtual hospital model providing proactive home monitoring and hospital-level care through a virtual observation unit (VOU) and a virtual acute care unit (VACU) in the home setting for eligible patients with COVID-19.

MEASUREMENTS

Patient demographic characteristics, comorbid conditions, treatments administered (intravenous fluids, antibiotics, supplemental oxygen, and respiratory medications), transfer to inpatient care, and hospital outcomes (length of stay, intensive care unit [ICU] admission, mechanical ventilation, and death) were collected from electronic health record data.

RESULTS

1477 patients received care in either the AH-HaH VOU or VACU or both settings, with a median length of stay of 11 days. Of these, 1293 (88%) patients received care in the VOU only, with 40 (3%) requiring inpatient hospitalization. Of these 40 patients, 16 (40%) spent time in the ICU, 7 (18%) required ventilator support, and 2 (5%) died during their hospital admission. In total, 184 (12%) patients were ever admitted to the VACU, during which 21 patients (11%) required intravenous fluids, 16 (9%) received antibiotics, 40 (22%) required respiratory inhaler or nebulizer treatments, 41 (22%) used supplemental oxygen, and 24 (13%) were admitted as an inpatient to a conventional hospital. Of these 24 patients, 10 (42%) required ICU admission, 1 (3%) required a ventilator, and none died during their hospital admission.

LIMITATION

Generalizability is limited to patients with a working telephone and the ability to comply with the monitoring protocols.

CONCLUSION

Virtual hospital programs have the potential to provide health systems with additional inpatient capacity during the COVID-19 pandemic and beyond.

PRIMARY FUNDING SOURCE

Atrium Health.

Interleukin-6, C-reactive protein, fibrinogen, and risk of recurrence after ischaemic stroke: Systematic review and meta-analysis

Background

Recent randomised trials showed benefit for anti-inflammatory therapies in coronary disease but excluded stroke. The prognostic value of blood inflammatory markers after stroke is uncertain and guidelines do not recommend their routine measurement for risk stratification.

Methods

We performed a systematic review and meta-analysis of studies investigating the association of C-reactive protein (CRP), interleukin-6 (IL-6) and fibrinogen and risk of recurrent stroke or major vascular events (MVEs). We searched EMBASE and Ovid Medline until 10/1/19. Random-effects meta-analysis was performed for studies reporting comparable effect measures.

Results

Of 2,515 reports identified, 39 met eligibility criteria (IL-6, n = 10; CRP, n = 33; fibrinogen, n = 16). An association with recurrent stroke was reported in 12/26 studies (CRP), 2/11 (fibrinogen) and 3/6 (IL-6). On random-effects meta-analysis of comparable studies, CRP was associated with an increased risk of recurrent stroke [pooled hazard ratio (HR) per 1 standard-deviation (SD) increase in log_e-CRP (1.14, 95% CI 1.06-1.22, p < 0.01)] and MVEs (pooled HR 1.21, CI 1.10-1.34, p < 0.01). Fibrinogen was also associated with recurrent stroke (HR 1.26, CI 1.07-1.47, p < 0.01) and MVEs (HR 1.31, 95% CI 1.15-1.49, p < 0.01). Trends were identified for IL-6 for recurrent stroke (HR per 1-SD increase 1.17, CI 0.97-1.41, p = 0.10) and MVEs (HR 1.22, CI 0.96-1.55, p = 0.10).

Conclusion

Despite evidence suggesting an association between inflammatory markers and post-stroke vascular recurrence, substantial methodological heterogeneity was apparent between studies. Individual-patient pooled analysis and standardisation of methods are needed to determine the prognostic role of blood inflammatory markers and to improve patient selection for randomised trials of inflammatory therapies.

The association between COVID-19 related stressors and mental health in refugees living in Australia

BACKGROUND

Refugees may be particularly vulnerable to the adverse effects of the COVID-19 pandemic on mental health due to their traumatic pasts and the challenges of the postmigration environment.

OBJECTIVE

To evaluate the prevalence of COVID-19 related stressors and their relationship to key mental health and functioning outcomes in a resettled refugee sample.

METHOD

N = 656 refugees and asylum seekers living in Australia completed a survey in June 2020 to index their mental health (posttraumatic stress disorder (PTSD), depression, health anxiety and disability) and COVID-19 experiences. The relationship between COVID-19 stressors and mental health was examined using a series of hierarchical linear regression models while controlling for other key demographic factors.

RESULTS

Refugees' most prevalent stressors related to worries of being infected by COVID-19 or the risk COVID-19 posed to others, which predicted health anxiety and PTSD. Social-related difficulties predicted depression and disability symptoms. Accessing and trusting information from authorities were the least prevalent stressors and were not significantly associated with mental health outcomes; neither was accessing basic supplies and financial support. Fears relating to the future such as concerns about visa application processes predicted health anxiety and disability. Crucially, the strongest predictor of all mental health outcomes was COVID-19 serving as a reminder of difficult past events.

CONCLUSIONS

Refugees may be uniquely affected by COVID-19 because the pandemic serves as a reminder of their past conflict and persecution trauma. It is critical that mental health strategies accommodate the specific needs of refugees during the COVID-19 pandemic.

Factors associated with COVID-19 vaccine hesitancy amongst refugees in Australia

BACKGROUND

Refugees may be especially vulnerable to the adverse effects of COVID-19. Therefore it is critical that refugee communities are supported to access COVID-19 vaccines and for public health responses to address vaccine hesitancy.

OBJECTIVE

To investigate the key demographic factors, barriers and attitudes associated with vaccine hesitancy in a community sample of refugees.

METHOD

Participants in the Refugee Adjustment Study, a cohort of refugees living in Australia, were invited to complete a survey about their COVID-19 vaccine intentions, barriers to access and attitudes relating to the vaccine.

RESULTS

Of the 516 participants, 88% were unvaccinated and 28.1% were classed as vaccine hesitant. Key predictors of vaccine hesitancy were younger age, information and trust barriers, lower logistical barriers, and attitudes relating to low control and risk posed by COVID-19.

CONCLUSIONS

Findings suggest that public health strategies need to address trust, control and risk perception attitudes to increase COVID-19 vaccine uptake in resettled refugee communities.