'Getting control of Corona takes many angles': COVID-19 vaccine knowledge, attitudes and beliefs among refugee/immigrant/migrant communities in four US cities

The objectives of the study were to (i) document refugee, immigrant and migrant (RIM) communities' knowledge, attitudes and beliefs (KABs) related to the Coronavirus disease (COVID-19) vaccine and (ii) identify best practices for developing and disseminating culturally and linguistically responsive health messaging addressing those KABs. Thirteen online focus groups (OFGs) in 10 languages were conducted. Each OFG was conducted in the participants' native language. OFGs were recorded, transcribed, translated and uploaded to qualitative software for coding. A thematic analysis was conducted. Results suggest that while there was some variation between different language groups (e.g. whether religious leaders were seen as trusted sources of information about COVID), there were also important commonalities. Most language groups (i) alluded to hearing about or having gaps in knowledge about COVID-19/the COVID-19 vaccine, (ii) reported hearing negative or conflicting stories about the vaccine and (iii) shared concerns about the negative side effects of the vaccine. There continues to be a need for health messaging in RIM communities that is culturally and linguistically concordant and follows health literacy guidelines. Message content about the COVID-19 vaccine should focus on vaccine importance, effectiveness and safety, should be multimodal and should be primarily delivered by healthcare professionals and community members who have already been vaccinated.

Clinical and cardiovascular magnetic resonance profile of cardiomyopathy patients from South Africa: Pilot of the IMHOTEP study

BACKGROUND

Cardiomyopathy is an important cause of heart failure, however, there is notable lack of data on causes and manifestations of cardiomyopathy in Africa.

AIMS

The African Cardiomyopathy and Myocarditis Registry Program (IMHOTEP) aims to address the knowledge gap on etiology, treatment, and outcomes of cardiomyopathy in sub-Saharan Africa.

METHODS AND RESULTS

We conducted a single-center pilot study to delineate the clinical and cardiovascular magnetic resonance (CMR) phenotypes of cardiomyopathy in South African patients. Assessment of the first 99 adult incident cases [mean age 36.8 ± 12.5 years; females 53.5%] enrolled in IMHOTEP showed that dilated cardiomyopathy (n = 77) was commonest, followed by hypertrophic (n = 13), restrictive (n = 5) and arrhythmogenic (n = 4) cardiomyopathies. A broad range of etiologies were encountered with secondary causes identified in 42% of patients. Onset of symptoms in the peripartum period was observed in 47% of women, and peripartum cardiomyopathy was diagnosed in 32.1% of women recruited. In addition to electrocardiography and echocardiography, CMR was performed in 67 cases and contributed diagnostically in a third of cases. Acute inflammation was rarely observed [2%] on CMR, however, late gadolinium enhancement (LGE) was noted in 92% of cases.

CONCLUSION

We report a diverse spectrum of causes of cardiomyopathy in the South African population, with secondary, potentially treatable, etiologies in a significant proportion of cases. CMR was useful in delineating specific phenotypes and etiologies, influencing clinical care. A higher-than-expected burden of LGE was observed in this young patient cohort - the implications of which are yet to be determined.

Development of Diagnostic Quality Metrics for Prosthetic Joint Infection

ABSTRACT

Although well-accepted clinical practice guidelines exist for the diagnosis of prosthetic joint infection (PJI), little is known about the quality of diagnosis for PJI. The identification of quality gaps in the diagnosis of PJI would facilitate the development of care structures and processes to shorten time to diagnosis and reduce the significant morbidity, mortality, and economic burden associated with this condition. Hence, we sought to develop valid clinical quality measures to improve the timeliness and accuracy of PJI diagnosis. We convened a nine-member multidisciplinary national panel of PJI experts including orthopedic surgeons, infectious disease specialists, an emergency medicine physician, and a patient previously treated for PJI to review, discuss, and rate the validity of proposed measures using a modification of the RAND-UCLA appropriateness method. In total, 57 permutations of six proposed measures were rated. Populations considered to be at high enough risk for PJI that certain care processes should always be performed were identified by the panel. Among the proposed quality measures, the panel rated five as valid. These novel clinical quality measures could provide insight into care gaps in the diagnosis of PJI.

Shark depredation: future directions in research and management

Shark depredation is a complex social-ecological issue that affects a range of fisheries worldwide. Increasing concern about the impacts of shark depredation, and how it intersects with the broader context of fisheries management, has driven recent research in this area, especially in Australia and the United States. This review synthesises these recent advances and provides strategic guidance for researchers aiming to characterise the occurrence of depredation, identify the shark species responsible, and test deterrent and management approaches to reduce its impacts. Specifically, the review covers the application of social science approaches, as well as advances in video camera and genetic methods for identifying depredating species. The practicalities and considerations for testing magnetic, electrical, and acoustic deterrent devices are discussed in light of recent research. Key concepts for the management of shark depredation are reviewed, with recommendations made to guide future research and policy development. Specific management responses to address shark depredation are lacking, and this review emphasizes that a "silver bullet" approach for mitigating depredation does not yet exist. Rather, future efforts to manage shark depredation must rely on a diverse range of integrated approaches involving those in the fishery (fishers, scientists and fishery managers), social scientists, educators, and other stakeholders.

Profile, presentation and outcomes of prosthetic valve endocarditis in a South African tertiary hospital: Insights from the Groote Schuur Hospital Infective Endocarditis Registry

BACKGROUND

Prosthetic valve infective endocarditis (PVE) is associated with high morbidity and mortality. The prevalence of PVE in South African retrospective studies ranges between 13% and 17%.

OBJECTIVES

To define the clinical profile and outcomes of patients with PVE, and compare them with those of native valve endocarditis (NVE) patients.

METHODS

We performed a prospective observational study of patients presenting or referred to Groote Schuur Hospital, Cape Town, with definite or possible infective endocarditis (IE) based on the 2015 European Society of Cardiology IE diagnostic criteria. Consenting adult patients who met the inclusion criteria were enrolled into the Groote Schuur Hospital Infective Endocarditis Registry, which was approved by the University of Cape Town Human Research Ethics Committee. This study is an analysis of the patients enrolled between 1 January 2017 and 31 December 2019.

RESULTS

During the study period, a total of 135 patients received a diagnosis of possible or definite IE (PVE n=18, NVE n=117). PVE therefore accounted for 13.3% of the overall IE cohort. PVE patients had a mean (standard deviation) age of 39.1 (14.6) years, and 56.6% were male. PVE occurred within 1 year of valve surgery in 50.0% of cases. Duke's modified diagnostic criteria for definite IE were met in 94.4% of the PVE cohort. Isolated aortic valve PVE was present in 33.3%, and a combination of aortic and mitral valve PVE in 66.6%. Tissue prosthetic valves were affected in 61.1% of cases. Of the PVE cases, 55.6% were healthcare associated. On transthoracic echocardiography, vegetations (61.1%), prosthetic valve regurgitation (44.4%) and abscesses (22.2%) were discovered. Staphylococcus and Streptococcus species accounted for 38.8% and 22.2% of PVE cases, respectively, and 27.8% of cases were blood culture negative. Valve surgery was performed in 38.7% of the PVE patients, and 55.6% of the patients died during the index hospitalisation. Secondary analysis indicated that the PVE patients were sicker than those with NVE, with a higher frequency of septic shock and atrioventricular block (22.2% v. 7%; p=0.02 and 27.8% v. 12%; p=0.04, respectively). In addition, in-hospital mortality was higher in PVE patients than NVE patients (55.6% v. 31.6%; p=0.04).

CONCLUSIONS

PVE was uncommon, mainly affecting tissue prosthetic valves and prosthetic valves in the aortic position. Patients with PVE were sicker than those with NVE and had high in-hospital mortality.

Prevalence of growth hormone deficiency in patients with unexplained chronic fatigue after undergoing bone marrow transplantation in adulthood

PURPOSE

Many patients who undergo bone marrow transplantation (BMT) in adulthood experience unexplained chronic fatigue which can have a major impact on their health-related quality of life (QoL). Pre-BMT treatment regimens increase the risk of developing acquired growth hormone deficiency (GHD), which results in a clinical syndrome with decreased energy and has additionally been linked to metabolic syndrome.

METHODS

Using the gold-standard insulin hypoglycemic test (IHT), we evaluated the prevalence of GHD in 18 post-BMT adult patients with unexplained chronic fatigue, as well as the correlation between peak serum GH response and QoL scores, the metabolic syndrome, and insulin resistance. Peak serum GH cut-point less than 3.0 ug/L was used for the diagnosis of severe GHD. The Fatigue Severity Scale and Quality of Life in Adult GHD Assessment questionnaires were used to quantify fatigue symptoms.

RESULTS

The prevalence of severe GHD within this sample of 18 patients was 50%. A trend between lower peak serum GH response and higher fatigue and QoL-AGHDA scores was observed.

CONCLUSIONS

GHD may represent a remediable contributor to post-BMT chronic fatigue in adults, further studies are needed to evaluate the potential role of screening and GH replacement therapy in this vulnerable patient population.

IMPLICATIONS FOR CANCER SURVIVORS

GHD may be a treatable explanation for disabling post-BMT fatigue pending results of intervention studies.

Effectiveness of implanted cardiac rhythm recorders with electrocardiographic monitoring for detecting arrhythmias in peripartum cardiomyopathy (PPCM)

Introduction

Peripartum cardiomyopathy (PPCM) is a form of dilated cardiomyopathy that occurs within the last months of pregnancy or up to 5 months postpartum. Previous studies have shown that up to 30% of deaths in PPCM are related to sudden cardiac death (SCD). However, little is known about the burden of arrythmias in PPCM and their contribution to SCD.

Purpose

We aimed to compare implantable loop recorder (ILR) plus 24-hour Holter monitoring to 24h Holter monitoring alone to assess its utility in the detection of arrhythmias in PPCM.

Methods

In this single-centre, prospective clinical trial, 20 consecutive patients with PPCM were randomized to either standard care (SC cohort: ECG & 24-hour Holter) or SC plus ILR (SC-ILR cohort: ECG, 24-hour Holter, ILR). Follow-up included the first six months after ILR implantation.

Results

The median age of this cohort was 31.7 years with a parity of 2 (IQR 1–4). They presented with a median left ventricular ejection fraction (LVEF) of 28% (IQR 24–35) and LVEDD of 60mm (IQR 55–66). The 12-lead ECG recorded sinus tachycardia in half of the patients, with median heart rate of 90bpm (IQR 79–106) compared to 94.5bpm (IQR 85–99) on 24h-Holter-monitoring. The median QTc-interval was 464ms (IQR 424–494). Ambulatory ECG monitoring detected major arrhythmias in three women (one in SC cohort, two in SC-ILR cohort). One patient (5%) died shortly after ILR implantation. Her ILR detected sinus arrest with an escape rhythm (figure 1A) that failed and resulted in an out of hospital cardiac arrest. Non-sustained ventricular tachycardia (nsVT) occurred in two women (10%), one of which was detected by Holter monitoring and the other on ILR (figure 1B, 1C). Both women presented with acute heart failure with severely impaired systolic function (LVEF 12% and 21% respectively). One of these patients had persistent LV systolic dysfunction despite optimal medical therapy and received an implantable cardioverter-defibrillator (ICD). The other patient had intractable heart failure requiring recurrent intensive-care treatment and underwent heart transplantation. There was no atrial fibrillation or atrioventricular block detected in any patient by ECG, Holter or ILR monitoring throughout the study period.

Conclusion

This study on ambulatory ECG monitoring in PPCM showed a high prevalence of potentially fatal arrhythmias, which occurred predominantly in the acute phase of the disease. One patient had sinus arrest and asystole detected by ILR as the terminal arrhythmia. Both Holter monitoring and ILR played an important role in ventricular arrhythmia detection, which in two cases had a direct influence on clinical decision making. ILR is more effective than 24-hour Holter monitoring in paroxysmal arrhythmia detection because of extended monitoring.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Medtronic South Africa Ambulatory ECG monitoring in PPCM

Real-world implementation of video-observed therapy in an urban TB program in the United States

BACKGROUND:

Video directly observed therapy (vDOT) was introduced to increase flexibility and meet patient-specific needs for TB treatment. This study aimed to assess the reach and effectiveness of vDOT for TB treatment under routine conditions in Alameda County, CA, USA, a busy, urban setting, from 2018 to 2020.

METHODS:

We prospectively evaluated routinely collected data to estimate 1) reach (proportion of patients initiated on vDOT vs. in-person DOT); and 2) effectiveness (proportion of prescribed doses with verified administration by vDOT vs. in-person DOT).

RESULTS:

Among 163 TB patients, 94 (58%) utilized vDOT during treatment, of whom 54 (57%) received exclusively vDOT. Individuals receiving vDOT were on average younger than those receiving in-person therapy (46 vs. 61 years; P < 0.001). The median time to vDOT initiation was 2.2 weeks (IQR 1.1–10.0); patients were monitored for a median of 27.0 weeks (IQR 24.6–31.9). vDOT led to higher proportions of verified prescribed doses than in-person DOT (68% vs. 54%; P < 0.001). Unobserved self-administration occurred for all patients on weekends based on clinic instructions, but a larger proportion of doses were self-administered during periods of in-person DOT than of vDOT (45% vs. 24%; P < 0.001).

CONCLUSION:

A TB program successfully maintained vDOT, reaching the majority of patients and achieving greater medication verification than in-person DOT.

Diurnal activity patterns and habitat use of juvenile Pastinachus ater in a coral reef flat environment

Stingrays are thought to play important ecological roles in coral reef ecosystems. However, little is known about juvenile stingray movement patterns and habitat use in coral reefs. This study used active acoustic telemetry to determine fine-scale diel movement patterns and habitat use of juvenile cowtail stingrays (Pastinachus ater) in a coral reef flat environment. Seven cowtail stingrays (4 males and 3 females) were manually tracked between April and December 2016. Each individual was tracked over 2 days, generating a total of 14 active tracks ranging from 4.91 to 9 h. Specimens moved at an average speed of 2.44 m min^-1 ± 0.87 SE, with minimum distances travelled ranging from 546 to 1446 m. Tracking data showed that juvenile cowtail stingrays move in response to tidal cycles, moving faster and in straighter pathways during incoming and outgoing tides. Juvenile cowtail stingrays also showed a strong affinity to sand flat areas and mangrove edge areas. These areas provide food resources and potential refuges for juvenile rays to avoid predators. Coral reef flats were identified as secondary refuge for juveniles during the lowest tides. Future research is necessary to fully unveil the major drivers of juvenile cowtail stingray seasonal and ontogenetic movement patterns and habitat use within coral reef flat environments. This information is important to establish a full understanding of juvenile cowtail stingray ecology, but could also improve management and conservation policies.

6133Profile of cardiomyopathy patients in Cape Town - pilot phase the IMHOTEP Study

Background

Cardiomyopathies pose a great challenge because of poor prognosis and high prevalence in LMIC with limited access to specialised care. Little is known about the clinical profile of cardiomyopathy in Africa.

Purpose

Delineation of clinical presentation and cardiovascular magnetic resonance (CMR) phenotypes of cardiomyopathy.

Method

The African Cardiomyopathy and Myocarditis Registry Program (IMHOTEP) is a prospective multi-centre, hospital-based study and aims to investigate the clinical characteristics, aetiology, genetics, management and outcomes of cardiomyopathies in Africans.

Results

Assessment of the first 99 adult cases showed that dilated cardiomyopathy (DCM; n=67) was commonest, followed by hypertrophic (HCM; n=13), left ventricular noncompaction (LVNC; n=11), restrictive (RCM; n=4) and arrhythmogenic (ARVC; n=4) cardiomyopathies. Idiopathic DCM (22%) and peripartum cardiomyopathy (16%) accounted for the majority (Figure). A family history of cardiomyopathy or SCD was reported in 20% of cases. Mean age of presentation was 37±12 years. Most patients (96%) were symptomatic at presentation. NYHA class III/IV was more frequently seen in DCM (61%), RCM (50%) and LVNC (64%), whereas syncope was more common in ARVC (50%) and HCM (23%). VT and aborted cardiac arrest were reported in 7% and 3%, respectively. Onset of symptoms in the peripartum period was observed in 47% of women. Beta-blockers and ACE-inhibitors were prescribed in 77% and 78%, respectively, however optimal dosing was achieved in ≤14% of patients at a median time of 5.4 months after symptom onset. CMR was performed in 67 (68%) cases (Table) and contributed diagnostically in a third of cases. Late gadolinium enhancement (LGE) was observed in 92%. In DCM, linear mid-wall and subendocardial patterns of LGE were seen in 95% and 8% of patients respectively – a much higher percentage than previously reported in the literature.

CMR volumetric and functional assessment DCM, n=38 HCM, n=11 ARVC, n=3 RCM, n=4 LVNC, n=11 LVEF (%) 27±15 78±7 55±5 52±7 32±17 LVEDV/BSA (ml/m2) 150±40 80±17 98±12 59±13 155±52 LV mass/BSA (g/m2) 82±23 102±35 74±3 71±14 88±31 RVEF (%) 34±15 68±10 22±15 49±18 33±15 RVEDV/BSA (ml/m2) 104±37 68±15 189±27 56±8 106±51 All continuous variables presented as mean ± standard deviation.

Cardiomyopathy diagnosis (n=99)

Conclusion

IMHOTEP is the first multi-centre registry for cardiomyopathy in Africa. Preliminary data suggests an earlier age of onset with female predominance compared to other cohorts, and DCM is the predominant form of cardiomyopathy in Africa.

Acknowledgement/Funding

NEWTON FUND NON-COMMUNICABLE DISEASE - South African Medical Research Council (SAMRC/GSK)

P2533Prospective randomized study on implanted cardiac rhythm recorders in pregnant women with symptomatic arrhythmia and/or structural heart disease

Background

Cardiac arrhythmia is an important cause of maternal morbidity and mortality in pregnancy, but is difficult to diagnose.

Purpose

The aim of this single-centre, prospective, randomized pilot study was to compare the implantable loop recorder (ILR) with standard assessment of arrhythmia (12-lead ECG; 24-hour Holter ECG) in terms of acceptability, detection of arrhythmias and impact on outcome in pregnant women with symptomatic arrhythmias and/or structural heart disease (SHD).

Methods

The study recruited 40 consecutive patients from a weekly, dedicated cardiac obstetric clinic. Inclusion criteria: symptoms of arrhythmia and/or having SHD at risk of arrhythmia. Patients were randomized to either standard care (SC) or standard care plus ILR (SC-ILR). ILR recordings were read at the monthly visits and/or when presenting with symptoms.

Results

There were no demographic differences between the study groups. Seventeen patients consented to ILR insertion, all of whom found the procedure acceptable. No arrhythmias were recorded by the 12-lead ECGs. Holter monitoring detected arrhythmias in 10 of 23 patients (43%) from the SC group. In the SC-ILR group, 8 of 17 patients (47%) had arrhythmias detected by Holter, whereas 13 of 17 patients (76%) patients had arrhythmias detected by ILR (p=0.157). One of 4 patients with supraventricular tachycardia, 2 of 3 patients with premature ventricular complexes and 2 patients with paroxysmal atrial fibrillation (AF) recorded by ILR did not have the arrhythmias detected by Holter monitoring (Figure 1A shows a scatter plot of the variable R-R intervals seen in AF and 1B a rhythm strip of AF with irregular RR intervals and the absence of P waves, both downloaded from the ILR). Four of these 5 patients (80%) had a change in management as a direct result of their ILR recordings. There were no maternal deaths up to 42 days postpartum in either of the study groups. Nine babies were born with a low birthweight (<2500g), 5 stillbirth/neonatal deaths and 1 pregnancy termination occurred (5 in the Holter group and 1 in ILR group, p=0.37).

Figure 1

Conclusion(s)

This study suggests that an ILR is an acceptable diagnostic modality in pregnant women with a suspected or at risk of arrhythmia. The ILR increased the diagnostic yield to detect arrhythmias that were not detected by routine ECG and Holter monitoring which led to a change in management in the SC-ILR group and was associated with better maternal and neonatal outcomes. The impact of ILR monitoring should be further assessed in larger studies with longer follow up.

Status of cardiac arrhythmia services in Africa in 2018: a PASCAR Sudden Cardiac Death Task Force report

Background

There is limited information on the availability of health services to treat cardiac arrhythmias in Africa.

Methods

The Pan–African Society of Cardiology (PASCAR) Sudden Cardiac Death Task Force conducted a survey of the burden of cardiac arrhythmias and related services over two months (15 October to 15 December) in 2017. An electronic questionnaire was completed by general cardiologists and electrophysiologists working in African countries. The questionnaire focused on availability of human resources, diagnostic tools and treatment modalities in each country.

Results

We received responses from physicians in 33 out of 55 (60%) African countries. Limited use of basic cardiovascular drugs such as anti–arrhythmics and anticoagulants prevails. Non–vitamin K–dependent oral anticoagulants (NOACs) are not widely used on the continent, even in North Africa. Six (18%) of the sub–Saharan African (SSA) countries do not have a registered cardiologist and about one–third do not have pacemaker services. The median pacemaker implantation rate was 2.66 per million population per country, which is 200–fold lower than in Europe. The density of pacemaker facilities and operators in Africa is quite low, with a median of 0.14 (0.03–6.36) centres and 0.10 (0.05–9.49) operators per million population. Less than half of the African countries have a functional catheter laboratory with only South Africa providing the full complement of services for cardiac arrhythmia in SSA. Overall, countries in North Africa have better coverage, leaving more than 110 million people in SSA without access to effective basic treatment for cardiac conduction disturbances.

Conclusion

The lack of diagnostic and treatment services for cardiac arrhythmias is a common scenario in the majority of SSA countries, resulting in sub–optimal care and a subsequent high burden of premature cardiac death. There is a need to improve the standard of care by providing essential services such as cardiac pacemaker implantation.

Sorbents can tailor nitrogen release from organic wastes to match the uptake capacity of crops

Delivering nutrients from mineral or organic fertilizers out of synchrony with crop uptake causes inefficiencies and pollution. We explore methodologies for evaluating sorbents as additives to organic agricultural wastes to retain nitrogen in an exchangeable form and deliver at rates that approximate the uptake capacity of roots. Focussing on ammonium (NH₄⁺) as the main inorganic nitrogen form in the studied wastes (sugarcane mill mud, poultry litter), we tested geo-sorbents and biochar for their ability to retain NH₄⁺. Sorption capacity was ranked palagonite < bentonite, biochar, vermiculite < chabazite, clinoptilolite (5.7 to 24.3 mg NH₄⁺ g^-1 sorbent). Sorbent-waste formulations were analysed for sorption capacity, leaching and fluxes of NH₄⁺. Ammonium-sorption capacity broadly translated to sorbent-waste formulations with clinoptilolite conferring the strongest NH₄⁺ attenuation (80%), and palagonite the lowest (7%). A 1:1 ratio of sorbent:waste achieved stronger sorption than a 0.5:1 ratio, and similar sorption as a 1:1.5 ratio. In line with these results, clinoptilolite-amended wastes had the lowest in situ NH₄⁺ fluxes, which exceeded the NH₄⁺ uptake capacity (I_max) of sugarcane and sorghum roots 9 to 84-fold, respectively. Less efficient sorbent-waste formulations and un-amended wastes exceeded I_max of crop roots up to 274-fold. Roots preferentially colonized stronger sorbent-waste formulations and avoided weaker ones, suggesting that lower NH₄⁺ fluxes generate a more favourable growth environment. This study contributes methodologies to identify suitable sorbents to formulate organic wastes as next-generation fertilizers with view of a crop's nutrient physiology. Efficient re-purposing of wastes can improve nutrient use efficiency in agriculture and support the circular nutrient economy.

Increasing body mass index and abdominal subcutaneous fat thickness are associated with increased skin-to-epidural space distance in pregnant women

BACKGROUND

Body mass index does not indicate the distribution of adipose tissue. Central adiposity may be measured using ultrasound measurement of subcutaneous fat thickness. This study determined if the abdominal subcutaneous fat thickness measured correlated with skin-to-epidural space distance at delivery, and compared this with the booking body mass index.

METHODS

We analysed a sub-set of participants from a single-centre, prospective cohort study that assessed the relationship between subcutaneous fat thickness and maternity outcomes. Abdominal subcutaneous fat thickness measurements were obtained during the routine fetal anomaly scan. The skin-to-epidural space distance was obtained in those having epidural or combined spinal-epidural analgesia. Linear regression was used to test for strength of association and adjusted R² values calculated to determine if subcutaneous fat thickness or body mass index was more strongly associated with skin-to-epidural space distance.

RESULTS

The 463 women had a median (IQR) booking body mass index of 25.0 kg/m² (21.8-29.3) and subcutaneous fat thickness of 16.2 mm (13.0-21.0). The median (IQR) skin-to-epidural space distance was 5.0 cm (4.5-6.0). Both parameters significantly correlated with skin-to-epidural space distance (r=0.53 and 0.68 respectively, P <0.001). Adjusted linear regression coefficient (95% CI) for subcutaneous fat thickness was 0.09 (0.08 to 0.11), R²=0.30 and for body mass index 0.12 (0.11 to 0.13), R²=0.47.

CONCLUSIONS

Booking body mass index had a stronger relationship with skin-to- epidural space distance at delivery than subcutaneous fat thickness, explaining 47% of the variation in the skin-to-epidural distance.

Epidural extension failure in obese women is comparable to that of non-obese women

BACKGROUND

Management of labor epidurals in obese women is difficult and extension to surgical anesthesia is not always successful. Our previous retrospective pilot study found epidural extension was more likely to fail in obese women. This study used a prospective cohort to compare the failure rate of epidural extension in obese and non-obese women and to identify risk factors for extension failure.

METHODS

One hundred obese participants (Group O, body mass index ≥ 40 kg/m² ) were prospectively identified and allocated two sequential controls (Group C, body mass index ≤ 30 kg/m² ). All subjects utilized epidural labor analgesia and subsequently required anesthesia for cesarean section. The primary outcome measure was failure of the labor epidural to be used as the primary anesthetic technique. Risk factors for extension failure were identified using Chi-squared and logistic regression.

RESULTS

The odds ratio (OR) of extension failure was 1.69 in Group O (20% vs. 13%; 95% CI: 0.88-3.21, P = 0.11). Risk factors for failure in obese women included ineffective labor analgesia requiring anesthesiologist intervention, (OR 3.94, 95% CI: 1.16-13.45, P = 0.028) and BMI > 50 kg/m² (OR 3.42, 95% CI: 1.07-10.96, P = 0.038).

CONCLUSION

The failure rate of epidural extension did not differ significantly between the groups. Further research is needed to determine the influence of body mass index > 50 kg/m² on epidural extension for cesarean section.

The Effectiveness of Regional Anaesthesia before and after the Introduction of a Dedicated Regional Anaesthesia Service Incorporating a Block Room

Dedicated regional anaesthesia services incorporating block rooms and/or block teams may facilitate theatre efficiency and improve training in regional anaesthesia. Currently, it is unknown if a dedicated regional anaesthesia service improves the effectiveness of regional anaesthesia. In November 2013, the Royal Brisbane and Women's Hospital established a dedicated regional anaesthesia service comprising a block team and a block room. Pre-intervention (conventional model of care) registry data was retrospectively compared with post-intervention (dedicated regional anaesthesia service) audit data, with regard to pain and opioid requirement in the post-anaesthesia care unit (PACU). The primary outcome was inadequate analgesia, defined as a numerical rating scale (NRS; 0, no pain; 10, worst pain imaginable) for pain >5 in the PACU. Pre- and post-intervention, 43.7% and 27.7% of patients respectively reported a NRS >5 (P <0.001). A difference in the type of blocks and surgery performed may have accounted for the improved outcome seen post-intervention. After adjustment for American Society of Anesthesiologists physical status, block type and surgery type, the odds ratio of having inadequate analgesia (NRS >5) was 0.54 (95% confidence interval 0.39 to 0.76) for post-intervention compared to pre-intervention. Secondary outcomes examined pre- and post-intervention were the absence of pain (39.3% and 55.1% of patients, respectively, P <0.001), systemic opioid analgesia requirement (48.6% and 30.5% of patients respectively, P <0.001) and median maximum NRS (4 [interquartile range (IQR) 0 to 8] and 0 [IQR 0 to 6] respectively, P <0.001). A dedicated regional anaesthesia service was associated with improved effectiveness of regional anaesthesia.

One-year efficacy and safety of saxagliptin add-on in patients receiving dapagliflozin and metformin

AIMS

Greater reductions in glycated haemoglobin (HbA1c) with saxagliptin, a dipeptidyl peptidase-4 inhibitor, versus placebo add-on in patients with type 2 diabetes who had inadequate glycaemic control with dapagliflozin 10 mg/d plus metformin were demonstrated after 24 weeks of treatment. Results over 52 weeks of treatment were assessed in this analysis.

MATERIALS AND METHODS

Patients (mean baseline HbA1c 7.9%) receiving open-label dapagliflozin 10 mg/d plus metformin were randomized to double-blind saxagliptin 5 mg/d or placebo add-on.

RESULTS

The adjusted mean change from baseline to week 52 in HbA1c was greater with saxagliptin than with placebo add-on -0.38% vs 0.05%; difference -0.42% (95% confidence interval -0.64, -0.20)]. More patients achieved the HbA1c target of <7% with saxagliptin than with placebo add-on (29% vs 13%), and fewer patients were rescued or discontinued the study for lack of glycaemic control with saxagliptin than with placebo add-on (19% vs 28%). Reductions from baseline in body weight (≤1.5 kg) occurred in both groups. Similar proportions of patients reported ≥1 adverse event with saxagliptin (58.2%) and placebo add-on (58.0%); no new safety signals were detected. Hypoglycaemia was infrequent in both treatment groups (≤2.5%), with no major episodes. The rate of urinary tract infections was similar in the saxagliptin and placebo add-on groups (7.8% vs 7.4%). The incidence of genital infections was 3.3% with saxagliptin versus 6.2% with placebo add-on.

CONCLUSIONS

Triple therapy with saxagliptin add-on to dapagliflozin plus metformin for 52 weeks resulted in sustained improvements in glycaemic control without an increase in body weight or increased risk of hypoglycaemia.

Cervical stenosis in spinal cord injury and disorders

CONTEXT/OBJECTIVE

The purpose of this study was to characterize etiologies of spinal cord injury and disorders (SCI/D) in persons with and without cervical stenosis/spondylosis (CSS) and to describe clinical characteristics and underlying comorbidities in these populations.

DESIGN AND SETTING

We reviewed administrative data for 1954 Veterans who had onset of traumatic or non-traumatic tetraplegia during FY 1999-2007. This included 1037 with a diagnosis of CSS at or in the two years prior to SCI onset of SCI/D and 917 without a diagnosis of CSS.

OUTCOME MEASURES

Demographics, etiologies of SCI/D and comorbidities by CSS status.

RESULTS

Veterans with SCI/D and CSS were older, more likely to have incomplete injuries and more likely to be Black than those with SCI/D and no CSS. Of patients with traumatic etiologies for SCI, 35.1% had a diagnosis of CSS at the time of or in the 2 years prior to SCI onset. Of those with tetraplegia due to falls, 40.0% had CSS, whereas for other known traumatic etiologies the percentages with CSS were lower: vehicular (25.0%); sports (16.1%); and acts of violence (10.2%). Total comorbidity scores measured by the Charlson co morbidity index and CMS Hierarchical Condition Category (CMS-HCC) were higher in those with CSS and SCI/D compared to those with SCI/D without CSS (P < 0.0001 respectively).

CONCLUSIONS

CSS is commonly present in patients with new traumatic tetraplegia. Falls are a particularly important potentially modifiable risk for SCI in patients with CSS.

The Glasgow Benefit Inventory: a systematic review of the use and value of an otorhinolaryngological generic patient-recorded outcome measure

BACKGROUND

The Glasgow Benefit Inventory (GBI) is a validated, generic patient-recorded outcome measure widely used in otolaryngology to report change in quality of life post-intervention.

OBJECTIVES OF REVIEW

To date, no systematic review has made (i) a quality assessment of reporting of Glasgow Benefit Inventory outcomes; (ii) a comparison between Glasgow Benefit Inventory outcomes for different interventions and objectives; (iii) an evaluation of subscales in describing the area of benefit; (iv) commented on its value in clinical practice and research.

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

'Glasgow Benefit Inventory' and 'GBI' were used as keywords to search for published, unpublished and ongoing trials in PubMed, EMBASE, CINAHL and Google in addition to an ISI citation search for the original validating Glasgow Benefit Inventory paper between 1996 and January 2015.

EVALUATION METHOD

Papers were assessed for study type and quality graded by a predesigned scale, by two authors independently. Papers with sufficient quality Glasgow Benefit Inventory data were identified for statistical comparisons. Papers with <50% follow-up were excluded.

RESULTS

A total of 118 eligible papers were identified for inclusion. A national audit paper (n = 4325) showed that the Glasgow Benefit Inventory gave a range of scores across the specialty, being greater for surgical intervention than medical intervention or 'reassurance'. Fourteen papers compared one form of surgery versus another form of surgery. In all but one study, there was no difference between the Glasgow Benefit Inventory scores (or of any other outcome). The most likely reason was lack of power. Two papers took an epidemiological approach and used the Glasgow Benefit Inventory scores to predict benefit. One was for tonsillectomy where duration of sore throat episodes and days with fever were identified on multivariate analysis to predict benefit albeit the precision was low. However, the traditional factor of number of episodes of sore throat was not predictive. The other was surgery for chronic rhinosinusitis where those with polyps on univariate analysis had greater benefit than those without. Forty-three papers had a response rate of >50% and gave sufficient Glasgow Benefit Inventory total and subscales for meta-analysis. For five of the 11 operation categories (vestibular schwannoma, tonsillectomy, cochlear implant, middle ear implant and stapes surgery) that were most likely to have a single clear clinical objective, score data had low-to-moderate heterogeneity. The value in the Glasgow Benefit Inventory having both positive and negative scores was shown by an overall negative score for the management of vestibular schwannoma. The other six operations gave considerable heterogeneity with rhinoplasty and septoplasty giving the greatest percentages (98% and 99%) most likely because of the considerable variations in patient selection. The data from these operations should not be used for comparative purposes. Five papers also reported the number of patients that had no or negative benefit, a potentially a more clinically useful outcome to report. Glasgow Benefit Inventory subscores for tonsillectomy were significantly different from ear surgery suggesting different areas of benefit

CONCLUSIONS

The Glasgow Benefit Inventory has been shown to differentiate the benefit between surgical and medical otolaryngology interventions as well as 'reassurance'. Reporting benefit as percentages with negative, no and positive benefit would enable better comparisons between different interventions with varying objectives and pathology. This could also allow easier evaluation of factors that predict benefit. Meta-analysis data are now available for comparison purposes for vestibular schwannoma, tonsillectomy, cochlear implant, middle ear implant and stapes surgery. Fuller report of the Glasgow Benefit Inventory outcomes for non-surgical otolaryngology interventions is encouraged.

Defining contralateral adrenal suppression in primary aldosteronism: implications for diagnosis and outcome

OBJECTIVE

Unilateral primary aldosteronism (PA) should have a contralaterally normal and therefore suppressed adrenal zona glomerulosa. However, there is no validated definition of adrenal suppression. We created two biochemical hypotheses of adrenal suppression based upon measurements taken during adrenal vein sampling (AVS) to determine whether either proved useful for interpretation of AVS or prediction of hypertension outcome in operated cases.

DESIGN

Retrospective database analysis.

PATIENTS

Ninety-nine cases of PA from a tertiary hypertension unit.

MEASUREMENTS

Hypothesis 1 was the proportional suppression of the uninvolved/lowest adrenal(aldo/cortisol) to IVC(aldo/cortisol) ratio pre- and post cosyntropin. Hypothesis 2 was the absolute decrease in the uninvolved adrenal(aldo/cortisol) ratio after cortrosyn injection. ROC analysis performed using lateralization and hypertension resolution as the outcomes of interest.

RESULTS

Hypothesis 1 proved highly predictive of lateralization with a ROC AUC of 0.958, P < 0.0001, giving adrenal(aldo/cortisol):IVC(aldo/cortisol) <1.4 as the optimized criterion (sensitivity 90%, specificity 94%). For blood pressure outcomes in the surgical subgroup (n = 52), hypertension resolution was most commonly seen among subjects with adrenal suppression by both definitions although there was significant overlap with subjects requiring ongoing medication.

CONCLUSIONS

Post cosyntropin suppression of the uninvolved adrenal-to-IVC ratio is a highly useful definition of adrenal suppression that accurately predicts unilateral PA. This may be particularly useful in a case where AVS fails to catheterize one of the adrenal veins but suppression is seen on the other side. Adrenal suppression may also predict blood pressure outcome, however, a much larger PA database is likely necessary to determine the relative contribution of this predictor.

Hypothalamic KISS1 expression, gonadotrophin-releasing hormone and neurotransmitter innervation vary with stress and sensitivity in macaques

The present study examined the effect of short-term psychosocial and metabolic stress in a monkey model of stress-induced amenorrhaea on the hypothalamic-pituitary-gonadal axis. KISS1 expression was determined by in situ hybridisation in the infundibular arcuate nucleus. Downstream of KISS1, gonadotrophin-releasing hormone (GnRH) axons in lateral areas rostral to the infundibular recess, serum luteinising hormone (LH) and serum oestradiol were measured by immunohistochemistry and radioimmunoassay. Upstream of KISS1, norepinephrine axons in the rostral arcuate nucleus and serotonin axons in the anterior hypothalamus and periaqueductal grey were measured by immunohistochemistry. Female cynomolgus macaques (Macaca fascicularis) characterised as highly stress resilient (HSR) or stress sensitive (SS) were examined. After characterisation of stress sensitivity, monkeys were either not stressed, or mildly stressed for 5 days before euthanasia in the early follicular phase. Stress consisted of 5 days of 20% food reduction in a novel room with unfamiliar conspecifics. There was a significant increase in KISS1 expression in HSR and SS animals in the presence versus absence of stress (P = 0.005). GnRH axon density increased with stress in HSR and SS animals (P = 0.015), whereas LH showed a gradual but nonsignificant increase with stress. Oestradiol trended higher in HSR animals and there was no effect of stress (P = 0.83). Norepinephrine axon density (marked with dopamine β-hydroxylase) increased with stress in both HSR and SS groups (P ≤ 0.002), whereas serotonin axon density was higher in HSR compared to SS animals and there was no effect of stress (P = 0.03). The ratio of dopamine β-hydroxylase/oestradiol correlated with KISS1 (P = 0.052) and GnRH correlated with serum LH (P = 0.039). In conclusion, oestradiol inhibited KISS1 in the absence of stress, although stress increased norepinephrine, which may over-ride oestradiol inhibition of KISS1 expression. We speculate that neural pathways transduce stress to KISS1 neurones, which changes their sensitivity to oestradiol.

Implementing a patient education intervention about Methicillin-resistant Staphylococcus aureus prevention and effect on knowledge and behavior in veterans with spinal cord injuries and disorders: a pilot randomized controlled trial

OBJECTIVES

To assess the feasibility and effect of a nurse-administered patient educational intervention about Methicillin-resistant Staphylococcus aureus (MRSA) prevention on knowledge and behavior of Veterans with spinal cord injuries and disorders (SCI/D).

DESIGN

Blinded, block-randomized controlled pilot trial.

SETTING

Two Department of Veterans Affairs (VA) SCI Centers.

PARTICIPANTS

Veterans were recruited March-September 2010 through referral by a healthcare provider from inpatient, outpatient, and residential care settings.

INTERVENTION

Thirty participants were randomized to the nurse-administered intervention and 31 to the usual care group. The intervention included a brochure and tools to assist nurses in conducting the education.

OUTCOME MEASURES

Pre- and post-intervention measurement of knowledge and behaviors related to MRSA and prevention strategies and feasibility measures related to implementation.

RESULTS

Participants were primarily male (95.1%), white (63.9%), with tetraplegia (63.9%) and mean age and duration of injury of 64.3 and 20.5 years, respectively. The intervention groups mean knowledge score significantly increased between pre- and post-test (mean change score = 1.70, 95% confidence interval, CI 0.25-3.15) while the usual care groups score did not significantly change (mean change score = 1.45, 95% CI -0.08-2.98). However, the mean knowledge change between intervention and usual care groups was not significantly different (P = 0.81). Overall behavior scores did not significantly differ between treatment groups; however, the intervention group was more likely to report intentions to clean hands (90.0% vs. 64.5%, P = 0.03) and asking providers about MRSA status (46.7% vs. 16.1%, P = 0.01). Nurse educators reported that the quality of the intervention was high and could be implemented in clinical care.

CONCLUSIONS

A targeted educational strategy is feasible to implement in SCI/D clinical practices and may improve some participants' knowledge about MRSA and increase intentions to improve hand hygiene and engagement with providers about their MRSA status.

Antibiotic prescribing trends in the emergency department for veterans with spinal cord injury and disorder 2002-2007

OBJECTIVE

Clinical guidelines exist to promote antibiotic stewardship, particularly in ambulatory care settings such as the emergency department (ED). However, there is limited evidence on prescribing practice for persons with spinal cord injury and disorder (SCI/D). The goal of this study was to assess trends in antibiotic prescribing in the ED setting for persons with SCI/D.

DESIGN

A retrospective dynamic cohort study design.

SETTING

ED visits that did not result in same day hospitalization over 6 years (fiscal year (FY) 2002-FY2007) in Department of Veterans Affairs (VA) facilities Participants Veterans with SCI/D.

OUTCOME MEASURES

VA clinical and administrative databases were used to identify the cohort and to obtain demographics, diagnoses, and medications. The rate of antibiotic prescribing for ED visits was defined as the number of antibiotics/total ED visits.

RESULTS

Veterans with SCI/D had 21 934 ED visits and 5887 antibiotics prescribed over the study period (rate of 268.4 prescriptions/1000 visits). The antibiotic prescribing rate increased from 238.8/1000 visits in FY2002 to 310.8/1000 visits in FY2007 (P < 0.0001). This increase in the rate of prescribing was seen across all patient demographics and factors assessed.

CONCLUSION

Although clinical guidelines for judicious use of antibiotics in persons with SCI/D have been disseminated to providers, antibiotic prescribing in an ED setting is high and continuing to rise in this population.

Population structure and residency patterns of the blacktip reef shark Carcharhinus melanopterus in turbid coastal environments

This study examined the characteristics of a blacktip reef shark Carcharhinus melanopterus population in turbid coastal habitats through a multi-year fishery-independent sampling and tag-recapture programme. Results revealed a highly structured population comprised almost entirely of juveniles and adult females with individuals between 850 and 1050 mm total length effectively absent. Mature males were also rarely encountered with adult sex ratio highly biased towards females (female:male = 7:1). Mating scars were observed on adult females between December and April, and parturition was observed from December to March. Regression analysis showed that catch rates were significantly higher during the summer wet season between November and May. Recapture data suggested a highly resident population with a recapture rate of 21% and a mean recapture distance of 0·8 km. In addition, 33% of recaptured animals were captured multiple times, indicating long-term residency. Most recaptures were, however, of adults with few juveniles recaptured. Widespread sampling at the study site and in adjacent areas suggested that the population was highly localized to a specific bay. The bimodal and sex-segregated population structure observed here differs from previous reports for this species, and in combination with reproductive observations, suggests population structuring to facilitate reproductive and recruitment success. These data also highlight the potential ecosystem functions performed by coastal habitats in sustaining C. melanopterus populations.

The role of mechanical forces and adenosine in the regulation of intestinal enterochromaffin cell serotonin secretion

Enterochromaffin (EC) cells of the diffuse neuroendocrine cell system secrete serotonin (5-HT) with activation of gut motility, secretion, and pain. These cells express adenosine (ADORA) receptors and are considered to function as mechanosensors. Physiological pathways mediating mechanosensitivity and adenosine responsiveness remain to be fully elucidated, as do their roles in inflammatory bowel disease (IBD) and neoplasia. Pure (98-99%) FACS-sorted normal and IBD human EC cells and neoplastic EC cells (KRJ-I) were studied. IBD-EC cells and KRJ-I overexpressed ADORA2B. NECA, a general ADORA receptor agonist, stimulated, whereas the A2B receptor antagonist MRS1754 inhibited, 5-HT release (EC50 = 1.8 × 10-6 M; IC50 = 3.7 × 10-8 M), which was associated with corresponding alterations in intracellular cAMP levels and pCREB (Ser133). Mechanical stimulation using a rhythmic flex model induced transcription and activation of Tph1 (tryptophan hydroxylase) and VMAT₁ (vesicular monoamine transporter 1) and the release of 5-HT, which could be inhibited by MRS1754 and amplified by NECA. Secretion was also inhibited by H-89 (PKA inhibitor) while Tph1 and VMAT₁ transcription was regulated by PKA/MAPK and PI₃K-mediated signaling. Normal and IBD-EC cells also responded to NECA and mechanical stimulation with PKA activation, cAMP production, and 5-HT release, effects reversible by MRS1754. EC cells express stimulatory ADORA2B, and rhythmic stretch induces A2B activation, PKA/MAPK/IP3-dependent transcription, and PKA-dependent secretion of 5-HT synthesis and secretion. Receptor expression is amplified in IBD and neoplasia, and 5-HT release is increased. Determination of factors that regulate EC cell function are necessary for understanding its role as a mechanosensory cell and to facilitate the development of agents that can selectively target cell function in EC cell-associated disease.