Synthesis of the European ALARA network 20th workshop 'ALARA for interventional radiology and nuclear medicine'

The European as low as reasonably achievable(ALARA) network regularly organises workshops on topical issues in radiation protection (RP). The topic of the 20th workshop was: 'ALARA for interventional radiology (IR) and nuclear medicine (NM)'. The objective was to examine the challenges faced when applying the optimisation principle (ALARA) in IR and NM and to consider how ALARA could be better implemented for patient and staff exposures. This memorandum provides a synthesis of the workshop sessions, and recommendations coming from the working groups discussion. Parallels are drawn with the recommendations arising from the 13th EAN workshop on 'ALARA and the medical sector (2011)' to consider how the optimisation challenges in IR and NM have evolved over the past decade. Current levels of exposure are presented along with operational practice and the challenges and opportunities for improvement, both in monitoring and practice. Whilst RP challenges remain, the application of ALARA appears more established in IR compared with experiences reported in 2011. The application of ALARA to emerging technologies in the NM setting is in need of further development to ensure that RP is considered at all stages in the development process of new radiopharmaceuticals. Besides the obvious technical and operational aspects, the importance of education and training, human factors and broadly the RP 'culture' were deemed fundamental to the success of the application of ALARA and where further emphasis is needed. All concerned parties, medical physics experts (MPEs), radiation protection experts, clinical staff, manufacturers and regulators have a role to play in the application of ALARA and this is discussed in the memorandum. Many of the recommendations from the 13th EAN workshop remain applicable today and overlap with the recommendations arising from the 20th workshop. This should prompt attention given that the use of IR and the development of novel radiopharmaceuticals for NM is only anticipated to increase with time.

Combined approaches, including long-read sequencing, address the diagnostic challenge of HYDIN in primary ciliary dyskinesia

Primary ciliary dyskinesia (PCD), a disorder of the motile cilia, is now recognised as an underdiagnosed cause of bronchiectasis. Accurate PCD diagnosis comprises clinical assessment, analysis of cilia and the identification of biallelic variants in one of 50 known PCD-related genes, including HYDIN. HYDIN-related PCD is underdiagnosed due to the presence of a pseudogene, HYDIN2, with 98% sequence homology to HYDIN. This presents a significant challenge for Short-Read Next Generation Sequencing (SR-NGS) and analysis, and many diagnostic PCD gene panels do not include HYDIN. We have used a combined approach of SR-NGS with bioinformatic masking of HYDIN2, and state-of-the-art long-read Nanopore sequencing (LR_NGS), together with analysis of respiratory cilia including transmission electron microscopy and immunofluorescence to address the underdiagnosis of HYDIN as a cause of PCD. Bioinformatic masking of HYDIN2 after SR-NGS facilitated the detection of biallelic HYDIN variants in 15 of 437 families, but compromised the detection of copy number variants. Supplementing testing with LR-NGS detected HYDIN deletions in 2 families, where SR-NGS had detected a single heterozygous HYDIN variant. LR-NGS was also able to confirm true homozygosity in 2 families when parental testing was not possible. Utilising a combined genomic diagnostic approach, biallelic HYDIN variants were detected in 17 families from 242 genetically confirmed PCD cases, comprising 7% of our PCD cohort. This represents the largest reported HYDIN cohort to date and highlights previous underdiagnosis of HYDIN-associated PCD. Moreover this provides further evidence for the utility of LR-NGS in diagnostic testing, particularly for regions of high genomic complexity.

The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

National UK Survey of Radiation Doses During Endovascular Aortic Interventions

PURPOSE

Endovascular aortic repair (EAR) interventions, endovascular abdominal aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR), are associated with significant radiation exposures. We aimed to investigate the radiation doses from real-world practice and propose diagnostic reference level (DRL) for the UK.

MATERIALS AND METHODS

Radiation data and essential demographics were retrospectively collected from 24 vascular and interventional radiology centres in the UK for all patients undergoing EAR-standard EVAR or complex, branched/fenestrated (BEVAR/FEVAR), and TEVAR-between 2018 and 2021. The data set was further categorised according to X-ray unit type, either fixed or mobile. The proposed national DRL is the 75th percentile of the collective medians for procedure KAP (kerma area product), cumulative air kerma (CAK), fluoroscopy KAP and CAK.

RESULTS

Data from 3712 endovascular aortic procedures were collected, including 2062 cases were standard EVAR, 906 cases of BEVAR/FEVAR and 509 cases of TEVAR. The majority of endovascular procedures (3477/3712) were performed on fixed X-ray units. The proposed DRL for KAP was 162 Gy cm2, 175 Gy cm2 and 266 Gy cm2 for standard EVAR, TEVAR and BEVAR/FEVAR, respectively.

CONCLUSION

The development of DRLs is pertinent to EAR procedures as the first step to optimise the radiation risks to patients and staff while maintaining the highest patient care and paving the way for steps to reduce radiation exposures.

Airo® navigation versus freehand fluoroscopy technique: A comparative study of accuracy and radiological exposure for thoracolumbar screws placement

PURPOSE

The aim was to compare the accuracy of freehand fluoroscopy and CT based navigation on thoracolumbar screws placement and their respective effects on radiological exposure to the patient. No previous study directly compared the Airo® navigation system to freehand technique.

METHODS

In this monocentric retrospective study, 156 consecutive patients who underwent thoracolumbar spine surgery were included. Epidemiological data and surgical indications were noted. Heary classification was used for thoracic screws and Gertzbein-Robbins classification for lumbar screws. Radiological exposure was collected for each surgery.

RESULTS

A total of 918 screws were implanted. We analyzed 725 lumbar screws (Airo® 287; freehand fluoroscopy 438) and 193 thoracic screws (Airo® 49; freehand fluoroscopy 144). Overall, lumbar screws accuracy (Gertzbein-Robbins grade A and B) was good in both groups (freehand fluoroscopy 91.3%; Airo® 97.6%; P<0.05). We found significantly less Grade B and C in the Airo® group. Thoracic accuracy was also good in both groups (Heary 1 and 2; freehand fluoroscopy 77.8%; Airo® 93.9%), without reaching statistical significance. Radiological exposure was significantly higher in the Airo® group with a mean effective dose of 9.69 mSv versus 0.71mSv for freehand fluoroscopy.

CONCLUSION

Our study confirmed that the use of Airo® navigation yielded good accuracy. It however exposed the patient to higher radiological exposure compared with freehand fluoroscopy technique.

LEVEL OF EVIDENCE

Level 3.

A comparison of self-reported risk and protective factors and the death implicit association test in the prediction of future suicide attempts in adolescent emergency department patients

BACKGROUND

Concerns have been raised about the utility of self-report assessments in predicting future suicide attempts. Clinicians in pediatric emergency departments (EDs) often are required to assess suicidal risk. The Death Implicit Association Test (IAT) is an alternative to self-report assessment of suicidal risk that may have utility in ED settings.

METHODS

A total of 1679 adolescents recruited from 13 pediatric emergency rooms in the Pediatric Emergency Care Applied Research Network were assessed using a self-report survey of risk and protective factors for a suicide attempt, and the IAT, and then followed up 3 months later to determine if an attempt had occurred. The accuracy of prediction was compared between self-reports and the IAT using the area under the curve (AUC) with respect to receiver operator characteristics.

RESULTS

A few self-report variables, namely, current and past suicide ideation, past suicidal behavior, total negative life events, and school or social connectedness, predicted an attempt at 3 months with an AUC of 0.87 [95% confidence interval (CI), 0.84-0.90] in the entire sample, and AUC = 0.91, (95% CI 0.85-0.95) for those who presented without reported suicidal ideation. The IAT did not add significantly to the predictive power of selected self-report variables. The IAT alone was modestly predictive of 3-month attempts in the overall sample ((AUC = 0.59, 95% CI 0.52-0.65) and was a better predictor in patients who were non-suicidal at baseline (AUC = 0.67, 95% CI 0.55-0.79).

CONCLUSIONS

In pediatric EDs, a small set of self-reported items predicted suicide attempts within 3 months more accurately than did the IAT.

The Value of Sport: Wellbeing Benefits of Sport Participation during Adolescence

Insight into the unique benefits of sport participation above and beyond those associated with participation in other physical activities among adolescents is limited in Aotearoa New Zealand (NZ). The purpose of this study was to examine the association between wellbeing and organised sport participation among adolescents whilst accounting for demographic characteristics and other recreational physical activity. Demographic characteristics (age, gender, ethnicity, deprivation, (dis)ability status), organized sport, recreational physical activity, and wellbeing were assessed in cohorts of NZ adolescents (11–17 years) between 2017 and 2019. After adjusting for demographics, better wellbeing was associated with participation in any recreational physical activity (OR = 2.49, 95%CI = 1.97–3.13), meeting physical activity recommendations (OR = 1.63, 95%CI = 1.47–1.81), and each additional hour of recreational physical activity (OR = 1.03, 95%CI = 1.02–1.04). After adjusting for demographics and overall recreational physical activity participation, better wellbeing was also associated with participation in any organized sport (OR = 1.66, 95%CI = 1.49–1.86), and each additional hour of organized sport (OR = 1.09, 95%CI = 1.07–1.11). Although participation in recreational physical activity appears to be beneficial for wellbeing, organized sport appears to offer unique additional wellbeing benefits. Positive experiences of organized sport participation may offer additional wellbeing value above and beyond other recreational physical activity types in young people who are active.

Machine-learned physiological signatures from the ECG predict sudden death in ischemic cardiomyopathy

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Health (NIH)

Background

Low left ventricular ejection fraction (LVEF) is an imperfect predictor of sudden cardiac death (SCD) in patients with ischemic cardiomyopathy. Novel features from the ECG might provide a readily available tool to better predict risk.

Purpose

We hypothesized that machine learning (ML) of the ECG can be used to predict SCD, and the ML-learned ECG features could be referenced to interpretable intracardiac signals (monophasic action potentials: MAP) to provide mechanistic insights.

Methods

We studied 5603 ECG Lead V1 beats in 41 patients (64±10 Y) with coronary disease and LVEF≤40% in steady-state pacing. Patients were randomly allocated to independent training and test cohorts in a 70:30 ratio, repeated K=10-fold. Support vector machines were trained to predict mortality at 3Y from the top 20 features derived from these beats. Patient-level predictions were made by computing an ECG score that indicates the proportion of test set beats in that patient computed by the beat-level model to predict death. Explainability analysis was performed using the arithmetic mean of MAP and ECG beats that predicted SCD versus those that predicted survival.

Results

Fig 1A. shows ECG lead V1 and MAP in a 79 Y man with LVEF 29%. Fig 1B shows the dataflow in the study. Predictive accuracies of ML models were 78 and 70% and optimal with 20 features for both ECG and MAP models respectively (Fig. 1C). Beat-level predictions in the validation (n=1678 Lead I beats) cohorts yielded c-statistics of 0.78 with the ECG (95% CI, 0.62–0.91) and 0.75 with MAPs (95% CI, 0.75-0.76) (data not shown). In multivariable patient-level models, c-statistic was 0.87 with ECGs (95% CI, 0.76-0.98) (Fig 1D) and 0.82 with MAPs. On explainability analysis, ECG beats that predicted SCD (Fig 2; red) had lower amplitude and more notched T-waves in lead V1 than beats that predicted no SCD (Fig 2; blue). MAP that predicted SCD had higher repolarization current at the same time points. Both QT duration (ECG) and action potential duration (MAP) did not differ (Fig 2).

Conclusions

Machine learning of the ECG reveals novel predictors of SCD risk in patients with ischemic cardiomyopathy analogous to those identified in intracardiac signals. This approach can be used as a point-of-care ECG risk tool to improve risk stratification and allocation for ICD therapy beyond LVEF alone and may shed insights into the pathophysiology of ventricular arrhythmias.

Prescribing and using vitiligo treatments - lessons from a nested Process Evaluation within the HI-Light Vitiligo Randomised Controlled Trial

Background

The HI‐Light Trial demonstrated that for active, limited vitiligo, combination treatment with potent topical corticosteroid (TCS) and handheld narrowband ultraviolet B offers a better treatment response than potent TCS alone. However, it is unclear how to implement these findings.

Aim

We sought to answer three questions: (i) Can combination treatment be used safely and effectively by people with vitiligo?; (ii) Should combination treatment be made available as routine clinical care?; and (iii) Can combination treatment be integrated within current healthcare provision?

Methods

This was a mixed‐methods process evaluation, including semi‐structured interviews with a purposive sample of trial participants, structured interviews with commissioners, and an online survey and focus groups with trial staff. Transcripts were coded by framework analysis, with thematic development by multiple researchers.

Results

Participants found individual treatments easy to use, but the combination treatment was complicated and required nurse support. Both participants and site investigators felt that combination treatment should be made available, although commissioners were less certain. There was support for the development of services offering combination treatment, although this might not be prioritized above treatment for other conditions. A ‘mixed economy’ model was suggested, involving patients purchasing their own devices, although concerns regarding the safe use of treatments mean that training, monitoring and ongoing support are essential. The need for medical physics support may mean that a regional service is more practical.

Conclusion

Combination treatment should be made available for people seeking treatment for vitiligo, but services require partnership with medical physics and ongoing training and support for patients.

Measuring the 15O(α,γ)19Ne Reaction in Type I X-ray Bursts using the GADGET II TPC: Software

15O(α,γ)19Ne is regarded as one of the most important thermonuclear reactions in type I X-ray bursts. For studying the properties of the key resonance in this reaction using β decay, the existing Proton Detector component of the Gaseous Detector with Germanium Tagging (GADGET) assembly is being upgraded to operate as a time projection chamber (TPC) at FRIB. This upgrade includes the associated hardware as well as software and this paper mainly focusses on the software upgrade. The full detector set up is simulated using the ATTPCROOTv 2 data analysis framework for 20Mg and 241Am.

Measuring the 15O(α, γ)19Ne reaction in Type I X-ray bursts using the GADGET II TPC: Hardware

Sensitivity studies have shown that the 15O(α, γ)19Ne reaction is the most important reaction rate uncertainty affecting the shape of light curves from Type I X-ray bursts. This reaction is dominated by the 4.03 MeV resonance in 19Ne. Previous measurements by our group have shown that this state is populated in the decay sequence of 20Mg. A single 20Mg(βp α)15O event through the key 15O(α, γ)19Ne resonance yields a characteristic signature: the emission of a proton and alpha particle. To achieve the granularity necessary for the identification of this signature, we have upgraded the Proton Detector of the Gaseous Detector with Germanium Tagging (GADGET) into a time projection chamber to form the GADGET II detection system. GADGET II has been fully constructed, and is entering the testing phase.

Learning from mistakes when reporting urgent and emergency vascular studies

The majority of out-of-hours cases relate to neurological, chest, and gastrointestinal pathologies with acute vascular cases being encountered less commonly. Trainees and exposure of non-vascular/interventional radiology (IR) consultants to angiographic imaging is often limited in working hours and this may lead to reporting on-call cases outside of normal daytime practice. In a recent local review, a number on-call vascular studies were found to contain a number of vascular-related discrepancies. Vascular reporting is a complex subspecialty, which comprises many clear diagnoses (large vessel occlusions, large vessel aneurysms, or dissections); however, also several subtle and complex abnormalities. These more subtle abnormalities, at times, require dedicated vascular specialist review to ensure subtle findings are communicated appropriately to the clinical team. The recent increased complexity of endovascular treatments and their complications has also provided further challenge for the non-specialist reporter. Similarly, improved imaging techniques have allowed for non-obvious but significant findings that may require urgent management, such as small aneurysms and dissection flaps. We will review a range of key vascular findings that demonstrate learning opportunities, particularly within the acute and on-call settings. These will include gastrointestinal haemorrhage, subtle aortic pathologies, head and neck vascular emergencies, small to mid-sized vessel injuries and imaging of post-procedural complications. Educational hints and tips will be provided to enable learning from mistakes encountered by trainees and non-vascular specialist radiologists in the on-call or urgent reporting settings, and these will be reviewed with reference to the literature.

Optimal timing and technique for endoscopic management of dysphagia in pediatric aerodigestive patients

INTRODUCTION

The best strategy to manage an interarytenoid defect [Type 1 laryngeal cleft (LC-1) or deep interarytenoid groove (DIG)] in pediatric aerodigestive patients with dysphagia remains uncertain. This study compared benefit of interarytenoid augmentation (IAA) to suture repair or clinical observation alone in pediatric patients.

METHODS

A 3-year retrospective, single-center analysis of children with dysphagia undergoing endoscopic airway evaluation was performed. Physician preference guided treatment plan: suture repair with CO2 laser, IAA (carboxy methylcellulose or calcium hydroxyapatite), or observation. Primary outcome was improved post-operative diet. Significance was assumed at p < 0.05.

RESULTS

449 patients underwent diagnostic endoscopy. Mean age (±SD) at procedure was 21 ± 13 months, with nearly one fourth (28 %) of children ≤ 12 months. Eighty (18 %) had either an LC-1 (n = 55) or DIG (n = 25). Of these, 35 (42 %) underwent suture repair, 22 (28 %) IAA, and 23 (30 %) observation only. Aspiration improved overall in the interventional groups compared to observational controls (58 % vs. 9 %, p < 0.05), with no change in benefit observed by age of intervention. IAA was as effective as suture repair (59 % vs 55 %, p = 0.46). In patients with only a DIG, IAA intervention alone significantly improved swallow function (66.6 % vs. 0 %, p < 0.05).

CONCLUSION

In pediatric aerodigestive patients with dysphagia, 18 % of children have an addressable lesion. IAA or suture repair similarly improves dietary advancement. IAA improves swallow function in patients with DIG. These findings support a novel protocol to intervene in dysphagia patients with LC-1 or DIG via IAA at the initial operative evaluation.

A case of intramuscular lumbar myxoma: Uncertainty in the preoperative diagnosis of a spinal soft tissue tumour

We report an uncommon case of a 76-year-old woman who presented with lower back pain, an intermittent L5 radiculopathy and a right palpable paraspinal mass. Imaging studies revealed a 7-cm lumbar paraspinal pseudo-cystic soft tissue tumour developed in the paravertebral musculature, without a clear radiological diagnosis. Gross total surgical resection was performed, resulting in complete resolution of pain. Histopathological studies revealed an intramuscular (IM) myxoma. With a low positive predictive value of radiological work-up and a poor yield of percutaneous biopsies, surgery remains the mainstay treatment for these rare soft tissue tumours of the lumbar spine. Intramuscular myxomas show excellent postoperative results.

A comparison of two peak skin dose metrics calculated by patient dose management systems: implications for clinical management

Objective:

The patient dose monitoring systems DoseWatch and DoseWise were compared to evaluate their reported patient Peak Skin Dose.

Methods:

20 patients with the highest Peak Skin Dose on DoseWise were obtained; the values were converted to a Reference Point Air Kerma (RPAK) value and used for comparison. These patients were accessed in DoseWatch to obtain the recorded Worst Case RPAK. The co-ordinates for the position were obtained for each patient to find a primary and secondary angular position for the peak skin dose. The two positions produced by the two softwares were compared.

Results:

There is a mean deviation of over 0.5 Gy between the two software packages when comparing the calculated maximum skin air kerma Peak skin dose from DoseWise and the Worst Case RPAK from DoseWatch.

Conclusion:

We have shown mean deviations between these two systems. This difference is enough, for higher peak skin absorbed dose patients, to change the management of patients, so local services must understand their models to properly implement patient management.

Advances in knowledge:

Neither system is incorrect, but these differences show that a deeper understanding of the analysis limitations is required to properly inform post-procedural high-skin dose follow-up procedures.

684 Use of Overnight Pulse Oximetry and STBUR Questionnaire for Paediatric OSA In A District General Setting

Introduction

Overnight pulse oximetry (OPO) is often used to support the diagnosis of obstructive sleep apnoea (OSA) and stratify risk of peri-operative breathing difficulties in children undergoing adenotonsillectomy for OSA. Our objective was to audit our indications for OPO and the impact on subsequent ENT management. We sought to assess the correlation of STBUR (Snoring, Troubled-breathing, Unrefreshed Questionnaire) score with OPO values in these patients.

Method

Retrospective review of 32 OPO reports over a 7-month period. Data collected included age, weight, indication, mean spO2, number of dips &gt;4%, outcome and STBUR score.

Results

The commonest indication (19) for OPO was to assess severity of OSA in children &lt;3 or those with significant comorbidity to determine best setting for surgery; 50% were ultimately managed in a tertiary centre. 10 children underwent OPO due to diagnostic uncertainty but significant parental concern; all studies normal and parents reassured. STBUR score correlated poorly with number of dips &gt;4% (R = 0.0109) and mean nadir &gt;4% (R = 0.0031) Weight poorly recorded (19%).

Conclusions

Referrals were generally appropriate and influenced management in all cases. STBUR scores insufficiently sensitive to stratify severity of OSA. New protocol developed.

345 A Novel Study Exploring the Hidden Cost of Insufficient Investment in Computer Technology in a District General Hospital

Introduction

The NHS’ move towards increasing digitisation is limited by inadequate resourcing. It is estimated 70% of a junior doctor’s time is spent completing computer-based administrative work. Aging and insufficient equipment leads to inefficiency. The objective of this study is to investigate the hidden cost of insufficient and poorly performing computer technology.

Method

Surveys were disseminated to doctors and data was collected regarding designation, ward, salary and estimated ‘minutes-waiting’ for computers to become free (CF) and to load (CL).

Results

33 surveys were completed. The hospital-wide average CF and CL were 25 minutes and 31.06 minutes respectively, with a corresponding average daily cost per doctor of £10.16 (CF) and £12.63 (CL), totalling £22.79/doctor/day. In the highest-expense ward, CF (31.66 minutes) and CL (38.33 minutes) equated to £30.28/doctor/day. Following acquisition of new hardware and re-audit, CL was significantly reduced to 20.4 minutes (p = 0.0142).

Conclusions

This study highlights the hidden cost of insufficient, poorly performing hardware. Every day the total cost of time-wasted greatly surpasses the cost of a single computer unit, illustrating the false economy of reduced capital investment in computer technology.

O38: TACKING VERSUS NO TACKING IN LAPAROSCOPIC TOTALLY EXTRAPERITONEAL REPAIR OF PRIMARY INGUINAL HERNIA - A SYSTEMATIC REVIEW AND META-ANALYSIS

Introduction

The necessity of mesh fixation in laparoscopic totally extraperitoneal (TEP) inguinal hernia repair remains controversial. We performed a systematic review and meta-analysis to compare the effectiveness of mesh tacking versus no tacking in laparoscopic TEP repair for primary inguinal hernia.

Materials and Methods

PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until November 2019. All studies that compared tacking versus no tacking in TEP repairs for inguinal herniae were included. Recurrent and femoral herniae were excluded from the current analysis. The primary outcome measure was recurrence, while secondary outcomes included postoperative pain scores at discharge and at 1 month, mean operative time, length of stay and seroma rates. Random effects models were used to calculate pooled effect size estimates.

Result

Eight randomised controlled trials were included capturing 557 patients and 715 inguinal herniae. On random effects analysis, there were no significant differences between tacking and no tacking in terms of recurrence (OR 0.94, 95% CI=0.10 to 9.28, p=0.96), postoperative pain scores on discharge (Mean difference 0.82, 95% CI=-0.35 to 2.00, p=0.17) or at 1 month (Mean difference 0.53, 95% CI=-0.75 to 1.82, p=0.41), mean operative time (Mean difference 1.58 mins, 95% CI=-0.22 to 3.37, p=0.09), seroma (OR=0.70, 95% CI=0.28 to 1.74, p=0.44) or length of stay (Mean difference 0.11 days, 95% CI=-0.04 to 0.25, p=0.14).

Conclusion

Mesh tacking in laparoscopic TEP repair for primary inguinal herniae does not translate into improved postoperative outcomes and may be omitted.

Take-home message

Mesh tacking in laparoscopic TEP repair for primary inguinal herniae does not translate into improved postoperative outcomes and may be omitted.

Sex differences in the mortality rate for coronavirus disease 2019 compared to other causes of death

Men are more likely than women to die due to coronavirus disease 2019 (COVID-19). This paper sets out to examine whether the magnitude of the sex differences in the COVID-19 mortality rate are unusual when compared to other common causes of death. In doing so, we aim to provide evidence as to whether the causal pathways for the sex differences in the mortality rate of COVID-19 likely differ from those for other causes of death. We found that sex differences in the age-standardized COVID-19 mortality rate were substantially larger than for the age-standardized all-cause mortality rate and most other common causes of death. These differences were especially large in the oldest age groups.

One Sentence Summary

The sex difference in the mortality rate of coronavirus disease 2019 is substantially larger than for other common causes of death.

Randomized controlled trial of topical corticosteroid and home-based narrowband ultraviolet B for active and limited vitiligo: results of the HI-Light Vitiligo Trial

BACKGROUND

Evidence for the effectiveness of vitiligo treatments is limited.

OBJECTIVES

To determine the effectiveness of (i) handheld narrowband UVB (NB-UVB) and (ii) a combination of potent topical corticosteroid (TCS) and NB-UVB, compared with TCS alone, for localized vitiligo.

METHODS

A pragmatic, three-arm, placebo-controlled randomized controlled trial (9-month treatment, 12-month follow-up). Adults and children, recruited from secondary care and the community, aged ≥ 5 years and with active vitiligo affecting < 10% of skin, were randomized 1 : 1 : 1 to receive TCS (mometasone furoate 0·1% ointment + dummy NB-UVB), NB-UVB (NB-UVB + placebo TCS) or a combination (TCS + NB-UVB). TCS was applied once daily on alternating weeks; NB-UVB was administered on alternate days in escalating doses, adjusted for erythema. The primary outcome was treatment success at 9 months at a target patch assessed using the participant-reported Vitiligo Noticeability Scale, with multiple imputation for missing data. The trial was registered with number ISRCTN17160087 on 8 January 2015.

RESULTS

In total 517 participants were randomized to TCS (n = 173), NB-UVB (n = 169) and combination (n = 175). Primary outcome data were available for 370 (72%) participants. The proportions with target patch treatment success were 17% (TCS), 22% (NB-UVB) and 27% (combination). Combination treatment was superior to TCS: adjusted between-group difference 10·9% (95% confidence interval 1·0%-20·9%; P = 0·032; number needed to treat = 10). NB-UVB alone was not superior to TCS: adjusted between-group difference 5·2% (95% CI - 4·4% to 14·9%; P = 0·29; number needed to treat = 19). Participants using interventions with ≥ 75% expected adherence were more likely to achieve treatment success, but the effects were lost once treatment stopped. Localized grade 3 or 4 erythema was reported in 62 (12%) participants (including three with dummy light). Skin thinning was reported in 13 (2·5%) participants (including one with placebo ointment).

CONCLUSIONS

Combination treatment with home-based handheld NB-UVB plus TCS is likely to be superior to TCS alone for treatment of localized vitiligo. Combination treatment was relatively safe and well tolerated but was successful in only around one-quarter of participants.

An economic evaluation of the randomized controlled trial of topical corticosteroid and home-based narrowband ultraviolet B for active and limited vitiligo (the HI-Light Vitiligo Trial)

BACKGROUND

Economic evidence for vitiligo treatments is absent.

OBJECTIVES

To determine the cost-effectiveness of (i) handheld narrowband ultraviolet B (NB-UVB) and (ii) a combination of topical corticosteroid (TCS) and NB-UVB compared with TCS alone for localized vitiligo.

METHODS

Cost-effectiveness analysis alongside a pragmatic, three-arm, placebo-controlled randomized controlled trial with 9 months' treatment. In total 517 adults and children (aged ≥ 5 years) with active vitiligo affecting < 10% of skin were recruited from secondary care and the community and were randomized 1: 1: 1 to receive TCS, NB-UVB or both. Cost per successful treatment (measured on the Vitiligo Noticeability Scale) was estimated. Secondary cost-utility analyses measured quality-adjusted life-years using the EuroQol 5 Dimensions 5 Levels for those aged ≥ 11 years and the Child Health Utility 9D for those aged 5 to < 18 years. The trial was registered with number ISRCTN17160087 on 8 January 2015.

RESULTS

The mean ± SD cost per participant was £775 ± 83·7 for NB-UVB, £813 ± 111.4 for combination treatment and £600 ± 96·2 for TCS. In analyses adjusted for age and target patch location, the incremental difference in cost for combination treatment compared with TCS was £211 (95% confidence interval 188-235), corresponding to a risk difference of 10·9% (number needed to treat = 9). The incremental cost was £1932 per successful treatment. The incremental difference in cost for NB-UVB compared with TCS was £173 (95% confidence interval 151-196), with a risk difference of 5·2% (number needed to treat = 19). The incremental cost was £3336 per successful treatment.

CONCLUSIONS

Combination treatment, compared with TCS alone, has a lower incremental cost per additional successful treatment than NB-UVB only. Combination treatment would be considered cost-effective if decision makers are willing to pay £1932 per additional treatment success.

Deep neural network trained on surface ECG improves diagnostic accuracy of prior myocardial infarction over Q wave analysis

Background

Detection of prior myocardial infarction (MI) may inform arrhythmia treatment and prognosis, yet cardiac imaging is resource intensive. ECG Q-wave analysis is quick and inexpensive but has poor accuracy for assessing prior MI.

Purpose

To evaluate the ability of a deep neural network (DNN) trained on the surface ECG to identify patients with prior MI.

Methods

We assessed 608 well-characterized patients (61.4±14.5 years, 31.2% female) at 2 academic centers. From one 12-lead ECG, median beats were calculated in 3 orthogonal planes (X, Y, Z; Fig. 1A) and used to train a DNN to identify a history of prior MI. Accuracy was compared to manual assessment of pathologic Q waves, defined as a deflection &gt;25% of the subsequent R wave, &gt;40ms in width, and &gt;0.2mV amplitude in 1 of 3 ECG planes.

Results

Of 608 patients, 175 had history of MI (28.7%). The DNN outperformed the accuracy of pathologic Q waves. In training, DNN converged to &gt;98% accuracy and in testing, its accuracy was 71±5% (Fig. 1B) (k=5-fold cross validation). This outperformed the 62% accuracy of pathologic Q waves in this study (red dotted line, Fig. 1B). In the validation cohort, DNN provided an area under the receiver operating characteristics curve of 0.730 (Fig. 1C).

Conclusion

Deep learning of a 12-lead ECG can identify features of prior myocardial injury more accurately than Q-wave analysis. In attempting to improve these results further, studies should explain what inputs weighted DNN decisions, and identify those that reflect abnormalities detectable clinically or on imaging.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): NIH NRSA F32

Complete transmural epicardial ablation reduces organized areas in atrial fibrillation

Background

The surgical maze is suggested to be effective in persistent atrial fibrillation (AF) by reducing the area for fibrillatory wavelets. However, the mechanism for recurrence and next treatment steps are unclear.

Purpose

We set out to evaluate the impact of complete transmural epicardial maze lesion sets on the extent atrial organization using novel analyses of wide-area recordings of AF.

Methods

19 patients (age 50.9±12.0, 78% male) underwent maze followed by endocardial mapping of AF with a 64-pole basket catheter. Block across roof, floor, and pulmonary vein lesions sets was assessed by high-density voltage mapping and organized zones of AF were assessed by panoramic recordings. Total organized area and mean area of the dominant site were evaluated using automated custom scripts.

Results

Patients had 3.2±0.9 organized regions in 1 minute of LA recordings. A 54 yo F showed residual conduction to the posterior wall from the roof (purple, Fig. 1A) and a figure-of-8 propagation pattern during AF (arrows, fig B) which terminated with localized ablation (yellow lesions, Fig. 1A, red X, Fig. 1B). Overall, patients with complete block on epicardial lesion set had smaller areas of organization (13.7±8% vs. 45.7±32% of mapped areas, p=0.029) vs. those with gaps. The average size of the dominant area was smaller with complete transmural lines than with gaps (5.7±3% vs. 15.9±10%, p=0.033) (Fig. 1C).

Conclusion

These results show that complete transmural lesion sets constrain the critical mass available for AF, with smaller resulting organized zones. Future studies that quantify how partitioning the atrial surface affects AF may help personalize lesion sets after maze.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): NIH NRSA F32 United States

Implementing a social network intervention: can the context for its workability be created? A quasi-ethnographic study

Background

Policy makers and researchers recognise the challenges of implementing evidence-based interventions into routine practice. The process of implementation is particularly complex in local community environments. In such settings, the dynamic nature of the wider contextual factors needs to be considered in addition to capturing interactions between the type of intervention and the site of implementation throughout the process. This study sought to examine how networks and network formation influence the implementation of a self-management support intervention in a community setting.

Methods

An ethnographically informed approach was taken. Data collection involved obtaining and analysing documents relevant to implementation (i.e. business plan and health reports), observations of meetings and engagement events over a 28-month period and 1:1 interviews with implementation-network members. Data analysis utilised the adaptive theory approach and drew upon the Consolidated Framework for Implementation Research. The paper presents the implementation events in chronological order to illustrate the evolution of the implementation process.

Results

The implementation-network was configured from the provider-network and commissioning-network. The configuration of the implementation-network was influenced by both the alignment between the political landscape and the intervention, and also the intervention having a robust evidence base. At the outset of implementation, the network achieved stability as members were agreed on roles and responsibilities. The stability of the implementation-network was threatened as progress slowed. However, with a period of reflection and evaluation, and with a flexible and resilient network, implementation was able to progress.

Conclusions

Resilience and creativity of all involved in the implementation in community settings is required to engage with a process which is complex, dynamic, and fraught with obstacles. An implementation-network is required to be resilient and flexible in order to adapt to the dynamic nature of community contexts. Of particular importance is understanding the demands of the various network elements, and there is a requirement to pause for "reflection and evaluation" in order to modify the implementation process as a result of learning.

The broken circle method: a novel technique that enhances detection of Hill-Sachs lesions on internal rotation shoulder radiographs

AIM

To describe and test a new method that increases the conspicuity of a Hill-Sachs lesion on internal rotation (IR) radiographs.

MATERIALS AND METHODS

This study had institutional review board approval. A retrospective search for patients with a prior shoulder dislocation and a Hill-Sachs lesion documented on magnetic resonance imaging (MRI) was performed over a 10-year period identifying 256 test patients. In Part 1, the IR radiographs from test cases were randomised with controls, and three readers scored them independently for the defect. The readers were then taught the Broken Circle (BC) method and re-scored the radiographs. In Part 2, 15 cases of Hill-Sachs lesions that were missed by all readers in Part 1 were randomised with controls, and were shown to 25 radiology residents before (pre-test) and after (post-test) learning the BC method. A paired t-test was used to compare the differences in sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

In Part 1, the sensitivity increased 19.7% (54.1%-73.8%; p<0.05) and NPV increased 10.8% (62.5%-73.3%; p<0.01). In Part 2, post-test sensitivity for residents increased 16.3% (55.2%-71.5%; p<0.0001), accuracy increased 13.4% (64%-77.4%; p<0.0001), and NPV increased 13.3% (40.8%-54.1%; p<0.0001) independent of the level of training. The change in accuracy was also statistically significant for every individual class.

CONCLUSION

The BC method was an effective technique that facilitated detection of a Hill-Sachs lesion at all levels of training, and was useful as a teaching tool.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Repeatability of plantar pressure assessment during barefoot walking in people with stroke

Purpose

Stroke-related changes in foot structure and function affect balance and mobility and quantifying foot function following stroke could offer clinically useful information to inform rehabilitation. The aim of this work was to explore the feasibility of undertaking plantar pressure assessment during barefoot walking in people with stroke, and evaluate the repeatability of the assessment protocol and regional footprint analysis as a measure of dynamic foot characteristics.

Materials & methods

Plantar pressure analysis was undertaken using a pressure platform (Tekscan HR Mat) on two test sessions, approximately two weeks apart (mean = 15.64 ± 11.64 days). Peak plantar pressure (kPa) and contact area (cm²) for foot regions were extracted and repeatability analysis undertaken. Descriptive evaluation of field notes and experiences of the participants was undertaken to inform the feasibility of the data collection protocol.

Results

Twenty-one participants (61.8 ± 9.2 years; 11 male, 10 female; 8 right-sided, 13 left-sided stroke) were recruited and 18 returned for retesting. Full data capture was achieved from 14 participants. Peak pressure and contact area demonstrated moderate to good repeatability for at the toes (ICC 0.76 and 0.58 respectively) and good to excellent repeatability for the other foot regions (ICC ≥ 0.82).

Conclusion

The protocol adopted in this study was feasible and yielded good to excellent repeatability for the foot regions, except the toes. The challenges with data collection in our study cohort could help inform future studies adopting similar protocols. This work also has relevance for use of pressure technology in clinical practice for assessing and monitoring foot function following stroke.

1062 The Role of Sleep in Sex and Racial/Ethnic Differences in 10-Year CVD Risk in the Sleep Heart Health Study: The Use of Machine-Learnt and Precision Insights to Understand Racial/Ethnic and Sex Differences in Sleep-CVD Disparity

Introduction

The current study investigated whether insufficient sleep (&lt;7 hrs.) explains differences in 10-year CVD risk, using Framingham risk (FRS) and Reynolds risk (RRS) scores, between blacks and whites and characterized risk and protective CVD risk profiles.

Methods

Using the Sleep Heart Health Study (SHHS) (N=6,441) data, we investigated the independent role of insufficient sleep in explaining differences in 10-years CVD between blacks and whites via a proportional odds model of four 10-year CVD risk groups: low (&lt;5%), low-medium (5% to &lt;10%), medium-high (10% to &lt;20%) and high (≥20%), adjusting for age, sex, and apnea-hypopnea index (AHI). We performed two levels of cluster analyses; via hierarchical cluster algorithm with entire sample (Level 1), and latent profiles in the low (protective profiles) and high (risk profiles) CVD risk groups (Level 2) to determine overall CVD risk, and risk and protective CVD profiles.

Results

Blacks had a higher prevalence of smoking behavior, diabetes, mean systolic blood pressure, body mass index, total cholesterol compared to whites. Conversely, whites had a higher mean HDL cholesterol, sleep hours, and sleep efficiency compared to blacks. Men had higher 10-year CVD risk than women. AHI and race/ethnicity-sleep interaction were positively associated, while sleep was negatively associated with FRS and RRS. Across all CVD risk groups, whites who slept less than 5.5 hrs. had a higher CVD risk and those who slept more than 6.5 hrs. had a lower CVD risk compared to blacks. In Level 1 cluster analyses, we found two clusters: Cluster 1 (n= 3233): 6.17 sleep hours, apnea-index 11.84, age 59, SBP 125.43, total cholesterol 209, HDL 51.39, BMI 29.03, and slightly more than 50% female; and Cluster 2 (n=1657): 5.61 sleep hours, apnea-index 13.41, age 74, SBP 131, total cholesterol 204, HDL 50.30, BMI 26.45, and slightly less than 50% female. In Level 2 cluster analyses, we found two profiles within the low and high CVD risk groups.

Conclusion

These findings suggest that blacks may not receive full protection from long-term CVD risk with longer sleep duration, as their white counterparts.

Support

K01HL135452, R01MD007716, R01HL142066, K07AG052685

1058 Modeling Self-reported Sleep Duration And Hypertension Using Deep Learning Network: Analysis Of The National Health And Nutrition Examination Survey Data

Introduction

Epidemiologic data show strong associations between self-reported sleep duration and hypertension (HTN). Modeling these associations is suboptimal when utilizing traditional logistic regressions. In this study, we modeled the associations of sleep duration and HTN using Deep Learning Network.

Methods

Data were extracted from participants (n=38,540) in the National Health and Nutrition Examination Survey (2006-2016), a nationally representative study of the US civilian non-institutionalized population. Self-reported demographic, medical history and sleep duration were determined from household interview questions. HTN was determined as SBP ≥ 130 mmHg and DBP ≥ 80 mmHg. We used a deep neural network architecture with three hidden layers with two input features and one binary output to model associations of sleep duration with HTN. The input features are the hours of sleep (limited to between 4 and 10 hours) and its square; and the output variable HTN. Probability predictions were generated 100 times from resampled (with replacement) data and averaged.

Results

Participants ranged from 18 to 85 years old; 51% Female, 41% white, 22% black, 26% Hispanic, 46% married, and 25% &lt; high school. The model showed that sleeping 7 hours habitually was associated with the least observed HTN probabilities (P=0.023%). HTN probabilities increased as sleep duration decreased (6hrs=0.05%; 5hrs=0.110%; 4hrs=0.16%); HTN probabilities for long sleepers were: (8hrs=0.027; 9hrs=0.024; 10hrs=0.022). Whites showed sleeping 7hrs or 9hrs was associated with lowest HTN probabilities (0.008 vs. 0.005); blacks showed the lowest HTN probabilities associated with sleeping 8hrs (0.07), and Hispanics showed the lowest HTN probabilities sleeping 7hrs (0.04).

Conclusion

We found that sleeping 7 hours habitually confers the least amount of risk for HTN. Probability of HTN varies as a function of individual’s sex and race/ethnicity. Likewise, the finding that blacks experience the lowest HTN probability when they sleep habitually 8 hours is of great public health importance.

Support

This study was supported by funding from the NIH: R01MD007716, R01HL142066, R01AG056531, T32HL129953, K01HL135452, and K07AG052685.

1102 Relationship Between Emotional Distress And Sleep Duration Among Hispanics Using The 2018 National Health Interview Survey Dataset

Introduction

Although Hispanics experience a high level of shorter sleep duration (&lt; 7 hrs./24 period), a clear mechanism or cause is lacking. Previous research indicate that emotional distress may explain the burden of shorter sleep among blacks. Applying these findings to Hispanics, we investigated whether emotional distress explains the burden of short sleep duration (&lt; 7 hrs.) among Hispanics and if this relationship varies by sex

Methods

We used data from the 2018 National Health Interview Survey (NHIS) dataset, a nationally representative sample, in which only Hispanic ethnicity participants (N=3,091) were analyzed. Average sleep duration was self-reported and measured in hours. Emotional distress was measured using Kessler 6, which measures how an individual felt over the past 30 days: nervous, hopeless, restless/fidgety, depressed, effortful and worthless. To assess the association between short sleep duration and emotional distress, we performed Pearson correlation, hierarchical regression analyses, and stratified this relationship by sex to determine if this relationship differed between males and females, adjusting for covariates.

Results

Of the total sample of 3,091 Hispanics, 1,762 were female, and 1,329 were male. Sleep duration and emotional distress were negatively correlated among females (r = -.27, p &lt;.001) and males (r=-.18, p &lt;.001). Among Hispanic females, sleep duration significantly predicted emotional distress, β = -.27, t = -11.60, p &lt;.001, and explained a significant portion of variance in emotional distress, R2 = .07, F= 134.63, p &lt;.001. While, among Hispanic males, sleep significantly predicted emotional distress (β = -.18, t =-6.5, p &lt;.001) and explained a significant portion of the variance in emotional distress (R2 = .03, F= 42.37, p &lt;.001).

Conclusion

Our findings indicate that a negative sleep-ED relationship, suggesting that shorter sleep was predictive of higher levels of emotional distress among Hispanics and that this relationship is greater among Hispanic females, compared males.

Support

K01HL135452, R01MD007716, R01HL142066, and K07AG052685

0621 Utilization of the Ares to Predict OSA Among Blacks Using Home-Based Watchpat Recording

Introduction

In two waves of data we collected in Brooklyn New York, we observed blacks were at high risk for obstructive sleep apnea (OSA). In the NIH-funded study ‘Metabolic Syndrome Outcome Study (MetSO), blacks enrolled from primary-care settings had a 59% risk of OSA. Similarly, blacks surveyed in churches and barbershops had a 43% risk of OSA. While these studies showed higher than expected risk as noted in the general population (29%), it remains uncertain how many of those blacks would be diagnosed with OSA in that population. The purpose of this study was to explore the rate of OSA using the WatchPat device in a community-based setting.

Methods

Data were collected from an NIH-funded study ‘Peer-Enhanced Education to Reduce Sleep Ethnic Disparities, designed to navigate blacks at risk of OSA to receive timely diagnosis and treatment using peer-delivered linguistically and culturally tailored sleep health education. Blacks were screened for OSA using the Apnea Risk Evaluation System (ARES) Questionnaire; a score ≥6 denoted moderate-high OSA risk. Individuals were asked to wear the WatchPAT 200 for one night during a week-long sleep assessment. WatchPat 200 measures SaO2 to determine respiratory-related arousals, defined as an Apnea-Hypopnea Index (AHI) ≥5, which is used to identify and diagnose OSA. We used SPSS 25.0 to perform logical regression analysis to assess associations between ARES and WatchPat AHI.

Results

A sample of 111 blacks provided valid ARES and WatchPat data for the present analyses. Of the sample, the mean age was 62.26 (SD=13.52 years; female = 55%); 49% reported annual income &gt;20K and 79.5% reported a high school education. Moreover, 27% reported high blood pressure, 13%, diabetes, and 65% were overweight/obese. Multivariate-adjusted logical regression analyses indicated that blacks at risk for OSA were 66% more likely to receive an OSA diagnosis based on WatchPat AHI data (OR = 1.662, p &lt; 0.01). The model adjusted for age, sex, income, and education.

Conclusion

The present study demonstrated that blacks at risk for OSA at the community level have a significant likelihood of receiving an OSA diagnosis using home-based recordings.

Support

NIH Support (T32HL129953, RO1MD007716, K01HL135452 and K07AG052685).

1046 Assessing Sleep-Related Hypertension Risks Using JNC 8 Guidelines: Analysis Of The National Health And Nutrition Examination Survey Data

Introduction

Associations between self-reported sleep duration and risk of hypertension (HTN) are well established. The level of sleep-related HTN risk based on the new JNC 8 classification guidelines requires further research. In this study, we modeled the associations of insufficient sleep with HTN using the National Health and Nutrition Examination Survey (NHANES).

Methods

Data were extracted from the 2006-2016 NHANES (n=38,540), a nationally representative study of the US civilian population. Self-reported demographic and sleep duration were determined from household interview questions. Insufficient sleep was categorized as sleeping &lt;7hrs. Using 2017 ACC/AHA guidelines, HTN was classified as elevated (SBP:120-129mmHg and DBP &lt;80mmHg, Stage I (SBP:130-139mmHg and DBP:80-89mmHg), or Stage II (SBP ≥140mmHg and DBP ≥90mmHg). Logistic regression modeling was performed using R.

Results

Participants’ ages ranged from 18-85 years. Of the sample, 51% were female, 41% white, 22% black, 26% Hispanic, 8% others; 46% were married, and 25% completed &lt;high school. The model showed strong age and BMI-adjusted associations of insufficient sleep with HTN at all levels: (elevated: OR=1.079, CI=1.03-1.13; Stage I: OR=1.127, CI=1.07-1.18, and Stage II: OR=1.334, CI=1.17-1.52). Important sex and race/ethnicity differences in sleep-related HTN risks were observed: males (elevated: OR=1.024, CI=0.95-1.10; Stage I: OR=1.077, CI=1.01-1.15, and Stage II: OR=1.254, CI=1.06-1.48); females (elevated: OR=1.125, CI=1.05-1.21; Stage I: OR=1.170, CI=1.08-1.26, and Stage II: OR=1.445, CI=1.17-1.79); whites (elevated: OR=1.007, CI=0.93-1.08; Stage I: OR=1.030, CI=0.95-1.12, and Stage II: OR=1.131, CI=0.90-1.43); blacks (elevated: OR=1.047, CI=0.94-1.16; Stage I: OR=1.080, CI=0.97-1.20, and Stage II: OR=1.179, CI=0.95-1.46); and Hispanics (elevated: OR=1.066, CI=0.94-1.21; State I: OR=1.089, CI=0.96-1.24, and Stage II: OR=1.337, CI=0.92-1.92).

Conclusion

Our analyses showed that sleep-related HTN risks vary as a function of individual’s sex and race/ethnicity. Increasing sleep duration at all HTN severity level is important and males and Hispanics at Stage II HTN might benefit the most.

Support

This study was supported by funding from the NIH: R01MD007716,R01HL142066, R01AG056531, T32HL129953, K01HL135452 and K07AG052685

Optimising and profiling pre-implementation contexts to create and implement a public health network intervention for tackling loneliness

Background

The implementation of complex interventions experiences challenges that affect the extent to which they become embedded and scaled-up. Implementation at scale in complex environments like community settings defies universal replication. Planning for implementation in such environments requires knowledge of organisational capacity and structure. Pre-implementation work is an important element of the early phase of preparing the setting for the introduction of an intervention, and the factors contributing towards the creation of an optimal pre-implementation community context are under-acknowledged.

Methods

To explore the factors contributing towards the creation of an optimal pre-implementation context, a quasi-ethnographic approach was taken. The implementation of a social network intervention designed to tackle loneliness in a community setting acts as the case in example. Observations (of meetings), interviews (with community partners) and documentary analysis (national and local policy documents and intervention resources) were conducted. Layder’s adaptive theory approach was taken to data analysis, with the Consolidated Framework for Implementation Research (CFIR) and a typology of third-sector organisations used to interpret the findings.

Results

Community settings were found to sit along a continuum with three broad categories defined as Fully Professionalised Organisations; Aspirational Community, Voluntary and Social Enterprises; and Non-Professionalised Community-Based Groups. The nature of an optimal pre-implementation context varied across these settings. Using the CFIR, the results illustrate that some settings were more influenced by political landscape (Fully professional and Aspirational setting) and others more influenced by their founding values and ethos (Non-Professionalised Community-Based settings). Readiness was achieved at different speeds across the categories with those settings with more resource availability more able to achieve readiness (Fully Professional settings), and others requiring flexibility in the intervention to help overcome limited resource availability (Aspirational and Non-Professionalised Community-Based settings).

Conclusions

The CFIR is useful in highlighting the multiple facets at play in creating the optimal pre-implementation context, and where flex is required to achieve this. The CFIR illuminates the similarities and differences between and across settings, highlighting the complexity of open system settings and the important need for pre-implementation work.

Trial registration

ISRCTN19193075

Carotid artery vein-pouch bifurcation aneurysm in rats: An experimental model for microneurosurgical training

BACKGROUND

In the era of endovascular treatment of intracranial aneurysms, surgical clipping is still a relevant treatment method in some cases. However, it has become harder to teach this skill, as the number of surgical cases has decreased over the past years. We therefore decided to use a previously described experimental aneurysm model for surgical training.

MATERIAL AND METHODS

We operated on 8 rats and constructed a vein-pouch aneurysm at a surgically created carotid bifurcation. Survivors were kept alive for 1 month and operated on to clip the aneurysm.

RESULTS

Only 3 rats had survived at 1 month. All the carotid arteries were permeable. Only 2 aneurysms were circulating at 1 month, as 1 had thrombosed. They were successfully clipped at 1 month.

CONCLUSIONS

These preliminary results enabled our junior surgeon to clip two circulating aneurysms, under an operative microscope reproducing surgical conditions. Although the efficacy of the model could be improved, we believe it could be used as a first step in training neurosurgical residents in the basics of aneurysm clipping and microsurgical techniques in a realistic setting.

A novel exploration of the support needs of people initiating insulin pump therapy using a social network approach: a longitudinal mixed-methods study

AIMS

To establish what practical and emotional means of support are required on initiation of insulin pump therapy and how needs change over time, using GENIE, a social network intervention.

METHODS

The study's longitudinal design used semi-structured interviews, surveys (PAID, CLARKE) and HbA_1c values at time of pump initiation, and at 3 and 6 months. Interviews used GENIE to capture participants' expectations and experiences of pump therapy and associated support and resources. Thematic analysis was used with sequential, time-ordered matrices.

RESULTS

A total of 16 adults undertook 47 interviews. A total of 94 services, resources and activities were acquired, while tally, frequency and value of network members increased over time. The novelty of pump therapy impacted on participants' self-management needs. Key themes included: 1) the independent nature of managing diabetes; 2) overcoming the challenges and illness burden associated with pump use; 3) the need for responsive and tailored emotional and practical support; and 4) useful resources when incorporating pump therapy. GENIE was thought to be novel and beneficial.

CONCLUSIONS

A social network approach determined what resources and support people with diabetes require when incorporating a new health technology. Visualisation of support networks using concentric circles enabled people to consider and mobilise support and engage in new activities as their needs changed. The novelty of pump therapy creates new illness-related work, but mobilisation of personally valued flexible, tailored support can improve the process of adaptation.

Evaluation of the GeneQuence® DNA Hybridization Method in Conjunction with 24-Hour Enrichment Protocols for Detection of Salmonella spp. in Select Foods: Collaborative Study

A multilaboratory study was conducted to compare performance of the GeneQuence® DNA hybridization (DNAH) method incorporating new 24 h enrichment protocols and reference culture procedures for detection of Salmonella spp. in select foods. Six food types (raw ground turkey, raw ground beef, dried whole egg, milk chocolate, walnuts, and dry pet food) were tested by the DNAH method and by the culture methods of either the U.S. Department of Agriculture-Food Safety and Inspection Service (USDA-FSIS) or the U.S. Food and Drug Administration's Bacteriological Analytical Manual (FDA/BAM). Fifteen laboratories participated in the study. Four of the foods tested (raw ground turkey, dried whole egg, milk chocolate, and dry pet food), showed no statistically significant differences in performance between the DNAH method and the reference procedure as determined by Chi square analysis. Sensitivity rates for the DNAH method ranged from 92 to 100. The DNAH method, with the specific enrichment protocol evaluated, was found to be ineffective for detection of Salmonella spp. in walnuts. For raw ground beef, results from one trial showed a statistically significant difference in performance, with more positives obtained by the reference method. However, evidence suggests that the difference in the number of positives was likely due to lack of homogeneity of the test samples rather than to DNAH method performance.

A multicentre, clinical evaluation of a hydro-responsive wound dressing: the Glasgow experience

OBJECTIVE

Our aim was to assess the effectiveness of hydro-responsive wound dressing (HRWD) in debridement and wound bed preparation of a variety of acute and chronic wounds that presented with devitalised tissue needing removal so that healing may proceed.

METHOD

This was a non-comparative evaluation of acute and chronic wounds that required debridement as part of their normal treatment regimen. Clinicians recorded wound changes including a subjective assessment level of devitalised tissue and wound bed preparation, presence of pain, wound status (e.g., wound size) and periwound skin condition. Data was also collected from clinicians and patients to provide information on clinical performance of the dressing.

RESULTS

We recruited 100 patients with a variety of wound types into the study. Over 90% of the clinicians reported removal of devitalised tissue to enable a healing response in both chronic and acute wounds. Specifically, over the course of the evaluation period, levels of devitalised tissue (necrosis and slough) reduced from 85.5% to 26.3%, and this was accompanied by an increase in wound bed granulation from 12.0% to 33.7%. Correspondingly, there was a 40% reduction in wound area, hence a clinically relevant healing response was seen upon treatment with HRWD. It is also noteworthy that this patient population included a significant proportion of chronic wounds (51.4%) that showed no signs of wound progression within <4 weeks before study inclusion. Of these chronic wounds, 93% demonstrated wound progression upon treatment with HRWD. Despite reported pain levels being low pre- and post-dressing change, overall wound pain improved (reduced) in 48% of patients. Periwound skin condition showed a tendency towards improvement, and the fluid management capabilities of the HRWD was reported as good to excellent in the majority of cases. Wound infections were reduced by at least 60% over the evaluation period. A simple cost-effective analysis demonstrated significant savings using HRWD (£6.33) over current standard practice regimens of a four-step debridement process (£8.05), larval therapy (£306.39) and mechanical pad debridement (£11.46).

CONCLUSION

HRWD was well tolerated and was demonstrated to be an efficient debridement tool providing rapid, effective and pain free debridement in a variety of wound types.