Co-design and mixed methods evaluation of an interdisciplinary digital resource for undergraduate health profession students to improve the prevention, recognition, and management of delirium in Ireland: a study protocol

BACKGROUND

Delirium is a common symptom of acute illness which is potentially avoidable with early recognition and intervention. Despite being a growing concern globally, delirium remains underdiagnosed and poorly reported, with limited understanding of effective delirium education for undergraduate health profession students. Digital resources could be an effective approach to improving professional knowledge of delirium, but studies utilising these with more than one profession are limited, and no evidence-based, interdisciplinary, digital delirium education resources are reported. This study aims to co-design and evaluate a digital resource for undergraduate health profession students across the island of Ireland to improve their ability to prevent, recognise, and manage delirium alongside interdisciplinary colleagues.

METHODS

Utilising a logic model, three workstreams have been identified. Workstream 1 will comprise three phases: (1) a systematic review identifying the format, methods, and content of existing digital delirium education interventions for health profession students, and their effect on knowledge, self-efficacy, and behavioural change; (2) focus groups with health profession students to determine awareness and experiences of delirium care; and (3) a Delphi survey informed by findings from the systematic review, focus groups, and input from the research team and expert reference group to identify resource priorities. Workstream 2 will involve the co-design of the digital resource through workshops (n = 4) with key stakeholders, including health profession students, professionals, and individuals with lived experience of delirium. Lastly, Workstream 3 will involve a mixed methods evaluation of the digital resource. Outcomes include changes to delirium knowledge and self-efficacy towards delirium care, and health profession students experience of using the resource.

DISCUSSION

Given the dearth of interdisciplinary educational resources on delirium for health profession students, a co-designed, interprofessional, digital education resource will be well-positioned to shape undergraduate delirium education. This research may enhance delirium education and the self-efficacy of future health professionals in providing delirium care, thereby improving practice and patients' experiences and outcomes.

TRIAL REGISTRATION

Not applicable.

The assessment of dietary carotenoid intake of the Cardio-Med FFQ using food records and biomarkers in an Australian cardiology cohort: a pilot validation

Dietary carotenoids are associated with lower risk of CHD. Assessment of dietary carotenoid intake using questionnaires can be susceptible to measurement error. Consequently, there is a need to validate data collected from FFQs which measure carotenoid intake. This study aimed to assess the performance of the Cardio-Med Survey Tool (CMST)-FFQ-version 2 (v2) as a measure of dietary carotenoid intake over 12-months against plasma carotenoids biomarkers and 7-Day Food Records (7DFR) in an Australian cardiology cohort. Dietary carotenoid intakes (β- and α-carotene, lycopene, β-cryptoxanthin and lutein/zeaxanthin) were assessed using the 105-item CMST-FFQ-v2 and compared to intakes measured by 7DFR and plasma carotenoid concentrations. Correlation coefficients were calculated between each dietary method, and validity coefficients (VCs) were calculated between each dietary method and theoretical true intake using the 'methods of triads'. Thirty-nine participants aged 37-77 years with CHD participated in the cross-sectional study. The correlation between FFQ and plasma carotenoids were largest and significant for β-carotene (0.39, p=0.01), total carotenoids (0.37, p=0.02) and β-cryptoxanthin (0.33, p=0.04), with weakest correlations observed for α-carotene (0.21, p=0.21) and lycopene (0.21, p=0.21). The FFQ VCs were moderate (0.3-0.6) or larger for all measured carotenoids. The strongest were observed for total carotenoids (0.61) and β-carotene (0.59), while the weakest were observed for α-carotene (0.33) and lycopene (0.37). In conclusion, the CMST-FFQ-v2 measured dietary carotenoids intakes with moderate confidence for most carotenoids, however, there was less confidence in ability to measure α-carotene and lycopene intake, thus further research is warranted using a larger sample.

What do people with cystic fibrosis eat? Diet quality, macronutrient and micronutrient intakes (compared to recommended guidelines) in adults with cystic fibrosis-A systematic review

BACKGROUND

Treatment advancements have improved life expectancy and nutritional status of people with cystic fibrosis (CF). Alongside reductions in malnutrition, incidences of overweight, obesity and risk factors for diet-related chronic diseases have increased in recent years. This study aimed to synthesise the available literature on diet quality, macronutrient and micronutrient intakes compared to the recommended guidelines in adults with CF, an essential step in deducing the optimal dietary pattern and intakes for CF adults.

METHODS

A systematic search of five electronic databases from inception until April 2023 was conducted using keywords related to CF, diet quality and nutrient intakes.

RESULTS

Twenty-one studies were included comprising 18 cross-sectional, one cohort and two case control studies, reporting data from 724 adults with CF. Energy and / or macronutrient intake data was reported across 17 cohorts, eight studies provided micronutrients data, and diet quality was determined for four CF cohorts by using a diet quality score, and / or categorising food intake into servings per day for food groups and comparing findings to national dietary guidelines. Although energy intake recommendations were met, and most micronutrient requirements were achieved through supplementation, total energy intake from fat was above recommendations and diet quality was poor.

CONCLUSION

This is the first systematic review comprehensively evaluating literature on dietary intakes of adults with CF. Energy-dense, nutrient-poor foods contribute to intakes which pose risk in developing diet-related chronic diseases. Revision of dietary guidelines and practice change in CF nutritional therapy is warranted to optimise nutrition and health outcomes.

'Good, honest food': older adults' and healthcare professionals' perspectives of dietary influences and food preferences in older age in Ireland

BACKGROUND

This study aimed to explore older adults' and healthcare professionals' (HCPs) perceptions of dietary influences and food preferences in older age.

METHODS

The research design was phenomenological qualitative description. Semistructured one-to-one interviews and focus groups were held separately with community-dwelling older adults and HCPs involved in care of the older person in Ireland. Data were analysed using inductive thematic analysis.

RESULTS

A total of 47 adults aged 55+ years were recruited (50% male; 49% aged 60-69 years; 28% aged above 70 years), and 26 HCPs were involved, comprising dietitians (n = 8); geriatricians (n = 6); clinical therapists (n = 4); and nurses, pharmacists, catering managers and meal delivery service coordinators (n = 2 each). There are strong desires for 'good, honest food' within the diet for an older person; however, gaps in current nutrition priorities, dietary guidance and health promotion were perceived. There were differences in the perspectives held by HCPs and adults aged 55+ years, as some HCPs centred their discussion around nutrition for preventing sarcopenia, frailty or cognitive decline, whereas many adults aged 55+ years desired foods which promote cardiometabolic health and reflect wider personal health and environmental values. Other themes included the impact of health and lifestyle changes accompanying ageing on dietary priorities, the importance of personal and psychosocial values in determining food choice and the impact of the external food environment on accessibility and shopping experiences.

CONCLUSIONS

Influences on dietary choice for the older person are multifactorial, driven by a range of health, psychological, sociocultural and environmental perspectives. Future nutrition priorities for older adults should encourage health-promoting approaches and not just disease-mitigating efforts.

Experience and perceptions among rheumatoid arthritis patients following a telehealth-delivered dietary intervention: a qualitative study

The effects of dietary modifications have been assessed in people living with rheumatoid arthritis (RA) with consistent benefits reported from clinical trials. However, the lived experience of making and sustaining positive dietary changes for people with RA remains unknown. The aim of this qualitative study was to explore the experiences of adults with RA and their perceptions of a 12-week telehealth-delivered dietary intervention and to assess the acceptability of the programme. Qualitative data was collected via four online focus groups with participants who had just completed a 12-week dietary intervention programme delivered through telehealth methods. Thematic analysis was used to code and summarize the identified key themes. Twenty-one adults with RA (47.5 ± 12.3 years, 90.5% females) were included in this qualitative study. Overarching themes included: (a) motivation to join the programme, (b) benefits of the programme, (c) factors influencing adherence to dietary prescription, and (d) advantages and disadvantages of telehealth. The study demonstrated that a dietary intervention delivered through telehealth methods by a Registered Dietitian (RD) appears to be well-accepted and may be used to complement face-to-face care for people with RA. The identified factors influencing the adoption of a healthier eating pattern will aid in the development of future dietary interventions for a RA population.

Modified indirect calorimetry for patients on venoarterial extracorporeal membrane oxygenation: a pilot feasibility study

BACKGROUND/OBJECTIVES

Traditional indirect calorimetry is unable to capture complete gas exchange in patients receiving venoarterial extracorporeal membrane oxygenation (VA ECMO). We aimed to determine the feasibility of using a modified indirect calorimetry protocol in patients receiving VA ECMO, report measured energy expenditure (EE) and compare EE to control critically ill patients.

SUBJECTS/METHODS

Mechanically ventilated adult patients receiving VA ECMO were included. EE was measured within 72 h of VA ECMO commencement (timepoint one [T1]) and on approximately day seven of Intensive Care Unit (ICU) admission (timepoint two [T2]). Traditional indirect calorimetry via the ventilator was combined with calculations of oxygen consumption and carbon dioxide production derived from pre- and post-ECMO membrane blood gas analyses. Completion of ≥60% EE measurements was deemed feasible. Measured EE was compared between T1 and T2 and to control patients not receiving VA ECMO. Data is presented as n(%) and median[interquartile range (IQR)].

RESULTS

Twenty-one patients were recruited; 16(76%) male, aged 55[42-64] years. The protocol was feasible to complete at T1 (14(67%)) but not at T2 (7(33%)) due to predominantly ECMO decannulation, extubation or death. EE was 1454[1213-1860] at T1 and 1657[1570-2074] kcal/d at T2 (P = 0.043). In patients receiving VA ECMO versus controls, EE was 1577[1434-1801] versus 2092[1609-2272] kcal/d, respectively (P = 0.056).

CONCLUSION

Modified indirect calorimetry is feasible early in admission to ICU but is not possible in all patients receiving VA ECMO, especially later in admission. EE increases during the first week of ICU admission but may be lower than EE in control critically ill patients.

Multidisciplinary inpatient rehabilitation for older adults with COVID-19: a systematic review and meta-analysis of clinical and process outcomes

BACKGROUND

Older adults are at increased risk for disease severity and poorer prognosis following COVID-19 infection. The aim of this systematic review and meta-analysis is to explore the impact of multidisciplinary rehabilitation in the acute or post-acute hospital setting for older adults with COVID-19.

METHODS

The Cochrane library, EMBASE, Cinahl and Medline (via EBSCO), PubMed, and Web of Science were systematically searched in June 2022 and a repeat search was completed in March 2023. Screening, data extraction and quality appraisal were conducted independently by two reviewers. Studies reporting outcomes for older adults following multidisciplinary rehabilitation (provided by two or more Health and Social Care Professionals) were included. Both observational and experimental study designs were included. The primary outcome was functional ability. Secondary outcomes included discharge disposition, acute hospital and rehabilitation unit length of stay, mortality, primary and secondary healthcare utilisation, and long-term effects of COVID-19.

RESULTS

Twelve studies met the inclusion criteria, comprising a total of 570 older adults. Where reported, older adults stayed in the acute hospital for a mean of 18 days (95%CI, 13.35- 23.13 days) and in rehabilitation units for 19 days (95%CI, 15.88-21.79 days). There was a significant improvement in functional ability among older adults with COVID-19 who received multidisciplinary rehabilitation (REM, SMD = 1.46, 95% CI 0.94 to 1.98). The proportion of older adults who were discharged directly home following rehabilitation ranged from 62 to 97%. Two studies reported a 2% inpatient mortality rate of older persons during rehabilitative care. No study followed up patients after the point of discharge and no study reported on long term effects of COVID-19.

CONCLUSIONS

Multidisciplinary rehabilitation may result in improved functional outcomes on discharge from rehabilitation units/centres for older adults with COVID-19. Findings also highlight the need for further research into the long-term effect of rehabilitation for older adults following COVID-19. Future research should comprehensively describe multidisciplinary rehabilitation in terms of disciplines involved and the intervention provided.

Is Extra Virgin Olive Oil the Critical Ingredient Driving the Health Benefits of a Mediterranean Diet? A Narrative Review

Most chronic diseases are preventable with a healthy diet, although there is debate about the optimal dietary approach. Increasingly more countries are focusing on food-based guidelines rather than the traditional nutrient-based approach. Although there is good agreement on plant foods, controversy remains about the types and amounts of fats and oils. This narrative review aims to systematically summarize and evaluate the latest evidence on the protective effects of extra virgin olive oil (EVOO) on disease risk factors. A systematic search of the relevant literature using PubMed, Cochrane Library, and Embase databases was conducted for the years 2000 through December 2022. A narrative synthesis was then undertaken. Of 281 retrieved articles, 34 articles fulfilled our inclusion criteria and were included. Compared with other dietary fats and low-fat diets, EVOO is superior in the management of clinical biomarkers including lowering blood pressure and LDL-c, increasing protective HDL-c, improving glycemic control, and weight management. The protective effects of EVOO are likely due to its polyphenol content rather than the monounsaturated fat content. It is therefore important to promote the regular use of EVOO in the context of healthy dietary patterns such as the Mediterranean diet for maximal health benefit.

Older adults and healthcare professionals have limited awareness of the link between the Mediterranean diet and the gut microbiome for healthy aging

Objectives

Strategies to improve the gut microbiome through consuming an improved diet, including adopting the Mediterranean Diet (MD), may promote healthy aging. We explored older adults' and healthcare professionals' (HCPs) perspectives of the MD, gut health, and microbiome for their role in healthy aging.

Design

Phenomenological qualitative.

Setting

Community-dwelling older adults and HCPs in primary and secondary care in Ireland.

Participants

Older adults (aged 55 + years), recruited through social, retirement and disease-support groups. HCPs recruited through researcher networks and professional associations.

Measurements

Semi-structured 1:1 interviews and focus groups (FGs) conducted remotely with older adults and HCPs separately. Interviews/FGs were recorded, transcribed, and coded using inductive thematic analysis.

Results

Forty-seven older adults were recruited (50% male; 49% aged 60-69 years; 28% 70 +), and 26 HCPs including dietitians (n = 8); geriatricians (n = 6); clinical therapists (n = 4); nurses, pharmacists, catering managers, and meal-delivery service coordinators (n = 2 each). Older adults considered the MD "a nice way to enjoy food," good for cardiovascular health and longevity, but with accessibility and acceptability challenges (increased salads/fish, different food environments, socio-cultural differences). HCPs felt the MD is included in healthy eating advice, but not overtly, mostly through the promotion of mixed-fiber intake. Older adults considered "live" yogurt and probiotics, and to a lesser extent fiber, to maintain a "healthy gut," suggesting the gut has "something to do with" cognitive and digestive health. Overall, microbiota-health effects were considered "not common knowledge" among most older adults, but becoming more topical among both professionals and the public with advancing scientific communication.

Conclusion

While "gut health" was considered important, specific effects of the MD on gut microbiota, and the significance of this for healthy aging, was under-recognized. Future efforts should explain the importance to older adults of maintaining the gut microbiota through diet, while appreciating perspectives of probiotic products and supplements.

36 WHAT DO OLDER ADULTS AND HEALTH CARE PROFESSIONALS LOOK FOR IN A FOOD PRODUCT?

Background

The Mediterranean diet (Medi-diet) has proven benefits for healthy ageing but isn’t the habitual diet of most middle-aged or older adults in Ireland; there can be accessibility and tolerability issues with high amounts of fresh fruit and vegetables. Providing key Medi-diet nutrients in a food product is a novel approach to this challenge. This research aims to explore what ‘younger-old’ adults and healthcare professionals (HCPs) would value in such a novel food product.

Methods

Semi-structured 1:1 interviews and Focus Groups (FGs) were conducted remotely from July 2021 to January 2022. Older adults, defined as over 55’s, were recruited through relevant social, retirement and disease-support groups. Purposive sampling recruited a gender balance and a range of ages and disease profiles. HCPs were recruited through researcher networks and professional associations. Interviews/FGs were recorded, transcribed, and subsequently examined using inductive thematic analysis.

Results

Older adults (n=47; 50% male) were mostly aged 60-69 years (48.9%). Recruited HCPs (n=26) included dieticians (n=8); geriatricians (n=5); therapists (n=4); and nurses, pharmacists, catering managers (community; residential), and meal delivery service coordinators (n=2 each). Participants supported a food product for older adults requiring a nutrient-dense “boost”, or supplementary fibre or protein, but generally preferred a “food-first” approach, as opposed to a “silver bullet” product. Older adults largely associated functional foods with probiotic products “to repair the gut”, something to have “every now and then”. Product texture and portion size should consider changing dentition and appetite, and consider packaging (dexterity) and preparation ease, but should not stigmatize older adults through targeted branding. Participants felt pre-made soups or cake-type bars would be appealing, but not drinks.

Conclusion

A novel food product could supplement a balanced diet for older adults, providing high-protein content, and high-fibre for gut health, complimenting an overall lifestyle approach to health improvement and disease prevention.

POS0243 THE EFFECT OF A MEDITERRANEAN DIET ON PHYSICAL FUNCTION AND QUALITY OF LIFE IN PATIENTS WITH RHEUMATOID ARTHRITIS – THE MEDRA STUDY

Background

The immunomodulatory and anti-inflammatory effects of the Mediterranean Diet (MedDiet) suggest a protective role in rheumatic conditions1. A small but increasing body of evidence from randomised controlled trials demonstrates that increased adherence to a MedDiet in patients with Rheumatoid Arthritis (RA) can have a beneficial effect on disease activity, pain levels and physical function2.

Objectives

The primary aim of the MEDRA study was to determine the effects of a MedDiet compared to the current food based dietary guidelines in Ireland (Healthy Eating Guidelines/HEG) on the physical function and quality of life in patients with RA.

Methods

In this randomised controlled trial, 44 patients with RA were randomly allocated to either the MedDiet or the HEG arm of the study. The 12-week dietary intervention study was delivered online by a Registered Dietitian (RD) and included data collection at three time points: baseline, mid-intervention (6 weeks) and post-intervention (12 weeks). Participants in both dietary intervention groups attended three video consultations with the RD, at baseline, weeks 6 and 12, and two follow up reviews by telephone at weeks 3 and 9. All participants were provided resources designed to specifically explain the assigned diet and how it can be successfully adhered to. Primary outcomes were changes in physical function and quality of life measured using the validated Health Assessment Questionnaire - Disability Index (HAQ-DI) and Rheumatoid Arthritis Quality of Life Questionnaire (RAQoL), respectively. Secondary outcomes included changes in physical activity and patient-reported pain levels.

Results

Forty patients with RA completed the study (mean age:47.5 SD10.9 years, females: 87.5%). No significant differences were found in the distribution of age, anthropometric measures, disease duration, physical activity, and quality of life between the two diet groups at baseline. However, the group assigned to the MedDiet had better mean values for quality of life compared to the HEG group; 0.9 ± 0.5 vs. 1.4 ±0.7, p<0.001, respectfully. Compared to baseline, there was a significant improvement in HAQ-DI scores in participants following both the MedDiet (0.9 ±0.5 to 0.5 ± 0.4, p<0.001) and HEG (1.4 ± 0.7 to 1.0 ± 0.6, p<0.001). Significant improvements in RAQoL scores were also seen in both the MedDiet (10.1 ±7.5 to 4.0 ± 4.7, p<0.001) and HEG (11.25 ± 7.2 to 7.9 ± 6.4, p=0.02) groups. At 12 weeks, participants in the MedDiet group reported a significantly better physical function status (mean difference -0.5, 95% CI -0.8 to -0.1, p=0.007) and quality of life (mean difference -3.9, 95% CI -7.5 to -0.2, p=0.04) compared to the HEG group. Participants in the MedDiet group demonstrated a significant increase in physical activity levels (56.7 ± 28.6 to 70.6 ± 33.5, p=0.01). Conversely, a non-significant decrease in physical activity levels was observed in the HEG group from baseline to post-intervention.

Conclusion

The study indicates positive effects of a Mediterranean and low-fat diet as per the Healthy Eating Guidelines on physical function and quality of life in patients with RA. The MedDiet may be superior in improving physical activity levels. Further studies and a larger cohort are needed to confirm these findings.

References

[1]Oliviero, F., Spinella, P., Fiocco, U., Ramonda, R., Sfriso, P. and Punzi, L., 2015. How the Mediterranean diet and some of its components modulate inflammatory pathways in arthritis. Swiss medical weekly, 145(4546).

[2]Forsyth, C., Kouvari, M., D’Cunha, N.M., Georgousopoulou, E.N., Panagiotakos, D.B., Mellor, D.D., Kellett, J. and Naumovski, N., 2018. The effects of the Mediterranean diet on rheumatoid arthritis prevention and treatment: a systematic review of human prospective studies. Rheumatology international, 38(5), pp.737-747.

Acknowledgements

This work was funded by the School of Allied Health Postgraduate scholarship at the University of Limerick.

Disclosure of Interests

None declared

Diet quality in cystic fibrosis – associations with patient reported outcome measures and enablers and barriers to eating a healthy diet: A protocol paper for a mixed methods study

Background: People with cystic fibrosis (PWCF) have increased energy requirements. However, in recent years concerns have emerged regarding the ‘cystic fibrosis (CF) diet’ in terms of reliance on energy-dense, nutrient poor foods, which tend to be higher in saturated fat, sugar, and salt. These foods lack essential nutrients and are aetiologically linked with diet-related chronic diseases. The aim is to explore habitual dietary intakes in PWCF and (i) assess adherence to CF dietary guidelines and population specific healthy eating guidelines; (ii) derive a diet quality score and the inflammatory potential for the average diet consumed by PWCF and assess associations with patient reported outcome measures; (iii) assess drivers for current consumption patterns and enablers and barriers to eating a healthy diet. Methods: The aim is to recruit between 100-180 PWCF. A mixed methods study will be performed. Using three-day food diaries and food frequency questionnaires, aims (i) and (ii) will be addressed. The Dietary Approaches to Stop Hypertension (DASH) score and Healthy Eating Index-International (HEI-I) will derive diet quality scores. The Dietary Inflammatory Index (DII®) will ascertain inflammatory potential of the diet. Validated questionnaires will be used to report health related quality of life measures. Online focus groups and semi-structured interview with PWCF will address aim (iii). Conclusions: It is timely to revise dietary priorities and targets for CF. However, a greater understanding of what adults with CF currently consume and what they require in terms of nutrition and dietary guidance into the future is needed. In doing so, this research will help to clarify nutrition priorities and simplify the dietary aspects of CF treatment, thereby supporting adherence.

A randomised controlled trial of a Mediterranean Dietary Intervention for Adults with Rheumatoid Arthritis (MEDRA): Study protocol

Background

Rheumatoid arthritis (RA) is the most common type of autoimmune arthritis affecting 0.5–1% of the adult population worldwide. While the primary line of treatment of RA includes pharmacological therapies, people living with the condition often seek non-pharmacological therapies such as diet and exercise in an attempt to attenuate their symptoms. Established, evidence-based dietary guidelines for RA are currently lacking. The MEDRA study aims to explore the effectiveness of implementing, via telehealth, a Mediterranean type diet (MedDiet) compared to a standard healthy diet as per the Healthy Eating Guidelines (HEG) in Ireland in terms of differences in physical function and quality of life in adults with RA living in Ireland.

Methods

The MEDRA study is a parallel, randomised controlled trial delivered through telehealth methods. Forty-four eligible participants who have RA will be randomly allocated to either a MedDiet or HEG group for a 12 weeks intervention period. Primary outcome measures include changes in physical function and quality of life, both of which will be measured using validated questionnaires at baseline, six and twelve weeks. Both intervention arms will attend a total five teleconsultations with a Registered Dietitian (RD). The MedDiet intervention arm focuses on recommendations from the traditional Mediterranean diet and HEG intervention arm will use the dietary recommendations as currently advised in Ireland.

Discussion

This study will provide evidence as to whether dietary treatment of RA can improve physical function and quality of life in a small cohort of participants with RA. The results of the study will be disseminated at national scientific conferences and published in peer-reviewed journals.

Ethics

This protocol has been approved by the Education and Health Sciences Research Ethics Committee at the University of Limerick (2020_09_05_EHS) and by the Health Service Executive Mid-Western Regional Hospital Research Ethics Committee (REC Ref 103/19).

Trial registration

ClinicalTrials.gov NCT04262505. Trial registration date: April 2, 2020.

The AWESCORE, a patient-reported outcome measure: development, feasibility, reliability, validity and responsiveness for adults with cystic fibrosis

Background

Quality of life has improved dramatically over the past two decades in people with cystic fibrosis (CF). Quantification has been enabled by patient-reported outcome measures (PROMs); however, many are lengthy and can be challenging to use in routine clinical practice. We propose a short-form PROM that correlates well with established quality-of-life measures.

Methods

We evaluated the utility of a 10-item score (AWESCORE) by measuring reliability, validity and responsiveness in adults with CF. The questions were developed by thematic analysis of survey questions to patients in a single adult CF centre. Each question was scored using a numerical rating scale 0 to 10. Total scores ranged from 0 to 100. Test-retest reliability was assessed over 24 h. To determine validity, comparisons were sought between stable subjects and those in pulmonary exacerbation, and between AWESCORE and Cystic Fibrosis Questionnaire - Revised (CFQ-R). Responsiveness to pulmonary exacerbation in individual subjects was evaluated.

Results

Five domains, each with two questions, were identified for respiratory, physical, nutritional, psychological and general health. A total of 246 consecutive adults attending the outpatient clinic completed the AWESCORE. Scores were higher during clinical stability compared to pulmonary exacerbation (mean± sd): 73±11 versus 48±11 (p<0.001). Each domain scored worse during an acute exacerbation (p<0.001). No differences in reliability were observed in scores on retesting using Bland-Altman comparison. The CFQ-R scores (mean±sd: 813±125) and AWESCORE (81±13) were moderately correlated (Pearson's r=0.649; p=0.002).

Conclusions

The AWESCORE is valid, reliable and responsive to altered health status in CF.

Accuracy of the ActivPAL and Fitbit Charge 2 in measuring step count in Cystic Fibrosis

BACKGROUND

Physical activity (PA) is important in Cystic Fibrosis (CF) management. Fitness wearables are becoming increasingly popular as measurement tools of PA; however, the accuracy of these devices should first be evaluated.

OBJECTIVE

The purpose of this study was to assess the accuracy of the ActivPAL and Fitbit Charge 2 as a measure of step count in Cystic Fibrosis.

METHODS

Twenty-one participants were recruited from an adult CF Center in Ireland for a single session of testing. Participants walked for 5 min at five pre-determined speeds in a controlled testing environment (2, 2.5, 3, 3.5 and 4 miles per hour on a treadmill) and at three self-selected speeds in a corridor (slow, medium, and fast). They concurrently wore an accelerometer (ActivPAL) and fitness wearable (Fitbit Charge 2), and both were compared to visual observations. Step count is the outcome being assessed.

RESULTS

The ActivPAL under-estimated step count by 0.63% across treadmill speeds and 1.1% across self-selected walking speeds. The Fitbit Charge 2 underestimated the step count by 2.97% across treadmill speeds and by 6.3% across self-selected walking speeds. Very strong correlations were found between the ActivPAL and visual observations (r: 0.93 to 0.99), while the Fitbit Charge 2 ranged from weak to very strong correlations when compared to visual observations (r: 0.34 to 0.84).

CONCLUSION

The ActivPAL and Fitbit Charge 2 demonstrated acceptable validity for step count measurement in CF. These devices can be used for tracking PA during interventions in people with CF.

OP0191-PARE DEVELOPMENT OF A PUBLIC AND PATIENT INVOLVEMENT (PPI) RESEARCH NETWORK FOR PEOPLE WHO HAVE RHEUMATIC CONDITIONS

Background:

Public and patient involvement (PPI) improves quality and relevance of research (1). PPI is advocated by policy makers and funding bodies and is supported by EULAR (2). Arthritis Research Limerick (ARL) is a partnership between researchers at the University of Limerick and clinicians at University Hospitals Limerick. PPI representatives have been involved in ARL projects, however no formal PPI network had been established prior to 2020. The need for a formal PPI network to collaborate with ARL was identified by both ARL and patient representatives. This need arose from a joint ambition to promote meaningful involvement of the public and patients in ARL projects and to develop a platform through which researchers and PPI representatives could collaboratively set research priorities.

Objectives:

The aim of this project was to create a formal PPI network to engage with people living with rheumatic and musculoskeletal diseases (RMDs) and their families and to identify collaborative research opportunities between ARL and PPI representatives.

Methods:

A face-to-face PPI seminar was planned for October 2020. The seminar consisted of speakers from ARL providing an overview of research projects and a World Café research ideas session. Funding was obtained through a competitive, peer-review funding call from the PPI Ignite group at the University of Limerick to support the PPI seminar. The funding application was a joint application between ARL members and a PPI partner (iCAN - Irish Children’s Arthritis Network). The seminar was advertised through national patient organisations (iCAN and Arthritis Ireland), social media and ARL research networks.

Results:

Due to Covid-19 public health restrictions the PPI seminar was held virtually. The ARL PPI inaugural seminar was attended by N=19 researchers and people living with RMDs. The seminar speakers included ARL researchers and a PPI representative. The World Café event was modified to adapt to the virtual seminar delivery. Research ideas were noted by the seminar organiser and summarised for attendees at the end of the research ideas and priorities session. An ARL PPI mailing list was set-up post seminar as a means of communicating with seminar attendees and will serve as a formal PPI network for ARL. Research updates and opportunities will be communicated via this formal network to people living with RMDs and researchers alike.

Conclusion:

This was the first PPI seminar organised by ARL in collaboration with a PPI seminar, and has led to the creation of a formal PPI network. Delivery mode of the PPI seminar was changed due to Covid-19 public health restrictions. This change may also have impacted engagement and attendance at the PPI seminar, given that virtual events are not accessible to all of the RMD population. Future PPI seminars will consider a hybrid approach of face-to-face and virtual attendance, to enhance accessibility. A formal PPI communication network has been established. Future work will focus future collaborative opportunities between the PPI panel and the ARL group, including project development, co-led research funding applications and joint research dissemination.

References:

[1]INVOLVE. (2012). Briefing notes for researchers: Involving the public in NHS, public health and social care research. Retrieved from www.invo.org.uk 7th January 2020.

[2]de Wit MPT, Berlo SE, Aanerud GJ, et al (2011). European League Against Rheumatism recommendations for the inclusion of patient representatives in scientific projects. Annals of the Rheumatic Diseases 70:722-726

Disclosure of Interests:

None declared

The impact of COVID-19 on clinical research: the PIPPRA and MEDRA experience

Background: Coronavirus disease 2019 (COVID-19) has had a significant impact on clinical research. This paper aims to provide an insight into how the COVID-19 pandemic, associated public health restrictions and international guidance on the conduct of clinical research impacted two clinical rheumatology research trials - the Physiotherapist-led Intervention to Promote Physical Activity in Rheumatoid Arthritis (PIPPRA) and the MEDiterranean diet in Rheumatoid Arthritis (MEDRA) projects. Methods: The March 2019 public health restrictions imposed to mitigate the risk of COVID-19 occurred at a time when PIPPRA was in the process of delivering assessment and intervention on a face-to-face basis (n=48) and MEDRA had commenced recruitment. Participants in PIPPRA and MEDRA had a diagnosis of rheumatoid arthritis, with some being immunosuppressed and thus at a higher risk for COVID-19. The decision-making processes of both trials is outlined to demonstrate the required amendments to continue in the context of the COVID-19 pandemic. Results: Amendments to PIPPRA and MEDRA trial protocols were agreed and received ethical and funder approval. Both trials switched from a face-to-face delivery to a telehealth using online platforms. The PIPPRA study was paused for five months (April-August 2020), resulting in n=33 (60%) deviations from assessment protocol. MEDRA switched from face-to-face to online recruitment with 20% (n=35/44) deviation in recruitment. Of the n=18 participants who consented to participating in a face-to-face trial, just n=2 (11%) opted to engage with telehealth delivery of the intervention. MEDRA assessment and intervention deviations were 100% as no sessions were completed as planned in 2020. Conclusions: The COVID-19 pandemic has severely impacted the PIPPRA and MEDRA clinical trials. Moving face-to-face clinical research to telehealth delivery may not be the panacea it is purported to be. Our experiences may be of benefit to researchers, clinicians, and funders in seeking to continue clinical research during a global pandemic.

RapidInfo4U ­– an online individualised COVID-19 support intervention for nursing and allied health professionals: study protocol

Background: The COVID-19 outbreak was declared a pandemic by the World Health Organization on March 11th, 2020. An ongoing challenge in healthcare is ensuring that up-to-date and high-quality research evidence is implemented in practice. In the context of a global pandemic it is assumed, given the increased pressures on healthcare professionals that this problem has the potential to be exacerbated. Furthermore, the COVID-19 pandemic resulted in many health professionals being reassigned to areas outside their usual scope, returning to practice following absence or commencing their career as new entrants in the midst of a major crisis. These professionals are likely to require additional support to assist their confidence and competence. Aims: This project has two broad aims: to design and deliver an online educational platform to support nursing and allied health professionals in their clinical practice throughout the pandemic and to evaluate that platform and its implementation. Methods: The research protocol for this study consists of two work streams: the development and delivery of the online platform; and the project evaluation. This research will have a mixed methods approach including website data analytics, quantitative surveys and qualitative data analysis of semi-structured interviews. Conclusion: Through knowledge brokering and adherence to principles of effective technology-enhanced-learning this project will provide an accessible, individualised online educational resource to effectively meet the needs of individual nurses and allied health professionals in this unprecedented time. The evaluation of the platform and its implementation will provide key learning for future initiatives and may act as proof-of-concept for other organisations and countries seeking to support healthcare professionals’ knowledge needs during similar future pandemics.

Sarcopenia, Diet, Physical Activity and Obesity in European Middle-Aged and Older Adults: The LifeAge Study

The revised European consensus defined sarcopenia as a progressive and generalized skeletal muscle disorder that is associated with an increased likelihood of adverse outcomes including falls, fractures, physical disability and mortality. The aim of this study was to determine the prevalence of sarcopenia and analyse the influence of diet, physical activity (PA) and obesity index as risk factors of each criteria of sarcopenia. A total of 629 European middle-aged and older adults were enrolled in this cross-sectional study. Anthropometrics were assessed. Self-reported PA and adherence to the Mediterranean diet were evaluated with the Global Physical Activity Questionnaire (GPAQ) and Prevention with Mediterranean Diet questionnaire (PREDIMED), respectively. The functional assessment included handgrip strength, lower body muscle strength, gait speed and agility/dynamic balance. Of the participants, 4.84% to 7.33% showed probable sarcopenia. Sarcopenia was confirmed in 1.16% to 2.93% of participants. Severe sarcopenia was shown by 0.86% to 1.49% of participants. Male; age group ≤65 years; lower body mass index (BMI); high levels of vigorous PA; and the consumption of more than one portion per day of red meat, hamburgers, sausages or cold cuts and/or preferential consumption of rabbit, chicken or turkey instead of beef, pork, hamburgers or sausages (OR = 0.126-0.454; all p < 0.013) resulted as protective factors, and more time of sedentary time (OR = 1.608-2.368; p = 0.032-0.041) resulted as a risk factor for some criteria of sarcopenia. In conclusion, age, diet, PA, and obesity can affect the risk of having low muscle strength, low muscle mass or low functional performance, factors connected with sarcopenia.

The prevalence of malnutrition and impact on patient outcomes among older adults presenting at an Irish emergency department: a secondary analysis of the OPTI-MEND trial

Background

Malnutrition is common among older adults and is associated with adverse outcomes but remains undiagnosed on healthcare admissions. Older adults use emergency departments (EDs) more than any other age group. This study aimed to determine the prevalence and factors associated with malnutrition on admission and with adverse outcomes post-admission among older adults attending an Irish ED.

Methods

Secondary analysis of data collected from a randomised controlled trial exploring the impact of a dedicated team of health and social care professionals on the care of older adults in the ED. Nutritional status was determined using the Mini Nutritional Assessment- short form. Patient parameters and outcomes included health related quality of life, functional ability, risk of adverse health outcomes, frailty, hospital admissions, falls history and clinical outcomes at index visit, 30-day and 6-month follow up. Aggregate anonymised participant data linked from index visit to 30-days and 6-month follow-up were used for statistical analysis.

Results

Among 353 older adults (mean age 79.6 years (SD = 7.0); 59.2% (n = 209) female) the prevalence of malnutrition was 7.6% (n = 27) and ‘risk of malnutrition’ was 28% (n = 99). At baseline, those who were malnourished had poorer quality of life scores, functional ability, were more frail, more likely to have been hospitalised or had a fall recently, had longer waiting times and were more likely to be discharged home from the ED than those who had normal nutrition status. At 30-days, those who were malnourished were more likely to have reported another hospital admission, a nursing home admission, reduced quality of life and functional decline than older adults who had normal nutrition status at the baseline ED visit. Differences between the MNA SF and 6-month outcomes were similar but not statistically significant.

Conclusion

Over one-third of older adults admitted to an Irish ED are either malnourished or at risk of malnourishment. Malnutrition was associated with a longer stay in the ED, functional decline, poorer quality of life, increased risk of hospital admissions and a greater likelihood of admission to a nursing home at 30 days.

Trial registration

Protocol registered in ClinicalTrials.gov, ID: NCT03739515, first posted November 13, 2018.

Dietary interventions with or without omega-3 supplementation for the management of rheumatoid arthritis: a systematic review protocol

Background: Rheumatoid arthritis (RA) is an autoimmune disease characterised by swollen and painful joints. It is hypothesised that changes in lifestyle factors such as consuming a healthier diet may  reduce the severity of RA symptoms. People living with RA commonly make alterations to their dietary intake with the hope of improving their symptoms. This systematic review aims to discuss the effects of dietary interventions with and without omega-3 supplementation for the management of rheumatoid arthritis. Methods: A systematic review of randomised controlled trials (RCTs) and non-randomised controlled trials (NRCTs) will be conducted. MEDLINE, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Methodology Register) and CINAHL will be searched from inception without using date restrictions. Primary outcomes will include measures of disease activity, inflammation and quality of life among adults living with RA. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the methodological appraisal of the studies will be assessed independently by two different reviewers (TR and AG) using the Cochrane Risk-of-Bias Tool for RCTs, and Risk-of-Bias In Non-Randomised Studies Tool for NRCTs. Ethics and dissemination: Ethical approval is not required for this systematic review. Only publically available data from previously published studies will be used. The findings of this systematic review will be submitted for publication in a peer-reviewed journal and presented at relevant conferences. PROSPERO registration: CRD42020147415 (11/02/2020).

Measured Energy Expenditure Compared With Best-Practice Recommendations for Obese, Critically Ill Patients-A Prospective Observational Study

BACKGROUND

This study aimed to compare recommendations in the American Society for Parenteral and Enteral Nutrition (ASPEN) Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient with measured energy expenditure in obese, critically ill adults.

METHODS

After enrollment, measured energy expenditure was attempted at baseline and twice weekly to extubation or day 14. Data are reported as median [interquartile range].

RESULTS

Twenty patients were included. The median baseline and subsequent measured energy expenditures were 2438 [1807-2703] kcal and 2919 [2318-3362] kcal, respectively. Baseline measured energy expenditures were -491 [-788 to -323] kcal lower than subsequent measurements, and week 1 measurements were lower than those of week 2. The median bias between the guideline recommendation of 11-14 kcal/kg of actual body weight and measured expenditure at baseline was -950 [-1254 to -595] kcal/d and -1618 [-1820 to -866] kcal/d at subsequent measurements.

CONCLUSION

Clinically significant variation was observed between measured expenditure and guideline recommendations at all time points.

Effect of resveratrol supplementation on cognitive performance and mood in adults: a systematic literature review and meta-analysis of randomized controlled trials

Context

The aim of this systematic review was to evaluate clinical trial data regarding the effect of resveratrol supplementation on cognitive performance and mood in populations that are healthy and in the clinical setting.

Data Sources

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic literature review of randomized controlled trials was conducted.

Data Extraction

A meta-analysis was also conducted to determine treatment effect on the following cognitive domains and mental processes: processing speed, number facility, memory, and mood. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias tool. Quality of the body of evidence was assessed by evidence for each outcome related to cognitive function for which data was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE).

Results

Ten studies were included. Three studies found resveratrol supplementation significantly improved some measures of cognitive performance, 2 reported mixed findings, and 5 found no effect. When data were pooled, resveratrol supplementation had a significant effect on delayed recognition (standardized mean difference [SMD], 0.39; 95% confidence interval [CI], 0.08-0.70; I2 = 0%; P = 0.01; n = 3 studies; n = 166 participants) and negative mood (SMD, -0.18; 95%CI, -0.31 to -0.05; I2 = 0%; P = 0.006; n = 3 studies; n = 163 participants). Included studies generally had low risk of bias and were of moderate or high quality.

Conclusions

The results of this review indicate that resveratrol supplementation might improve select measures of cognitive performance; however, the current literature is inconsistent and limited.

Validity of multi-frequency bioelectric impedance methods to measure body composition in obese patients: a systematic review

OBJECTIVE

Excessive lean tissue loss following bariatric surgery may pose serious metabolic consequences. Accurate methods to assess body composition following bariatric surgery are required. This review aimed to investigate if multi-frequency bioelectric impedance (MF-BI) is a valid tool to determine body composition in obese patients.

METHODS

MEDLINE, EMBASE, CINAHL and CENTRAL databases were searched until March 2017. Included studies were published in English with obese (body mass index (BMI) ≥ 30 kg/m²) adults measuring body composition with MF-BI methods in comparison with reference methods. Exclusions were pregnancy, animal studies, non-English language studies, single frequency BI. A total of 6395 studies were retrieved.

RESULTS

Sixteen studies were eligible for inclusion. Sample sizes ranged from 15 to 157, with BMI 26-48 kg/m². MF-BI underestimated fat mass (FM) in 11 studies and overestimated fat-free mass (FFM) in nine studies in comparison with reference methods. Correlations of absolute values from MF-BI and reference methods for FM and FFM were high, however, agreement was lower at an individual level. When adjustments for BMI were made to machine algorithms, measurement accuracy improved. Significant heterogeneity was evident among included studies.

CONCLUSIONS

This review found that MF-BI is reliable for use at a group level. Obese-specific adjustment of algorithms for MF-BI machines increases the accuracy of absolute measures of body composition in obese individuals, improving their utility in the clinical setting. Multiple variables contributed a lack of consistency among studies included, highlighting the need for more robust studies that control confounding variables to establish clear validity assessment.

Targeted full energy and protein delivery in critically ill patients: a study protocol for a pilot randomised control trial (FEED Trial)

BACKGROUND

Current guidelines for the provision of protein for critically ill patients are based on incomplete evidence, due to limited data from randomised controlled trials. The present pilot randomised controlled trial is part of a program of work to expand knowledge about the clinical effects of protein delivery to critically ill patients. The primary aim of this pilot study is to determine whether an enteral feeding protocol using a volume target, with additional protein supplementation, delivers a greater amount of protein and energy to mechanically ventilated critically ill patients than a standard nutrition protocol. The secondary aims are to evaluate the potential effects of this feeding strategy on muscle mass and other patient-centred outcomes.

METHODS

This prospective, single-centred, pilot, randomised control trial will include 60 participants who are mechanically ventilated and can be enterally fed. Following informed consent, the participants receiving enteral nutrition in the intensive care unit (ICU) will be allocated using a randomisation algorithm in a 1:1 ratio to the intervention (high-protein daily volume-based feeding protocol, providing 25 kcal/kg and 1.5 g/kg protein) or standard care (hourly rate-based feeding protocol providing 25 kcal/kg and 1 g/kg protein). The co-primary outcomes are the average daily protein and energy delivered to the end of day 15 following randomisation. The secondary outcomes include change in quadriceps muscle layer thickness (QMLT) from baseline (prior to randomisation) to ICU discharge and other nutritional and patient-centred outcomes.

DISCUSSION

This trial aims to examine whether a volume-based feeding protocol with supplemental protein increases protein and energy delivery. The potential effect of such increases on muscle mass loss will be explored. These outcomes will assist in formulating larger randomised control trials to assess mortality and morbidity.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN: 12615000876594 UTN: U1111-1172-8563.

Quinoa Seed Lowers Serum Triglycerides in Overweight and Obese Subjects: A Dose-Response Randomized Controlled Clinical Trial

Background: Quinoa (Chenopodium quinoa) is a pseudo-cereal originally cultivated in the Andean region. The popularity of its seeds has increased in recent years due to the claims of health benefits and superfood qualities. Studies to date on the health benefits of quinoa have been restricted to animal models, and the results provide weak to moderate evidence to support improved plasma lipid profiles. Clinical trials in humans to examine the claims of health benefits of quinoa are limited to a few prospective studies and one randomized trial carried out in postmenopausal women. To our knowledge, no studies have been conducted in the general population. Objective: The objective of this randomized clinical trial was to investigate the effect of different quinoa doses (25 and 50 g/d) on body composition, serum lipids and hormones, and nutrient intakes in overweight and obese humans. Methods: This was a dose-response randomized, controlled, single-blind trial with a parallel design (1 control and 2 treatment groups) that compared the effect of 25 and 50 g quinoa/d in 50 overweight and obese participants over a 12-wk intervention period. Results: Body composition, nutrient intake, and total, LDL, and HDL cholesterol were not significantly altered by quinoa consumption (P > 0.05). Mean serum triglyceride (TG) concentration was reduced significantly in the 50-g quinoa group from 1.14 to 0.72 mmol/L at 12 wk (P < 0.05). The prevalence of metabolic syndrome (MetS) was also reduced in this group by 70%. No significant changes in TGs were observed in the control and 25-g quinoa groups. The prevalence of MetS was reduced by 40% (from n = 7 at baseline to n = 4 at 12 wk) in the 25-g group. Conclusions: The consumption of 50 g quinoa/d lowers serum TGs in overweight and obese participants and reduces the prevalence of MetS. This trial was registered at clinicaltrials.gov as UTN U1111-1175-470.

Research literacy: an essential prerequisite for knowledge-led practice

Fitting to the theme of this first issue of Nurse Researcher, this article examines what the recently published Strategy for Research in Nursing, Midwifery and Health Visiting ( 1 ) has to say about raising the level of research appreciation in nursing and improving nurses' skills in accessing and reading reports of research. If all of the Strategy's recommendations relevant to this and other areas were to be implemented, then there would be solid grounds for optimism that longstanding notions of nursing as a research-based profession might become, at last, something more concrete than mere rhetoric.

Risk of malignant progression in Barrett's esophagus indefinite for dysplasia

Barrett's esophagus is a well-recognized risk factor for esophageal adenocarcinoma. The natural history of Barrett's esophagus classified as ‘indefinite for dysplasia’ (IND) is poorly characterized. The aim of this study is to characterize the natural history of IND by determining the rate of neoplastic progression and identifying risk factors for progression. Patients from the University of Pennsylvania Health System pathology database and Barrett's esophagus registry with a diagnosis of IND between 2000 and 2014 were identified. Exclusion criteria included: (1) prior diagnosis of low-grade dysplasia (LGD), high-grade dysplasia (HGD), or esophageal adenocarcinoma (EAC); (2) presence of LGD, HGD, or EAC at the time of diagnosis of IND; and (3) lack of follow-up endoscopy after diagnosis. Patients with neoplastic progression were classified as having either prevalent disease (LGD, HGD, or EAC on surveillance biopsy within 12 months of IND diagnosis) or incident disease (LGD, HGD, or EAC on surveillance biopsy >12 months after IND diagnosis). One hundred six patients were eligible for analysis. Of 87 patients with follow-up endoscopy and biopsies within 1 year of IND diagnosis, 7 (8%) had prevalent disease (2 LGD, 4 HGD, 1 EAC). The prevalence of LGD was 2.3%, HGD was 4.6%, and EAC was 1.1%. Importantly, four of the seven prevalent (2 LGD, 2 HGD) cases were found to have dysplasia within 6 months of IND diagnosis. No demographic or endoscopic characteristics studied were associated with prevalent disease. Of the 106 IND patients, there were 66 patients without prevalent dysplasia with >1-year follow-up. Three (4.5%) progressed (1 to LGD after 12 months, 2 to HGD after 16.5 and 28 months), yielding an incidence rate for any dysplasia of 1.4 cases/100 person-years and HGD/EAC of 0.9/100 person-years. Risk factors for incident disease were smoking (p = 0.02) and Barrett's esophagus segment length (p = 0.03). IND is associated with considerable risk of prevalent dysplasia, especially within the first 6 months after diagnosis. However, the incidence of HGD/EAC is low and similar to previous studies of IND. These data suggest that IND patients should have repeat endoscopy within 6 months with careful surveillance protocols. Longer BE length and smoking history may help predict which patients are more likely to develop dysplasia, and therefore identify patients who may warrant even closer monitoring.

Internal medicine in the bush: a clinical audit of a rural and remote outreach programme

BACKGROUND

Provision of internal medicine services in rural Australia is always problematic.

AIM

The aim was to undertake an audit of an outreach service operating in Northern New South Wales since 2006.

METHODS

The service is conducted eight times a year, involving a consultant and an advanced trainee who travel by car to the towns of Moree and Mungindi and conduct clinics in a general practice setting, an Aboriginal medical service and a local health district clinic. Since 2008, a cardiology service and a diabetes service have been added on a fly-in fly-out basis. Case records of all patients enrolled in the service between February 2006 and July 2013 were reviewed in determining the demographics, clinical presentations and level of service coverage. The experience of the authors in establishing the service provided insights into the challenges and the success factors involved.

RESULTS

Five hundred and eighty-three patients were seen on a total of 1070 occasions relating to a wide variety of clinical presentations. Of these, 31.3% were indigenous compared with 20% in the local statistical area, and both indigenous and non-indigenous patients were seen in all settings. Patients fell into 15 different diagnostic categories with indigenous patients more likely to present for diabetes (P < 0.001) and hepatitis B (P < 0.01), but less likely to present for treatment of hepatitis C (P < 0.01).

CONCLUSIONS

In providing an outreach service to a mixed community, flexibility in both setting and personnel are essential. Diabetes and liver disease are highly prevalent in indigenous patients, but the low numbers presenting for hepatitis C requires further study.

Surveillance of diarrhoea in small animal practice through the Small Animal Veterinary Surveillance Network (SAVSNET)

Using the Small Animal Veterinary Surveillance Network (SAVSNET), a national small animal disease-surveillance scheme, information on gastrointestinal disease was collected for a total of 76 days between 10 May 2010 and 8 August 2011 from 16,223 consultations (including data from 9115 individual dogs and 3462 individual cats) from 42 premises belonging to 19 UK veterinary practices. During that period, 7% of dogs and 3% of cats presented with diarrhoea. Adult dogs had a higher proportional morbidity of diarrhoea (PMD) than adult cats (P <0.001). This difference was not observed in animals <1 year old. Younger animals in both species had higher PMDs than adult animals (P < 0.001). Neutering was associated with reduced PMD in young male dogs. In adult dogs, miniature Schnauzers had the highest PMD. Most animals with diarrhoea (51%) presented having been ill for 2-4 days, but a history of vomiting or haemorrhagic diarrhoea was associated with a shorter time to presentation. The most common treatments employed were dietary modification (66% of dogs; 63% of cats) and antibacterials (63% of dogs; 49% of cats). There was variability in PMD between different practices. The SAVNET methodology facilitates rapid collection of cross-sectional data regarding diarrhoea, a recognised sentinel for infectious disease, and characterises data that could benchmark clinical practice and support the development of evidence-based medicine.

Adherence to the 2011 American Gastroenterological Association medical position statement for the diagnosis and management of Barrett's esophagus

Considerable variability exists in adherence to practice guidelines for Barrett's esophagus (BE). Rapid advances in management approaches to BE led to a new American Gastroenterological Association (AGA) medical position statement in 2011. Our aim was to assess how well members of the AGA Clinical Practice section adhered to these guidelines. A self-administered survey incorporating questions on diagnostic criteria, cancer risk estimates, screening, surveillance, and therapeutics for BE was distributed electronically to 5850 North American members of the AGA Clinical Practice section. The response rate was 470 of 2040 opened e-mails (23%). Intestinal metaplasia was required for diagnosis of BE by 90%, but the Prague classification was used by only 53% of those aware of it. The annual risk of progression to esophageal adenocarcinoma was reported as 0.1-0.5% by 76%. Screening practices were variable, with 35% screening all patients with chronic gastroesophageal reflux disease and 15% repeating endoscopy in patients with gastroesophageal reflux disease following a negative screening. Surveillance guidelines were followed by 79% for nondysplastic BE and 86% for low-grade dysplasia, with expert pathology confirmation of dysplasia reported by 86%. Proton pump inhibitor dosing was variable, with 18% administering twice-daily doses and 30% titrating dose to symptoms. Ablation therapy was recommended by 6% for nondysplastic BE, 38% for low-grade dysplasia, and 52% for high-grade dysplasia. There is satisfactory adherence to the new AGA guidelines with respect to diagnosis, cancer risk estimates, and surveillance intervals in a select group of respondents. However, adherence continues to be variable in the use of the Prague classification, screening, and dosing of antisecretory therapy. Use of ablation therapy increases with grade of dysplasia. The reason for continued variability in adherence to BE practice guidelines remains unclear, and more evidence-based guidance is required to enhance clinical practice.

Musicians have fine-tuned neural distinction of speech syllables

One of the benefits musicians derive from their training is an increased ability to detect small differences between sounds. Here, we asked whether musicians' experience discriminating sounds on the basis of small acoustic differences confers advantages in the subcortical differentiation of closely related speech sounds (e.g., /ba/ and /ga/), distinguishable only by their harmonic spectra (i.e., their second formant trajectories). Although the second formant is particularly important for distinguishing stop consonants, auditory brainstem neurons do not phase-lock to its frequency range (above 1000 Hz). Instead, brainstem neurons convert this high-frequency content into neural response timing differences. As such, speech tokens with higher formant frequencies elicit earlier brainstem responses than those with lower formant frequencies. By measuring the degree to which subcortical response timing differs to the speech syllables /ba/, /da/, and /ga/ in adult musicians and nonmusicians, we reveal that musicians demonstrate enhanced subcortical discrimination of closely related speech sounds. Furthermore, the extent of subcortical consonant discrimination correlates with speech-in-noise perception. Taken together, these findings show a musician enhancement for the neural processing of speech and reveal a biological mechanism contributing to musicians' enhanced speech perception in noise.