Association between maternal blood lipids during pregnancy and offspring growth trajectories in a predominantly macrosomic cohort: findings from the ROLO longitudinal birth cohort study

The purpose of this study is to examine associations between maternal lipid profiles in pregnancy and offspring growth trajectories in a largely macrosomic cohort. This is a secondary analysis of the ROLO birth cohort (n = 293), which took place in the National Maternity Hospital, Dublin, Ireland. Infants were mostly macrosomic, with 55% having a birthweight > 4 kg. Maternal mean age was 32.4 years (SD 3.9 years), mean BMI was 26.1 kg/m2 (SD 4.4 kg/m2) and 48% of children born were males. Total cholesterol, high density lipoprotein cholesterol (HDL-cholesterol), low density lipoprotein cholesterol (LDL-cholesterol) and triglycerides were measured from fasting blood samples of mothers at 14 and 28 week gestation. The change in maternal lipid levels from early to late pregnancy was also examined. Offspring abdominal circumference and weight were measured at 20- and 34-week gestation, birth, 6 months, 2 years and 5 years postnatal. Linear spline multilevel models examined associations between maternal blood lipid profiles and offspring growth. We found some weak, significant associations between maternal blood lipids and trajectories of offspring growth. Significant findings were close to the null, providing limited evidence. For instance, 1 mmol/L increase in maternal triglycerides was associated with faster infant weight growth from 20- to 34-week gestation (0.01 kg/week, 95% CI - 0.02, - 0.001) and slower abdominal circumference from 2 to 5 years (0.01 cm/week, 95% CI - 0.02, - 0.001). These findings do not provide evidence of a clinically meaningful effect.    Conclusion: These findings raise questions about the efficacy of interventions targeting maternal blood lipid profiles in pregnancies at risk of macrosomia. New studies on this topic are needed. What is Known: • Maternal fat accumulation during early pregnancy may potentially support fetal growth in the third trimester by providing a reserve of lipids that are broken down and transferred to the infant across the placental barrier. • There are limited studies exploring the impact of maternal lipid profiles on infant and child health using growth trajectories spanning prenatal to postnatal life. What is New: • Maternal blood lipid profiles were not associated with offspring growth trajectories of weight and abdominal circumference during pregnancy up to 5 years of age in a largely macrosomic cohort, as significant findings were close to the null, providing limited evidence for a clinically meaningful relationship. • Strengths of this work include the use of infant growth trajectories that span prenatal to postnatal life and inclusion of analyses of the change of maternal lipid levels from early to late pregnancy and their associations with offspring growth trajectories from 20-week gestation to 5 years of age.

Examining primary care provider experiences with using a clinical decision support tool for pain management

Objective

To evaluate primary care provider (PCP) experiences using a clinical decision support (CDS) tool over 16 months following a user-centered design process and implementation.

Materials and Methods

We conducted a qualitative evaluation of the Chronic Pain OneSheet (OneSheet), a chronic pain CDS tool. OneSheet provides pain- and opioid-related risks, benefits, and treatment information for patients with chronic pain to PCPs. Using the 5 Rights of CDS framework, we conducted and analyzed semi-structured interviews with 19 PCPs across 2 academic health systems.

Results

PCPs stated that OneSheet mostly contained the right information required to treat patients with chronic pain and was correctly located in the electronic health record. PCPs used OneSheet for distinct subgroups of patients with chronic pain, including patients prescribed opioids, with poorly controlled pain, or new to a provider or clinic. PCPs reported variable workflow integration and selective use of certain OneSheet features driven by their preferences and patient population. PCPs recommended broadening OneSheet access to clinical staff and patients for data entry to address clinician time constraints.

Discussion

Differences in patient subpopulations and workflow preferences had an outsized effect on CDS tool use even when the CDS contained the right information identified in a user-centered design process.

Conclusions

To increase adoption and use, CDS design and implementation processes may benefit from increased tailoring that accommodates variation and dynamics among patients, visits, and providers.

Generalizability and portability of natural language processing system to extract individual social risk factors

OBJECTIVE

The objective of this study is to validate and report on portability and generalizability of a Natural Language Processing (NLP) method to extract individual social factors from clinical notes, which was originally developed at a different institution.

MATERIALS AND METHODS

A rule-based deterministic state machine NLP model was developed to extract financial insecurity and housing instability using notes from one institution and was applied on all notes written during 6 months at another institution. 10% of positively-classified notes by NLP and the same number of negatively-classified notes were manually annotated. The NLP model was adjusted to accommodate notes at the new site. Accuracy, positive predictive value, sensitivity, and specificity were calculated.

RESULTS

More than 6 million notes were processed at the receiving site by the NLP model, which resulted in about 13,000 and 19,000 classified as positive for financial insecurity and housing instability, respectively. The NLP model showed excellent performance on the validation dataset with all measures over 0.87 for both social factors.

DISCUSSION

Our study illustrated the need to accommodate institution-specific note-writing templates as well as clinical terminology of emergent diseases when applying NLP model for social factors. A state machine is relatively simple to port effectively across institutions. Our study. showed superior performance to similar generalizability studies for extracting social factors.

CONCLUSION

Rule-based NLP model to extract social factors from clinical notes showed strong portability and generalizability across organizationally and geographically distinct institutions. With only relatively simple modifications, we obtained promising performance from an NLP-based model.

Barriers and Facilitators of Obtaining Social Determinants of Health of Patients With Cancer Through the Electronic Health Record Using Natural Language Processing Technology: Qualitative Feasibility Study With Stakeholder Interviews

BACKGROUND

Social determinants of health (SDoH), such as geographic neighborhoods, access to health care, education, and social structure, are important factors affecting people's health and health outcomes. The SDoH of patients are scarcely documented in a discrete format in electronic health records (EHRs) but are often available in free-text clinical narratives such as physician notes. Innovative methods like natural language processing (NLP) are being developed to identify and extract SDoH from EHRs, but it is imperative that the input of key stakeholders is included as NLP systems are designed.

OBJECTIVE

This study aims to understand the feasibility, challenges, and benefits of developing an NLP system to uncover SDoH from clinical narratives by conducting interviews with key stakeholders: (1) oncologists, (2) data analysts, (3) citizen scientists, and (4) patient navigators.

METHODS

Individuals who frequently work with SDoH data were invited to participate in semistructured interviews. All interviews were recorded and subsequently transcribed. After coding transcripts and developing a codebook, the constant comparative method was used to generate themes.

RESULTS

A total of 16 participants were interviewed (5 data analysts, 4 patient navigators, 4 physicians, and 3 citizen scientists). Three main themes emerged, accompanied by subthemes. The first theme, importance and approaches to obtaining SDoH, describes how every participant (n=16, 100%) regarded SDoH as important. In particular, proximity to the hospital and income levels were frequently relied upon. Communication about SDoH typically occurs during the initial conversation with the oncologist, but more personal information is often acquired by patient navigators. The second theme, SDoH exists in numerous forms, exemplified how SDoH arises during informal communication and can be difficult to enter into the EHR. The final theme, incorporating SDoH into health services research, addresses how more informed SDoH can be collected. One strategy is to empower patients so they are aware about the importance of SDoH, as well as employing NLP techniques to make narrative data available in a discrete format, which can provide oncologists with actionable data summaries.

CONCLUSIONS

Extracting SDoH from EHRs was considered valuable and necessary, but obstacles such as narrative data format can make the process difficult. NLP can be a potential solution, but as the technology is developed, it is important to consider how key stakeholders document SDoH, apply the NLP systems, and use the extracted SDoH in health outcome studies.

257 THE INTRODUCTION OF THE SSKIN BUNDLE IN A REHABILITATION SETTING

Background

The SSKIN Bundle is a care bundle in which each component acts as an intervention in preventing pressure ulcers. SSKIN stands for Surface, Skin Inspection, Keep Moving, Incontinence Management, and Nutrition. This quality improvement initiative outlines the introduction of the SSKIN Bundle in an attempt to address the issue of pressure ulcers in a rehabilitation hospital. There is a significant amount of research attesting to the physical, psychological, and economic impact pressure ulcers have on patients, particularly older adults.

Methods

Following the Health Service Executive (HSE) Pressure Ulcer to Zero (PUTZ) campaign (HSE National Wound Management Guidelines 2019), this initiative was introduced to the hospital by an interdisciplinary committee in February 2019. Patients who met the inclusion criteria were regularly assessed using the SSKIN Bundle. Data was visually audited via the PUTZ safety cross and analysed using Run Charts.

Results

Results showed a clear decrease in the number of pressure ulcers following introduction of the SSKIN Bundle. Within a six-month timeframe and following the introduction of the SSKIN Bundle, the incidence percentage of newly acquired pressure ulcers was reduced by 50%. Despite incidences where partial increases occurred, this was quickly rectified by facilitating targeted education sessions to staff and the appointment of a tissue viability nurse.

Conclusion

The conclusions of this campaign ultimately found that the introduction of a SSKIN Bundle helped to improve staff knowledge on the monitoring, recognition, grading, and prevention of pressure ulcers. The visual of the safety cross worked particularly well as a means to tailor this education where knowledge gaps existed.

Study protocol for a type III hybrid effectiveness-implementation trial to evaluate scaling interoperable clinical decision support for patient-centered chronic pain management in primary care

Background

The US continues to face public health crises related to both chronic pain and opioid overdoses. Thirty percent of Americans suffer from chronic noncancer pain at an estimated yearly cost of over $600 billion. Most patients with chronic pain turn to primary care clinicians who must choose from myriad treatment options based on relative risks and benefits, patient history, available resources, symptoms, and goals. Recently, with attention to opioid-related risks, prescribing has declined. However, clinical experts have countered with concerns that some patients for whom opioid-related benefits outweigh risks may be inappropriately discontinued from opioids. Unfortunately, primary care clinicians lack usable tools to help them partner with their patients in choosing pain treatment options that best balance risks and benefits in the context of patient history, resources, symptoms, and goals. Thus, primary care clinicians and patients would benefit from patient-centered clinical decision support (CDS) for this shared decision-making process.

Methods

The objective of this 3-year project is to study the adaptation and implementation of an existing interoperable CDS tool for pain treatment shared decision making, with tailored implementation support, in new clinical settings in the OneFlorida Clinical Research Consortium. Our central hypothesis is that tailored implementation support will increase CDS adoption and shared decision making. We further hypothesize that increases in shared decision making will lead to improved patient outcomes, specifically pain and physical function. The CDS implementation will be guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. The evaluation will be organized by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. We will adapt and tailor PainManager, an open source interoperable CDS tool, for implementation in primary care clinics affiliated with the OneFlorida Clinical Research Consortium. We will evaluate the effect of tailored implementation support on PainManager’s adoption for pain treatment shared decision making. This evaluation will establish the feasibility and obtain preliminary data in preparation for a multi-site pragmatic trial targeting the effectiveness of PainManager and tailored implementation support on shared decision making and patient-reported pain and physical function.

Discussion

This research will generate evidence on strategies for implementing interoperable CDS in new clinical settings across different types of electronic health records (EHRs). The study will also inform tailored implementation strategies to be further tested in a subsequent hybrid effectiveness-implementation trial. Together, these efforts will lead to important new technology and evidence that patients, clinicians, and health systems can use to improve care for millions of Americans who suffer from pain and other chronic conditions.

Trial registration

ClinicalTrials.gov, NCT05256394, Registered 25 February 2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01217-4.

Assessment of structured data elements for social risk factors

OBJECTIVES

Computable social risk factor phenotypes derived from routinely collected structured electronic health record (EHR) or health information exchange (HIE) data may represent a feasible and robust approach to measuring social factors. This study convened an expert panel to identify and assess the quality of individual EHR and HIE structured data elements that could be used as components in future computable social risk factor phenotypes.

STUDY DESIGN

Technical expert panel.

METHODS

A 2-round Delphi technique included 17 experts with an in-depth knowledge of available EHR and/or HIE data. The first-round identification sessions followed a nominal group approach to generate candidate data elements that may relate to socioeconomics, cultural context, social relationships, and community context. In the second-round survey, panelists rated each data element according to overall data quality and likelihood of systematic differences in quality across populations (ie, bias).

RESULTS

Panelists identified a total of 89 structured data elements. About half of the data elements (n = 45) were related to socioeconomic characteristics. The panelists identified a diverse set of data elements. Elements used in reimbursement-related processes were generally rated as higher quality. Panelists noted that several data elements may be subject to implicit bias or reflect biased systems of care, which may limit their utility in measuring social factors.

CONCLUSIONS

Routinely collected structured data within EHR and HIE systems may reflect patient social risk factors. Identifying and assessing available data elements serves as a foundational step toward developing future computable social factor phenotypes.

Understanding Health Care Administrators’ Data and Information Needs for Decision Making during the COVID-19 Pandemic: A Qualitative Study at an Academic Health System

Objective. The COVID-19 pandemic created an unprecedented strain on the health care system, and administrators had to make many critical decisions to respond appropriately. This study sought to understand how health care administrators used data and information for decision making during the first 6 mo of the COVID-19 pandemic. Materials and Methods. We conducted semistructured interviews with administrators across University of Florida (UF) Health. We performed an inductive thematic analysis of the transcripts. Results. Four themes emerged from the interviews: 1) common types of health systems or hospital operations data; 2) public health and other external data sources; 3) data interaction, integration, and exchange; and 4) novelty and evolution in data, information, or tools used over time. Participants illustrated the organizational, public health, and regional information they considered essential (e.g., hospital census, community positivity rate, etc.). Participants named specific challenges they faced due to data quality and timeliness. Participants elaborated on the necessity of data integration, validation, and coordination across different boundaries (e.g., different hospital systems in the same metro areas, public health agencies at the local, state, and federal level, etc.). Participants indicated that even within the first 6 mo of the COVID-19 pandemic, the data and tools used for making critical decisions changed. Discussion. While existing medical informatics infrastructure can facilitate decision making in pandemic response, data may not always be readily available in a usable format. Interoperable infrastructure and data standardization across multiple health systems would help provide more reliable and timely information for decision making. Conclusion. Our findings contribute to future discussions of improving data infrastructure and developing harmonized data standards needed to facilitate critical decisions at multiple health care system levels.

The effectiveness of exercise interventions to increase physical activity in Cystic Fibrosis: A systematic review

Physical activity (PA) and exercise have numerous benefits in Cystic Fibrosis (CF) including improved lung function, exercise capacity and quality of life. Despite these benefits, the effectiveness of interventions to promote PA in this population are still largely unknown. The objective of this review was to synthesise existing research and determine whether exercise interventions are effective in promoting PA in people with CF. Using the PRISMA guidelines, a comprehensive search was conducted. Fifteen studies (463 participants) met the inclusion criteria. Eleven studies demonstrated improvements in PA in both short- and long-term interventions. However, the interventions were variable across the included studies, with a large inconsistency in PA assessment tools used. Aerobic training and activity counselling were the two elements identified in this review which most consistently improved PA. Future research should consider larger sample sizes and the use of accurate instruments to assess and track PA levels longitudinally.

Effect of supplement crude protein concentration on milk production over the main grazing season and on nitrogen excretion in late-lactation grazing dairy cows

The objectives of this study are to evaluate the effects of (1) a potential interaction between supplement crude protein (CP) concentration and differing cow genotypes on milk production, (2) differing cow genotypes on milk production, and (3) decreasing the supplement CP concentration on milk production and N excretion during the main grazing season within a spring-calving herd. A 2 × 2 factorial arrangement experiment, with 2 feeding strategies [14%; n = 30 (lower CP; LCP) and 18%; n = 28 (higher CP; HCP) CP concentrate supplements] offered at varying levels according to pasture availability and days in milk (DIM) was conducted over the main grazing season from April 3 to September 3, 2019, at University College Dublin Lyons Farm. Cows were also grouped into 2 genotype groups: lower milk genotype; n = 30 [LM; milk kg predicted transmitting ability (PTA): 45 ± 68.6 (mean ± SD); fat kg PTA: 10 ± 4.9; and protein kg PTA: 7 ± 2.3] and higher milk genotype; n = 28 [HM; milk kg PTA: 203 ± 55.0; fat kg PTA: 13 ± 3.8; and protein kg PTA: 10 ± 2.4]. A total of 46 multiparous and 12 primiparous (total; 58) Holstein Friesian dairy cows were blocked on parity and balanced on DIM, body condition score, and Economic Breeding Index. Cows were offered a basal diet of grazed perennial ryegrass pasture. The N partitioning study took place from August 25 to 30, 2019 (187 ± 15.2 DIM). No interactions were observed for any milk production or milk composition parameter. No effect of supplement CP concentration was observed for any total accumulated milk production, daily milk production, or milk composition parameter measured. The HM cows had increased daily milk yield (+1.9 kg), fat and protein (+0.15 kg), and energy-corrected milk (+1.7 kg), compared with the LM cows. Furthermore, HM cows had decreased milk protein concentration (-0.1%) compared with LM cows. For the N partitioning study, cows offered LCP had increased pasture dry matter intake (PDMI; +0.9 kg/d), dietary N intake (+0.022 kg/d), feces N excretion (+0.016 kg/d), and decreased N partitioning to milk (-2%), and N utilization efficiency (-2.3%). In conclusion, offering cows LCP had no negative influence on milk production or milk composition over the main grazing season where high pasture quality was maintained. However, any potential negative effects of offering LCP on milk production may have been offset by the increased PDMI. Furthermore, offering cows LCP decreased N utilization efficiency due to the higher PDMI and feed N intake associated with cows on this treatment in our study.s.

Peer review audit of non-specialist occupational physician reports

BACKGROUND

With declining specialist occupational physician (OP) numbers, there is increasing recognition of the importance of non-specialist physicians in occupational health (OH) service delivery, yet to date, this physician group remains understudied and their competency requirements poorly understood.

AIMS

To evaluate the quality of a sample of non-specialist OH reports and compare these with specialist reports.

METHODS

A retrospective peer review audit of a convenience sample of 200 consecutive non-specialist and specialist OH reports from an Irish OH service using an assessment form based on the modified Sheffield Assessment Instrument for Letters SAIL(OH)1.

RESULTS

Of the 200 peer reviewed OH reports, 159 (80%) were from non-specialists. For all questions, 87% and above of non-specialist reports were 'satisfactory' or 'above expected'. On the overall assessment, out of 10, the mean non-specialist report score was 6.8 (standard deviation (SD) 3-10) and the specialist score was 7.3 (SD 3-10). Comparatively, non-specialist reports highlighted legal/ethical issues marginally more and adhered slightly better to contractual/ethical/legal boundaries, while specialist reports fared better in addressing manager's questions, in their structure and clarity and in covering all significant aspects of the case, particularly if the case was complex.

CONCLUSIONS

Our findings demonstrate a high standard of OH report quality in this sample of non-specialist OPs that is consistent across all key OH report components. Potential development areas are also identified that can inform education/training tailored to this physician group and assist in competency standard-setting.

Management referral triaging process pilot study: a 'telephone first' approach

BACKGROUND

In this Occupational Health Department (OHD), a 'telephone first' approach was introduced to triage management referrals with potential to convert to Telephone Independent Medical Assessment (TIMA). Telephone consultation has been widely used in the UK's NHS in the occupational health setting.

AIMS

To evaluate TIMA effectiveness and efficiency of OHD resources; comparing the outcome of a triage call compared to previous default allocation of next available appointment, percentage of telephone triage calls converted to TIMA and appointment waiting times. To assess use of OHD resources arising from TIMA. To evaluate service user satisfaction following TIMA. To examine service user characteristics.

METHODS

As management referrals were received, service users were given a telephone contact. Data were collected and anonymized regarding service users, who also consented to receive feedback questionnaire. Cross-sectional analysis of this management referral cohort was carried out.

RESULTS

Two hundred and sixty-one management referrals were received in the specified period. Eighty per cent had a TIMA carried out (n = 208); 64% of management referrals with TIMA had a report issued (n = 166). Response rate to feedback questionnaire was 38% (n = 70); 94% of survey participants found TIMA acceptable going forward for management referrals (n = 66).

CONCLUSIONS

Introduction of a 'telephone first' approach resulted in improved efficiency of this OHD, allowing maximum workforce planning, and positive service user feedback.

ISIS TS1 project – removal of the target, reflector and moderator (TRaM) support structure using a bandsaw within a remote handling cell

Target station 1 (TS1) is currently in the implementation stage of a large sustainability project to continue future operation, in addition to making improvements to the neutron performance, ease of operation, and various other factors (J. Phys.: Conf. Ser. 1021 (2018) 012053). One aspect of this project is the extraction of the current irradiated equipment situated within the target area to enable the replacement of the target, reflector and moderator assembly (TRaM). This new assembly will be modular to allow any future upgrades to be installed swiftly. Removal of the current TRaM systems support structure is discussed within this paper. This extraction comes with challenges; due to its abnormal size, the welded structure cannot simply be placed in a shielded flask and removed, it instead must be cut up into 2 sections inside the remote handling cell (RHC) (J. Phys.: Conf. Ser. 1021 (2018) 012077). Testing has been completed using a gravity fed hydraulic bandsaw, and various components have been manufactured to allow ease of adjustment using the remote handling system. However, there is still work to be done before the shutdown in 2020.

Structured opioid-free protocol following outpatient hypospadias repair - A prospective SQUIRE 2.0-compliant quality improvement initiative

BACKGROUND

Prescription opioids have been extensively to manage postoperative pain in children. A growing body of evidence from the adult literature, suggests however, that healthcare providers may be prescribing far more opioids than required, with some studies demonstrating equivalent post-operative pain and clinical outcomes with their omission.

OBJECTIVE

The objectives of this prospective study were to assess the current heterogeneity of practice in post-operative opioids prescription following day case hypospadias surgery, to establish a streamlined discharge protocol, and to reduce the use of post-operative opioid prescription by 30% within a 4 month period through the use of systemic forcing functions and education.

STUDY DESIGN

This prospective study was approved by the Quality Improvement (QI) sub-committee of the hospital's Research and Ethics Board (REB) and was compliant with the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines. Recruited parents (n = 84) were contacted for telephone interview following a combined intervention of education and omission of post-operative opioids from the discharge prescription. A mixture of qualitative and quantitative techniques were employed including an initial process analysis to assess current opioid use, the creation of balancing measures, and the creation of Plan-Do-Study-Act cycles. Age, procedure, post-operative outcomes and opioid prescription data were recorded over a period of 6 months in 2019.

RESULTS

Initial measures in our process analysis demonstrated significant institutional practice variation amongst our 84 post-intervention patients. Our process and fidelity measures confirmed 100% information provision. Following the point of intervention, there was a significant and sustained drop in opioid prescription, with an absolute reduction of 35%, and a relative reduction of 56%. There was no significant difference in patient age, pain scores, or outcomes pre- and post-intervention.

DISCUSSION

We have shown in this study that a sustainable decrease in post-operative opioid prescriptions following hypospadias surgery is possible. We managed to achieve a relative reduction 56% which is comparable to other specialties, however, did it within a quality improvement framework to ensure fidelity and no adverse balancing measures. We also managed to reduce the number of doses prescribed in those receiving opioids post-intervention at week 9.

CONCLUSION

Our study demonstrates opioids can be safely omitted in hypospadias cohorts without any adverse clinical outcomes or balancing measures. We recommend that opioids be used extremely judiciously in this population in order to minimize exposure in children.

Grey-scale silicon diffractive optics for selective laser ablation of thin conductive films

Laser beam shaping can play a crucial role in improving many laser processes, especially in selective laser patterning of thin films for display devices and solar cells. Typical Gaussian spatial energy distributions can increase damage to the substrate and lead to large crater edge ridges, which are sub-optimal for typical industrial thin film processes. We report on the design, fabrication, and testing of reflective silicon diffractive optics developed for spatial beam shaping at a wavelength of 355 nm. The application of the elements for laser-selective removal of 20 nm indium tin oxide thin films on glass substrates is demonstrated. The design of the phase profile is first generated using the numerical method of computer-generated holography. The phase profiles are realized on a silicon substrate using a novel two-step fabrication technique consisting of a calibrated focused ion beam and an inductively coupled plasma etch. This results in truly grey-scale, blazed diffractive optics, which were analyzed using white light interferometry and atomic force microscopy. Using the diffractive elements with 355 nm nanosecond pulses shows excellent focused spot profiles with a good reproduction of the intended design with a first-order off-axis diffractive efficiency of approximately 80% at a 45 deg angle of incidence.

A Novel Mental Health Crisis Service - Outcomes of Inpatient Data

INTRODUCTION

Northern Ireland has high mental health needs and a rising suicide rate. Our area has suffered a 32% reduction of inpatient beds consistent with the national drive towards community based treatment. Taking these factors into account, a new Mental Health Crisis Service was developed incorporating a high fidelity Crisis Response Home Treatment Team (CRHTT), Acute Day Care facility and two inpatient wards. The aim was to provide alternatives to inpatient admission. The new service would facilitate transition between inpatient and community care while decreasing bed occupancy and increasing treatment in the community.

METHODS

All services and processes were reviewed to assess deficiencies in current care. There was extensive consultation with internal and external stakeholders and process mapping using the COBRAs framework as a basis for the service improvement model. The project team set the service criteria and reviewed progress.

RESULTS

In the original service model, the average inpatient occupancy rate was 106.6%, admission rate was 48 patients per month and total length of stay was 23.4 days. After introducing the inpatient consultant hospital model, the average occupancy rate decreased to 90%, admissions to 43 per month and total length of stay to 22 days. The results further decreased to 83% occupancy, 32 admissions per month and total length of stay 12 days after CRHTT initiation.

DISCUSSION

The Crisis Service is still being evaluated but currently the model has provided safe alternatives to inpatient care. Involvement with patients, carers and all multidisciplinary teams is maximised to improve the quality and safety of care. Innovative ideas including structured weekly timetable and regular interface meetings have improved communication and allowed additional time for patient care.

An unusual lung mass post stem cell transplantation

We report a case of Mycobacterium kansasii presenting as an obstructing endobronchial mass in a patient post stem cell transplant. The patient had a complete clinical, microbiological, and radiological response to anti-tuberculous treatment. To our knowledge, this is the first case of M. kansasii presenting post transplant with an obstructing lung mass simulating relapse or post-transplant lymphoma.

Promising Practices in Mammography Recruitment, Retention and Rescreening for Breast Cancer Early Detection among Community-Based Programs Supported by the Avon Foundation Breast Care Fund

Background/Significance: National guidelines recommend women age 40 and older have mammograms every 1-2 years. Since 2000, the Avon Foundation Breast Care Fund (AFBCF), a project of Cicatelli Associates Inc., has supported nonprofit community-based organizations (CBOs) to provide breast health education and outreach to link medically underserved women with free/low-cost breast cancer screening services. These organizations have developed effective strategies for recruiting, retaining and rescreening clients. This evaluation study aims to identify promising practices for effective mammography recruitment, retention and rescreening among un/underinsured, low-income, and racial and/or ethnic minority women.Methods: Twenty of 144 AFBCF-funded CBOs were selected to participate in a retrospective study to determine clients' rescreening rates.CBOs provided de-identified data on mammography screening by age and visit date to determine their rescreening rate, defined as the proportion of female outreach clients age 40+ years receiving a mammogram and subsequent mammogram through that agency within the following 6-18 and/or 18-30 months. CBOs also completed a qualitative survey about program strategies and systems. Qualitative data were linked with rescreening rates to identify promising practices. Survey results were also used to develop a discrete questionnaire administered to 144 AFBCF-funded CBOs to identify which agencies currently employ identified promising practices.Results: Data analysis will be completed in September 2009.Preliminary results indicate that rescreening rates vary widely across agencies, from 15% to over 90%. In addition, findings indicate that some CBOs lack mechanisms to routinely monitor client rescreening. Utilizing unique client identifiers in conjunction with the use of electronic data tracking systems would facilitate tracking clients over time and improve targeted outreach efforts to increase rescreening rates.Discussion: Combined qualitative and quantitative analyses of differences in practices directed at encouraging mammography rescreening among medically underserved women will enable a description of promising practices for increasing rescreening rates in this population. Analysis will include an explanation of mammography rescreening rates among medically underserved women. Agencies with high rescreening rates will be identified and discussion regarding organizational characteristics and practices will be presented. Additionally, unique and innovative strategies for reaching specific populations will be examined.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3080.

Lipid resuscitation in a carnitine deficient child following intravascular migration of an epidural catheter

A child with cerebral palsy and carnitine deficiency developed ventricular arrhythmias with loss of cardiac output during elective surgery under general anaesthesia with concomitant epidural analgesia. Sinus rhythm was restored on administration of adrenaline, but hypotension persisted despite resuscitation. Bolus administration of 0.8 ml*kg(-1) (20 ml) lipid emulsion resulted in rapid improvement in cardiac output. Blood samples taken before and after the lipid bolus did not demonstrate toxic concentrations of bupivacaine. This case suggests that carnitine deficiency may increase susceptibility to bupivacaine cardiotoxicity.

Mumps epidemiology in the mid-west of Ireland 2004-2008: increasing disease burden in the university/college setting

Mumps is a contagious vaccine-preventable viral disease that is experiencing a revival in students attending second and third level colleges. Large mumps outbreaks have been reported in several countries despite the presence of childhood immunisation programmes over many years, including measles, mumps, and rubella (MMR) vaccination. In 2008, 1,377 cases of mumps were notified in Ireland and 1,734 in the first three months of 2009 (provisional data). This paper reviews the recent epidemiology of mumps in the Mid-West region of Ireland and highlights preventive measures. A substantial proportion of cases were not laboratory-confirmed and it is important that doctors continue to notify suspected cases. In the Irish Mid-West, data from enhanced surveillance shows a high proportion of mumps in the age group 15-24 years. Complications were uncommon and rarely severe. Where data were available, over half of the cases did not recall having received two doses of MMR, but most recalled one dose. Parents should continue to ensure children receive both MMR vaccinations so that uptake is optimal for protection. Steps were taken to increase awareness of the disease in the school, college and university settings. Preventive measures implemented to limit mumps transmission in the school/college setting over recent years included vaccination of close contacts, isolation for five days and hand hygiene.

Mumps epidemiology in the Mid-West of Ireland 2004-2008: increasing disease burden in the university/college setting

Mumps is a contagious vaccine-preventable viral disease that is experiencing a revival in students attending second and third level colleges. Large mumps outbreaks have been reported in several countries despite the presence of childhood immunisation programmes over many years, including measles, mumps, and rubella (MMR) vaccination. In 2008, 1,377 cases of mumps were notified in Ireland and 1,734 in the first three months of 2009 (provisional data). This paper reviews the recent epidemiology of mumps in the Mid-West region of Ireland and highlights preventive measures. A substantial proportion of cases were not laboratory-confirmed and it is important that doctors continue to notify suspected cases. In the Irish Mid-West, data from enhanced surveillance shows a high proportion of mumps in the age group 15-24 years. Complications were uncommon and rarely severe. Where data were available, over half of the cases did not recall having received two doses of MMR, but most recalled one dose. Parents should continue to ensure children receive both MMR vaccinations so that uptake is optimal for protection. Steps were taken to increase awareness of the disease in the school, college and university settings. Preventive measures implemented to limit mumps transmission in the school/college setting over recent years included vaccination of close contacts, isolation for five days and hand hygiene.

Effects of sequential changes from conventional ventilation to high-frequency oscillatory ventilation at increasing mean airway pressures in an ovine model of combined lung and head injury

BACKGROUND

The objective of this study was to determine the intracranial, cardiovascular and respiratory changes induced by conversion to high-frequency oscillator ventilation from conventional mechanical ventilation at increasing airway pressures.

METHODS

In this study, 11 anaesthetized sheep had invasive cardiovascular and intracranial monitors placed. Lung injury was induced by saline lavage and head injury was induced by inflation of an intracranial balloon catheter. All animals were sequentially converted from conventional mechanical ventilation to high-frequency oscillator ventilation at target mean airway pressures of 16, 22, 28, 34 and 40 cm H(2)O. The mean airway pressure was achieved by adjusting positive end expiratory pressure while on conventional mechanical ventilation, and continuous distending pressures while on high-frequency oscillator ventilation. Cerebral lactate production, oxygen consumption and venous oximetry were measured and analysed in relation to changes in transcranial Doppler flow velocity. Transcranial Doppler profiles together with other physiological parameters were measured at each airway pressure.

RESULTS

Cerebral perfusion pressure was significantly lower during high-frequency oscillator ventilation than during conventional mechanical ventilation (CMV: 45, 34, 22, 6, 9 mmHg vs. HFOV: 33, 20, 19, 5, 5 mmHg at airway pressures mentioned above, P = 0.02). Intracranial pressure and cerebrovascular resistance increased with increasing intrathoracic pressures (P = 0.001). Cerebral metabolic indices demonstrated an initial increase in anaerobic metabolism followed by a decrease in cerebral oxygen consumption progressing to cerebral infarction as intrathoracic pressures were further increased in a stepwise fashion. Arterial PaCO(2) increased significantly after converting from conventional mechanical ventilation to high-frequency oscillator ventilation (P = 0.001). However, no difference was observed between conventional mechanical ventilation and high-frequency oscillator ventilation when intracranial pressure, metabolic and transcranial Doppler indices were compared at equivalent mean airway pressures.

CONCLUSIONS

The use of high positive end expiratory pressure with conventional mechanical ventilation or high continuous distending pressure with high-frequency oscillator ventilation increased intracranial pressure and adversely affected cerebral metabolic indices in this ovine model. Transcranial Doppler is a useful adjunct to intracranial pressure and intracranial venous saturation monitoring when major changes in ventilation strategy are adopted.

Quantifying the effects of melittin on liposomes

Melittin, the soluble peptide of bee venom, has been demonstrated to induce lysis of phospholipid liposomes. We have investigated the dependence of the lytic activity of melittin on lipid composition. The lysis of liposomes, measured by following their mass and dimensions when immobilised on a solid substrate, was close to zero when the negatively charged lipids phosphatidyl glycerol or phosphatidyl serine were used as the phospholipid component of the liposome. Whilst there was significant binding of melittin to the liposomes, there was little net change in their diameter with melittin binding reversed upon salt injection. For the zwitterionic phosphatidyl choline the lytic ability of melittin is dependent on the degree of acyl chain unsaturation, with melittin able to induce lysis of liposomes in the liquid crystalline state, whilst those in the gel state showed strong resistance to lysis. By directly measuring the dimensions and mass changes of liposomes on exposure to melittin using Dual Polarisation Interferometry, rather than following the florescence of entrapped dyes we attained further information about the initial stages of melittin binding to liposomes.

Quantification of the effects of melittin on liposome structure

An optical technique, dual-polarization interferometry, has been used to examine lipid structures at the solid/liquid interface. Changes in the lipid structures, in real time, were examined as a consequence of challenging them with a peptide (melittin) that is known to induce liposome rupture. This work suggests that it should be possible to obtain a better understanding of the detail of the melittin rupture process.

Phase I study of twice-weekly gemcitabine and concomitant external-beam radiotherapy in patients with adenocarcinoma of the pancreas

PURPOSE

To determine the maximum tolerated dose and dose-limiting toxicity associated with twice-weekly gemcitabine and concomitant external-beam radiotherapy in patients with adenocarcinoma of the pancreas.

METHODS AND MATERIALS

Twenty-one patients with biopsy-proven adenocarcinoma of the pancreas were treated with external-beam radiotherapy to a dose of 50.4 Gy in 28 fractions, concurrent with gemcitabine, infused over 30 min before irradiation on a Monday and Thursday schedule. The dose of gemcitabine was escalated in 5 cohorts of 3--6 patients each. Initial gemcitabine dose was 10 mg/m(2), with dose escalation until dose-limiting toxicity was observed.

RESULTS

The maximum tolerated dose of gemcitabine was 50 mg/m(2), when given in a twice-weekly schedule with radiation. Dose-limiting toxicity was seen in 2 patients at 60 mg/m(2), and consisted of severe upper gastrointestinal bleeding approximately 1 month after completion of treatment. Six patients had radiographic evidence of response to treatment, and 5 of these underwent complete surgical resection. Three patients who underwent complete resection had been deemed to have unresectable tumors before enrollment on trial. Four patients are alive, including 2 without evidence of disease more than 1 year after resection.

CONCLUSION

The combination of external-beam radiation and twice-weekly gemcitabine at a dose of 50 mg/m(2) is well tolerated and shows promising activity for the treatment of pancreatic cancer. Our data suggest a higher maximum tolerated dose and different dose-limiting toxicity than previously reported. Further investigation of this regimen is warranted.

Recurrent postdural puncture headache

A14-year-old female presented with a 3-day history of generalized headache, photophobia, neck stiffness and nausea. She had no history of neurological illness or trauma. Clinical examination was normal. Complete blood count, serum urea and creatinine, urine culture and throat swab culture were normal. Dural puncture was carried out under aseptic technique. A 22-gauge Sprotte spinal needle was inserted between the third and fourth lumbar vertebrae, and thirty drops of clear cerebrospinal fluid were removed. Laboratory examination of the fluid was normal, and the patient was treated with analgesics. The headache improved, but did not resolve completely.

She was discharged the following day, but presented 4 weeks later, with a severe, intermittent frontotemporal headache. It was associated with nausea, aggravated by changing posture, and transiently relieved by abdominal pressure. Postdural puncture headache was diagnosed, and a blood patch relieved her symptoms completely.

Four weeks later, she presented with a recurrence of headache. A second blood patch relieved her symptoms again. Four weeks later, she presented again with a recurrence of headache. Computed tomography of brain and magnetic resonance imaging of lumbar spine were normal. She was treated with amitriptyline and carbamazepine. Symptoms improved, and her pain-free intervals became longer. Three months after the dural puncture she still had headache.

Analgesia in day case breast biopsy--the value of pre-emptive tenoxicam

PURPOSE

Inadequate analgesia is a major problem following ambulatory surgery. In this prospective randomised study, the use of pre-operative intravenous tenoxicam (a non steroidal anti-inflammatory agent) was compared with post-incision tenoxicam for the relief of post-operative pain in 77 patients undergoing day case breast biopsy.

METHODS

All patients received a standard general anaesthetic which included infiltration of the wound with bupivacalne after skin closure. Intravenous tenoxicam (20 mg) was administered as a single bolus either 30 min before surgery (37 patients) or after incision (40 patients). Pain scores (100 mm visual analog scale) were obtained at 30, 60, 120 and 240 min after surgery analgesic requirements recorded.

RESULTS

Both groups of patients were similar with respect to age, weight, operative time and length of the incision. Patients receiving the tenoxicam 30 min before surgery had lower pain scores at 30 min (22 +/- 3) vs 46 +/- 3; P < 0.0001), 60 min (9 +/- 2 vs 28 +/- 3); P < 0.0001), 120 min (6 +/- 2 vs 16 +/- 3); P = 0.0002) and 240 min (3 +/- 1) vs 7 +/- 2); P = 0.02) post-operatively. They had a longer time to first analgesia (55.1 +/- 4.6 vs 29.6 +/- 2.6) min; P = 0.0004), required less meperidine (5.4 +/- 2.6 vs 18.8 +/- 3.9) mg; P = 0.007) and were more likely not to require any further analgesia during the first four hours post-operatively.

CONCLUSION

Pre-operatively administered tenoxicam provides superior post-operative analgesia than tenoxicam administered after surgical incision in patients undergoing breast biopsy.

Determination of blood flow to the transplanted kidney. A novel application of phase-contrast, cine magnetic resonance imaging

There is at present no noninvasive method that reliably measures blood flow in the poorly functioning renal allograft. The present study was designed to evaluate phase-contrast cine magnetic resonance imaging (PC-cine-MRI) for this purpose. We recruited for study 18 patients who had received kidney transplants 13-66 months earlier from closely related living donors. As judged by the glomerular filtration rate, which was elevated for a single kidney (76 +/- 4 ml/min 1.73 m2), allograft function was excellent, permitting the assumption of unimpaired renal extraction of paminohippuric acid (PAH). Allograft blood flow was determined consecutively on the same day, first by the standard PAH clearance technique and they by the product of the velocity of protons and renal vein cross-sectional area using PC-cine-MRI. MRI determinations could not be completed because of claustrophobia in two patients and failure to image the terminus of the allograft vein another two. Comparison of blood flow in the remaining 14 subjects revealed the two techniques to be strongly related (r = 0.91, P < 0.001). On the average, the renal blood flow rate was similar by each method; 732 +/- 62 by PAH clearance and 703 +/- 69 ml/min by PC-cine-MRI, but the agreement among individuals between the two methods was only modest, with a 95% confidence interval of agreement from -214 to +254 ml/min. We conclude that PC-cine-MRI provides a fairly accurate and noninvasive method for determining the rate of blood flow in the transplanted kidney. With further refinement it should permit the role of depressed blood flow in a variety of acute and chronic forms of human allograft dysfunction to be elucidated in humans for the first time.

Physical overdistension converts ventricular cardiomyocytes to acquire endocrine property and regulate ventricular atrial natriuretic peptide production

Atrial natriuretic peptide (ANP) is present in adult atria but at very low concentrations in normal adult mammalian ventricles. In the atria, the production of ANP is regulated by physical distension of the atrial wall. The same phenomenon was investigated in the ventricles of rats and men. Cardiac tissues from human ventricular aneurysm (n = 5), spontaneously hypertensive rats (n = 30), and rats that had overloaded left ventricles induced by surgery (n = 84) were studied with the methods of light microscopic immunocytochemistry, electron microscopic immunogold staining, and RNA-RNA tissue in situ hybridization. It was found that the levels of ANP gene expression, ANP immunoreactivity, and ANP-containing specific granules in the overburdened ventricles were elevated and their degrees of fluctuation were directly proportional to the force of physical distension applied to the ventricular cardiomyocytes. In rats, ANP mRNA and ANP immunoreactivity returned to the control level seven days after the ventricular overload was surgically released. The changes of ANP and its mRNA in the ventricles were related more closely to the changes of intraventricular pressure than to cardiocytic hypertrophy. In addition, ANP immunoreactivity was demonstrated in Purkinje cells and periarteriolar cardiomyocytes in the ventricles of normotensive rats. In conclusion, physical overstretch of the ventricle wall is likely to be the triggering factor affecting ventricular cardiomyocytes to acquire endocrine property, and also to regulate the production of ventricular ANP, thereby contributing to the control of the blood volume and the blood pressure.

Acute and custodial care among impaired aged

The authors surveyed a community-based population of 628 persons who were 65 and over and who lived either in a rural Maryland county or in Baltimore. For each subject, the number of different medical problems, the subject's capacity to perform physical tasks, and the ability to function were assessed. The number and type of medical problems tended to be the best predictors of whether or not hospital or physician's office care were used, and of the volume of physician's office visits for subjects who sought outpatient care. The subject's ability to function was the best predictor of whether or not the subject used a paid home aide and the volume of family caregiving. Implications for research on association between need and use of long-term care are discussed.

Rapid processing of urine specimens by urine screening and the AutoMicrobic system

A total of 1,500 clean-voided urine specimens were analyzed for the presence of bacteria by urine screening with the Autobac 1 system. The specimens found positive by this method were further processed on the same day for identification and for antimicrobial susceptibility testing on the AutoMicrobic system with the Enterobacteriaceae-plus Card and the General Susceptibility Card, respectively. The inocula for these tests were prepared from the centrifuged and washed growth in the eugonic broth aspirated from the Autobac cuvette chambers. Of 1,500 specimens that were analyzed, 183 contained single isolates of gram-negative bacilli. The results of these rapid procedures were compared with results for the same organisms isolated from urine specimens cultured by the conventional method. The data showed 92.3% agreement for identification and a correlation of 93.6% for antibiotic susceptibility between the two procedures. It is concluded that gram-negative bacilli can be rapidly identified and tested for antimicrobial susceptibility with a high degree of accuracy from the centrifuged eugonic broth after urine screening. These findings also suggest that the AutoMicrobic system provides a rapid and convenient method for same-day processing of positive urine cultures when combined with the urine screening procedure.