Expanding Medical Education to Include Substance Use Disorders During Pregnancy and Postpartum: Preliminary Effectiveness of a Pilot Curriculum for Medical Students

OBJECTIVE

To effectively combat the simultaneous overdose and maternal mortality crises, a multimodal approach is needed. The aim of this study is to evaluate the preliminary effectiveness of a pilot, experiential learning, substance use disorder (SUD) curriculum embedded into a third-year medical student obstetrics and gynecology clerkship to improve self-reported confidence in SUD clinical skills.

METHODS

This SUD curriculum was designed and implemented in an outpatient clinic, which provides integrated obstetric, gynecologic, and addiction medicine services for pregnant and parenting people with SUD. Third-year medical students on their obstetrics and gynecology clerkship rotated 1 full day through the OB MOTIVATE clinic between August 2020 and April 2022 and completed this curriculum. Students completed preclinic assignments and in-clinic tasks (eg, practicing SBIRT under supervision: screening, brief intervention, referral to treatment). Paired t tests assessed changes in outcomes, with increasing scores (range 1-5) demonstrating improvement.

RESULTS

Sixty-three students rotated through the OB MOTIVATE clinic; 57 completed the curriculum and surveys. Results from the self-assessment tools demonstrated significant improvements in confidence in SUD clinical skills, including performing SBIRT (2.46 ± 0.80 vs 4.07 ± 0.59, P < 0.01), motivational interviewing (2.98 ± 0.86 vs 4.16 ± 0.65, P < 0.01), using evidence-based medicine (2.91 ± 1.09 vs 4.23 ± 0.66, P < 0.01), and collecting an SUD history (3.25 ± 1.04 vs 4.35 ± 0.55, P = 0.01).

CONCLUSIONS

The integration of interventional curriculums into medical school and residency programs could be an effective avenue to reinforce addiction knowledge and teach new skills. This practical 1-day pilot curriculum demonstrated preliminary effectiveness at introducing third-year medical students to the complexities of SUD in pregnancy and postpartum. Further investigations of feasible and acceptable SUD educational interventions are warranted.

Benchmarking non-attendance patterns in paediatric medical imaging: A retrospective cohort study spotlighting First Nations children

INTRODUCTION

Non-attendance at Medical Imaging (MI) appointments can result in inefficiencies in healthcare resource allocation, increased financial burdens, and lead to potential barriers to effective healthcare delivery. We evaluated factors associated with non-attendance of MI appointments for children including variables: gender; age groups; residential postcodes; Indigenous status; appointment dates; appointment reminders and socio-economic status.

METHOD

Retrospective cohort study of children with scheduled MI appointments at a Tertiary paediatric hospital in Australia, between January and December 2022. Data were extracted from the Radiology Information System and integrated with socio-economic census data through linking with postcode. Chi-squared, and logistic regression analysis were performed to identify significant predictors of non-attendance.

RESULTS

Out of 17,962 scheduled outpatient appointments, 6.2 % did not attend. Males were less likely to attend than females (7.3 % vs. 5.8 %; p < 0.001). Older children had the highest frequency of non-attendance (p < 0.001). First Nations identified children had a higher likelihood of non-attendance at 14.5 % compared to non-First Nations at 5.8 %, and the odds ratio (OR) of First Nation children not attending was 2.54 (CI 2.13-3.03; p < 0.001) higher than non-First Nations children. Children from areas of disadvantage were less likely to attend (p < 0.001). Bone mineral densitometry had the highest odds of non-attendance (19.4 % of bookings) compared to other imaging modalities (p < 0.001).

CONCLUSION

The following characteristics were associated with non-attendance: older male gender, residing in areas of socio-economic disadvantage, or identifying as First Nations Australians. By reviewing these findings with the cultural and professional experience of our Indigenous co-author, we have identified some strategies for improving attendance amongst First Nations children.

IMPLICATIONS FOR PRACTICE

Factors associated with non-attendance, or "missed opportunities for care", provide opportunities for intervention to improve attendance for vulnerable groups of children who require medical imaging.

GrassGroTM simulation of pasture, animal performance and greenhouse emissions on low and high sheep productivity grazing systems: 1-year validation and 25-year analysis

Globally, there is a focus on reducing the absolute methane (CH4) and nitrous oxide emissions, and the emissions intensity (EI, kg CO2e/kg animal product) of livestock production. Increasing the productivity of mixed pasture systems has the potential to increase food (e.g., lamb) and textile fibre (e.g., wool) production while reducing the EI of those products from grazing livestock. The objective of this study was to quantify the differences in greenhouse gas (GHG) emissions and EI between sheep on Low (i.e., low sustainable stocking rate) and High (i.e., high sustainable stocking rate) productivity grazing systems (PGSs). Therefore, a replicated breeding-ewe trial on 18 paddocks was established across 2 - years. Three flocks on Low (3 × 16 ewes/flock) and High PGSs (3 × 32 ewes/flock) rotated across three land-classes and three paddocks per PGS. In year 1, the observed on-farm pasture quantity, quality, and botanical composition, together with lamb BW (kg), and daily CH4 production (DMP, g CH4/head per day) using Open Path Fourier Transformed Infrared (OP-FTIR) spectrometers data were measured. Subsequently, two simulations using GrassGroTM were conducted: (1) a 1-year GrassGroTM simulation that used the observed on-farm data to adjust parameters: date of mating, paddock fertility, and weight of mature ewes to validate GrassGroTM predictions to achieve accuracy and precision targets; and (2) a 25-year (1986-2011) simulation to analyse the effects of Low and High PGSs on sheep production and GHG emissions across a variable climate. The 1-year validation predictions fitted well with the observed on-farm data for: pasture biomass (kg/ha), DM digestibility (%), botanical composition (kg/ha), lamb (kg) product, and DMP (g CH4/head per day). The subsequent predicted results from the 25-year GrassGroTM simulation showed minimal effect of PGS on the mean DM intake (kg DM/day) or DMP for Low and High PGSs, but this was thought to be due to the biomass in both PGSs exceeding 1 500 kg DM/ha. The EI, over the 25-year simulation, on the High PGS was 16.5% lower than the Low PGS. Additional calculations of DMP were conducted using a recent global equation, giving estimates of DMP that closely matched the observed on-farm OP-FTIR DMP measurements, but these were lower than the GrassGroTM predictions and improved the accuracy and precision. It is concluded that in some pasture situations, managing pastures and stock numbers to intensify grazing systems can allow increased livestock production, without increasing daily CH4 emissions/head while substantially decreasing the EI of the animal products generated.

Motivational Interviewing Education in North American Family Medicine Clerkships: A CERA Study

BACKGROUND AND OBJECTIVES

Many health conditions are preventable or modifiable through behavioral changes. Motivational interviewing (MI) is an evidence-based communication technique that explores a patient's reasons for behavioral changes. This study assesses the current landscape of MI training in North American Family Medicine (FM) clerkships.

METHODS

We analyzed data gathered as part of the 2022 Council of Academic Family Medicine's Educational Research Alliance (CERA) survey of FM clerkship directors (CDs). The survey was distributed via email invitation to 159 US and Canadian FM CDs in June 2022.

RESULTS

Of the 94 responses received, 61% indicated that MI training is provided in their FM clerkship. Medical school type, class size, and location were associated with MI training priority, offerings, and duration in the clerkship, respectively. CD experience correlated with MI training duration; student MI skill training level was associated with MI training duration and priority; the rigor of student MI skills evaluation was correlated with MI teaching methods and training duration; self-reported student MI competency was associated with the length of time students spent with FM community preceptors as well as MI training priority and teaching methods; and several items emerged as predictors of student, CD, and FM faculty MI training expansion.

CONCLUSIONS

Opportunities exist to enhance the volume, content, and rigor of MI training in North American FM clerkships as well as to improve self-reported student MI competency within those clerkships.

Adapting Compassionate Conversations for Virtual Mediated Communication

OBJECTIVE

The Covid-19 pandemic resulted in a shift in communication of difficult, emotionally charged topics from almost entirely in-person to virtual mediated communication (VMC) methods due to restrictions on visitation for safety. The objective was to train residents in VMC and assess performance across multiple specialties and institutions.

DESIGN

The authors designed a teaching program including asynchronous preparation with videos, case simulation experiences with standardized patients (SPs), and coaching from a trained faculty member. Three topics were included - breaking bad news (BBN), goals of care / health care decision making (GOC), and disclosure of medical error (DOME). A performance evaluation was created and used by the coaches and standardized patients to assess the learners. Trends in performance between simulations and sessions were assessed.

SETTING

Four academic university hospitals - Virginia Commonwealth University Medical Center in Richmond, Virginia, The Ohio State University Wexner Medical Center in Columbus, Ohio, Baylor University Medical Center in Dallas, Texas and The University of Cincinnati in Cincinnati, Ohio- participated.

PARTICIPANTS

Learners totaled 34 including 21 emergency medicine interns, 9 general surgery interns and 4 medical students entering surgical training. Learner participation was voluntary. Recruitment was done via emails sent by program directors and study coordinators.

RESULTS

A statistically significant improvement in mean performance on the second compared to the first simulation was observed for teaching communication skills for BBN using VMC. There was also a small but statistically significant mean improvement in performance from the first to the second simulation for the training overall.

CONCLUSIONS

This work suggests that a deliberate practice model can be effective for teaching VMC and that a performance evaluation can be used to measure improvement. Further study is needed to optimize the teaching and evaluation of these skills as well as to define minimal acceptable levels of competency.

OpNotes and Clinical Exercises: Activities to Enhance the Clinical Context of the Preclerkship Anatomy Dissection Laboratory

PROBLEM

Despite numerous pedagogical approaches and technologies now available for medical gross anatomy, students can find it difficult to translate what occurs in a dissection laboratory into the context of clinical practice.

APPROACH

Using complementary and collaborative approaches at 2 different medical schools, Virginia Commonwealth University (VCU) and University of Maryland (UM), we designed and implemented a series of clinical activities in the preclerkship medical gross anatomy laboratory that directly link dissected structures to clinical procedures. These activities specifically direct students to perform simulated clinically related procedures on anatomic donors during laboratory dissection sessions. The activities are called OpNotes at VCU and Clinical Exercises at UM. Each activity in the VCU OpNotes requires about 15 minutes of group activity at the end of a scheduled laboratory and involves faculty to grade the student responses submitted via a web-based-assessment form. Each exercise in UM Clinical Exercises also requires about 15 minutes of group activity during the schedule laboratory but does not involve faculty to complete grading.

OUTCOMES

Cumulatively, the activities in OpNotes and Clinical Exercises both brought clinical context directly to anatomical dissections. These activities began in 2012 at UM and 2020 at VCU, allowing a multiyear and multi-institute development and testing of this innovative approach. Student participation was high, and perception of its effectiveness was almost uniformly positive.

NEXT STEPS

Future iterations of the program will work to assess the efficacy of the program as well as to streamline the scoring and delivery of the formative components. Collectively, we propose that the concept of executing clinic-like procedures on donors in anatomy courses is an effective means of enhancing learning in the anatomy laboratory while concurrently underscoring the relevance of basic anatomy to future clinical practice.

A mixed methods exploration of the emergence of goal orientation in medical students' individualized learning plans

PURPOSE

Goal orientation (GO) describes an individual's approach to different achievement situations. Understanding the motivations and approach to achieving goals of medical students is vital with the increasing emphasis on self-directed learning. The purpose of this study was to identify themes in self-improvement reflections that relate to each GO dimension (learning, performance-prove, and performance-avoid).

METHODS

A sequential explanatory mixed methods design was used. GO data was used to categorize students into groups aligning with the GO dimension identified in the previous stage of quantitative analysis. Individualized learning plans (ILPs) for each GO dimension group were coded inductively to identify emergent themes related to goal setting and achievement.

RESULTS

The learning GO group was the largest of the three GOs. Five themes were identified from inductive analysis: importance of practice, identifying elements that helped, identifying structural barriers, opportunities for improvement, and acknowledging experience. While these themes occur across GO, patterns exist within their ILPs based on GO.

CONCLUSIONS

We identified common themes for motivations of medical students, and these motivations might differ depending on their GO. Further exploration into the themes over the course of their training will provide additional insights on what factors may be involved in student motivations towards learning and achievement. Educators can use this information to individualize feedback and students can better understand their motivations towards achieving goals.

Telehealth Training for Surgeons to Empathetically Deliver Bad News Via Video-Mediated Communication

BACKGROUND

The COVID-19 pandemic resulted in a sudden increase in the need to effectively use telehealth in all realms of health care communication, including the delivery of bad news.

METHODS

A single arm, unblinded, feasibility study was performed at a tertiary care center located in Central Virginia to explore the value and utility of providing a telehealth training program based on SPIKES to teach surgical residents and faculty best practice for disclosing difficult news via video-mediated communication (VMC). Surgical interns (categorical and preliminary), surgical residents, and surgical faculty from General, Neuro, Pediatric, Plastics, Oncology, Urology, and Vascular surgical specialties were recruited via email to voluntarily participate in a telehealth simulation-based workshop, with 33 surgical learners participating in the training and 28 completing evaluation surveys.

RESULTS

Only six respondents (22%) indicated they had prior formal training on telehealth communication with patients or families, while 13 (46%) said they had prior experience giving bad news via telehealth. Comments about improving the training focused on providing more scenarios to practice and more time for feedback. Overall, 25 learners (86%) agreed the activity was a valuable learning experience and the majority (61%) of responses were positive for future use of telehealth for breaking bad news.

DISCUSSION

Practicing communication skills with VMC was found to be valuable by surgical interns, residents, and faculty. Formal training should be provided for surgeons at every stage of training and practice to improve skill in the delivery of bad news to patients and their families.

Monobody adapter for functional antibody display on nanoparticles for adaptable targeted delivery applications

Vascular endothelial cells (ECs) play a central role in the pathophysiology of many diseases. The use of targeted nanoparticles (NPs) to deliver therapeutics to ECs could dramatically improve efficacy by providing elevated and sustained intracellular drug levels. However, achieving sufficient levels of NP targeting in human settings remains elusive. Here, we overcome this barrier by engineering a monobody adapter that presents antibodies on the NP surface in a manner that fully preserves their antigen-binding function. This system improves targeting efficacy in cultured ECs under flow by >1000-fold over conventional antibody immobilization using amine coupling and enables robust delivery of NPs to the ECs of human kidneys undergoing ex vivo perfusion, a clinical setting used for organ transplant. Our monobody adapter also enables a simple plug-and-play capacity that facilitates the evaluation of a diverse array of targeted NPs. This technology has the potential to simplify and possibly accelerate both the development and clinical translation of EC-targeted nanomedicines.

From chaos to creativity: Designing collaborative communication training for the delivery of bad news

Background

Before the COVID-19 pandemic, teaching communication skills in health care focused primarily on developing skills during face-to-face conversation. Even experienced clinicians were unprepared for the transition in communication modalities necessitated due to physical distancing requirements and visitation restrictions during the COVID-19 pandemic. We aimed to develop and pilot a comprehensive video-mediated communication training program and test its feasibility in multiple institutional settings and medical disciplines.

Methods

The education team, consisting of clinician-educators in general surgery and emergency medicine (EM) and faculty specialists in simulation and coaching, created the intervention. Surgery and EM interns in addition to senior medical students applying in these specialties were recruited to participate. Three 90-minute sessions were offered focusing on 3 communication topics that became increasingly complex and challenging: breaking bad news, goals of care discussions, and disclosure of medical error. This was a mixed-methods study using survey and narrative analysis of open comment fields.

Results

Learner recruitment varied by institution but was successful, and most (75%) learners found the experience to be valuable. All of the participants reported feeling able to lead difficult discussions, either independently or with minimal assistance. Only about half (52%) of the participants reported feeling confident to independently disclose medical error subsequent to the session.

Conclusion

We found the program to be feasible based on acceptability, demand, the ability to implement, and practicality. Of the 3 communication topics studied, confidence with disclosure of medical error proved to be the most difficult. The optimal length and structure for these programs warrants further investigation.

Reckoning with Our Racist Past: An Academic Health Center’s Engagement with History and Health

Academic health centers (AHC) both contribute to and are influenced by the communities they serve. As part of a central commitment to improving human health, there is a need for AHCs to acknowledge their history related to race and racism, the resulting impact on current health disparities, and the disparate treatment of racial and minoritized communities. As AHC’s care for Black and Brown communities, they have a unique responsibility to redress their respective legacies of bias, discriminatory practices, and experimentation without consent. One way to achieve this is to provide learning opportunities for in-depth engagement with students, faculty, staff, health care providers, and community members in conversations regarding racial equity, which are essential to shaping and impacting change at an individual and institutional level. Virginia Commonwealth University in Richmond, Virginia, launched a new initiative, History, and Health; Racial Equity, designed to (a) increase awareness of our institution’s history, impact, identity, and culture, and (b) support meaningful conversations around history, health equity, structural racism, and health sciences education. Urban and metropolitan universities may learn from and replicate this program and encourage such conversations in their communities.

The UK AVATAR 1 and 2 Trials for People with Distressing Voices – Findings and Learning from AVATAR1, and AVATAR2 Developments in Theory and Therapy

Introduction

Many people suffering from psychotic disorders report persistent auditory verbal hallucinations (‘voices’) despite pharmacological and psychological therapy. Interest is growing in approaches that emphasise the personal relationship between the patient and their voice(s). AVATAR therapy is one such approach that uses a digital representation (avatar) of a selected voice to facilitate a three-way discussion between patient, therapist and voice, the therapist speaking either as him/herself or in the digitally transformed voice of the avatar. Objectives: To describe AVATAR therapy and an ongoing multi-centre clinical trial. Methods: Encouraging findings from an earlier controlled trial (AVATAR1) comparing AVATAR therapy and supportive counselling informed our current multi-site cost-effectiveness trial of brief and extended versions of the therapy compared to treatment as usual (AVATAR2). Results: AVATAR1 delivered in 7 weekly sessions resulted in a reduction in the frequency, distress and power of voices that was significantly superior to supportive counselling. Clinical experience suggested that some participants improved in response to the early focus on anxiety while others seemed more responsive to later more formulation-driven approach. These findings led us to the current ongoing three arm clinical trial comprising a brief (6 session) focus on anxiety/assertiveness, an extended (12 session) formulation-driven approach both approaches compared to treatment as usual. Conclusion: Previous AVATAR studies suggest this is a therapy with considerable promise. It can be delivered through widely available laptop computers, usually in clinic but also remotely via existing commercial platforms. The current trial will address questions about dissemination, training and cost-effectiveness in NHS settings.

Disclosure

The digital technology employed in AVATAR therapy is provided by licence for the trial from Avatar Therapy Ltd

The Emirates Mars Mission

The Emirates Mars Mission (EMM) was launched to Mars in the summer of 2020, and is the first interplanetary spacecraft mission undertaken by the United Arab Emirates (UAE). The mission has multiple programmatic and scientific objectives, including the return of scientifically useful information about Mars. Three science instruments on the mission's Hope Probe will make global remote sensing measurements of the Martian atmosphere from a large low-inclination orbit that will advance our understanding of atmospheric variability on daily and seasonal timescales, as well as vertical atmospheric transport and escape. The mission was conceived and developed rapidly starting in 2014, and had aggressive schedule and cost constraints that drove the design and implementation of a new spacecraft bus. A team of Emirati and American engineers worked across two continents to complete a fully functional and tested spacecraft and bring it to the launchpad in the middle of a global pandemic. EMM is being operated from the UAE and the United States (U.S.), and will make its data freely available.

Addiction curriculum design for medical students

BACKGROUND

As mortality and morbidity due to substance use disorder (SUD) are increasing for women, especially during pregnancy and postpartum, it is imperative to equip medical providers with skills to identify SUD and initiate treatments. We designed a curriculum to provide third-year medical students with clinical exposure to SUD during pregnancy.

APPROACH

This novel, experience-based SUD curriculum was focused on providing adequate knowledge, skills and confidence to provide compassionate, patient-centred care to women with SUD. Obstetrics and Gynecology clerkship third-year medical students rotated 1 day through a clinic that provides Obstetrics and Gynecology and addiction medicine services. Congruent with COVID-19 limitations, students completed pre-clinic assignments and in-clinic tasks (e.g., screening, brief intervention, referral to treatment [SBIRT]) under supervision.

EVALUATION

After implementation of this pilot curriculum, 20 students and 10 teachers completed surveys (100% response rate) with open-ended response items. Quantitative data and open-ended responses using electronic surveys were sequentially analysed to evaluate the curriculum's feasibility and acceptability.

IMPLICATIONS

We designed a novel curriculum that focused on SUD learning objectives and providing exposure to third-year medical students, and our findings indicate that it is feasible and acceptable to both students and teachers. In the future, we plan to provide this curriculum to both our third- and fourth-year medical students, and we encourage teachers and providers at other institutions to utilise it during their clinical training.

The Role for Simulation in Professional Identity Formation in Medical Students

INTRODUCTION

Authentic clinical experiences and reflection are critical for medical student professional identity formation (PIF). Individualized learning plans and competency-based education accelerate time to graduation, thus creating more demand for students to gain PIF experiences early in medical education. This pilot study investigated student professional identity experiences related to participation in a clinical simulation during the first week of medical school.

METHODS

All first-year medical students at an academic health center participated in a clinically relevant simulation-based orientation to medical school (SOMS). Participants completed evaluation surveys measuring PIF-related experiences during the SOMS.

RESULTS

All participants completed the survey (N = 186). Students agreed that the SOMS helped them feel what it is like to be a doctor (90%) and transition to the role of student-physician (91%). Student comments about the SOMS-reflected PIF-related processes, such as building a sense of a community of practice among their peers in their roles as a healthcare team. Students also valued the opportunity to engage in reflection about their roles as student-physicians.

CONCLUSIONS

Simulation experiences can be used as a trigger for self-reflection to assist in medical student professional identity development as early as the first weeks of medical school. Simulation exercises may improve PIF and could further enhance medical student PIF by adding them longitudinally into the curriculum.

Management of well appearing infants born to afebrile mothers with inadequate GBS prophylaxis: A retrospective comparison of the three approaches recommended by the COFN

BACKGROUND

There are three different approaches set forth by the Committee on the Fetus and Newborn (COFN) for managing asymptomatic neonates born to mothers with inadequate intrapartum antibiotic prophylaxis (IAP) for early-onset Group B Strep (GBS) infection. The first approach is that of categorical risk factor assessments, and recommends that asymptomatic infants born to afebrile mothers with inadequate IAP for GBS be monitored with clinical observation for 36-48 hours. The second approach recommends serial physical examinations and vital signs for 36-48 hours to closely monitor changes in clinical condition for all patients. The Kaiser Permanente EOS risk calculator (SRC) is an example of the third approach, a multivariate risk assessment, and it takes into consideration several perinatal risk factors. This multivariate risk assessment then provides recommendations for reassessment and management based on presume risk of the infant developing or having Early Onset Sepsis (EOS). The aim of our study was to compare these three recently published recommendations from the COFN for the management of asymptomatic neonates born to afebrile mothers with inadequate IAP for GBS.

STUDY DESIGN

This is a retrospective study of asymptomatic neonates with gestational age ≥35 weeks born to afebrile mothers with indicated inadequate IAP for GBS between April 2017 and July 2020. Management recommendations of the SRC were compared to the recommendations of categorical risk assessment and risk assessment based on clinical condition.

RESULTS

A total of 7,396 infants were born during the study period, 394 (5.3%. to mothers with inadequate IAP. Recommendations for these infants according to both the categorical risk factor guideline and the clinical condition guideline include extended, close observation. However, the SRC recommended routine newborn care for 99.7%.f these infants. None of the infants developed EOS.

CONCLUSION

The SRC recommend routine neonatal care without enhanced and prolonged observation for nearly all asymptomatic infants born to afebrile mothers with inadequate IAP. As none of the infants in this cohort had EOS, further studies in a larger cohort are needed to establish the safety of SRC in neonates born to mothers with inadequate IAP.

Video-mediated breaking bad news simulation

BACKGROUND

Communication between clinicians, patients, and families is a core component of medical care that requires deliberate practice and feedback to improve. In March 2020, the COVID-19 pandemic caused a sudden transformation in communication practices because of new physical distancing requirements, necessitating physicians to communicate bad news via telephone and video-mediated communication (VMC). This study investigated students' experience with a simulation-based communications training for having difficult conversations using VMC.

METHODS

Thirty-eight fourth-year medical students preparing for their surgical residency participated in a simulated scenario where students discussed a new COVID-19 diagnosis with a standardised family member (SFM) of a sick patient via VMC. Learners were introduced to an established communications model (SPIKES) by an educational video. After the simulation, SFM and course facilitators guided a debrief and provided feedback. Learners completed surveys evaluating reactions to the training, preparedness to deliver bad news, and attitudes about telehealth.

RESULTS

Twenty-three students completed evaluation surveys (response rate=61%). Few students had prior formal training (17%) or experience communicating bad news using telehealth (13%). Most respondents rated the session beneficial (96%) and felt they could express empathy using the VMC format (83%). However, only 57% felt ready to deliver bad news independently after the training and 52% reported it was more difficult to communicate without physical presence. Comments highlighted the need for additional practice.

CONCLUSION

This pilot study demonstrated the value and feasibility of teaching medical students to break bad news using VMC as well as demonstrating the need for additional training.

Increasing Knowledge and Self-Efficacy on Differences in Sex Development (DSD): A Team-Based Learning Activity for Pediatric Residents

INTRODUCTION

Differences in sex development (DSD) are a heterogenous group of conditions estimated to affect 1 in 4500 infants. A paradigm shift has occurred in societal and cultural acceptance of variant gender outcomes along with increased awareness around diagnostic uncertainty inherent to DSD. Lack of provider knowledge in evaluation of DSD and/or awareness of evolving paradigms relevant to care for patients with DSD can accentuate barriers to access optimal care for this already vulnerable population.

METHODS

To address this unmet need, we used Kern's six-step framework and piloted a team-based learning (TBL) activity for pediatric residents and medical students (36 learners). This included preactivity reading, an 11-item self-efficacy survey around treatment of patients with DSD at the beginning of the TBL, and a seven-question individual readiness assurance test (RAT). Mixed teams of five to seven learners completed the RAT in small groups followed by large-group discussion. An application exercise followed with two cases focused on initial evaluation of a newborn/child with suspected DSD and an older child with suspected DSD. At the conclusion, learners repeated the self-efficacy measure and answered several evaluation questions.

RESULTS

Individual RAT scores had a mean of 59%, while groups scored with a mean of 82%. Mean self-efficacy scores also increased significantly from 2.4 to 3.4 on a 5-point scale. Of learners, 80% agreed or strongly agreed that the activity was effective for improving DSD skills and knowledge.

DISCUSSION

TBL is a valuable educational strategy to enhance knowledge and self-efficacy of DSD care for general pediatricians.

Management of infants born to mothers with chorioamnionitis: A retrospective comparison of the three approaches recommended by the committee on fetus and newborn

BACKGROUND

Based on the most recently published recommendations from the Committee on the Fetus and Newborn (COFN), three approaches currently exist for the use of risk factors to identify infants who are at increased risk of early-onset sepsis (EOS). Categorical risk factor assessments recommend laboratory testing and empiric antibiotic therapy for all infants born to mothers with a clinical diagnosis of chorioamnionitis. Risk assessments based on clinical condition recommend frequent examinations and close vital sign monitoring for infants born to mothers with chorioamnionitis. The Kaiser Permanente EOS risk calculator (SRC) is an example of the third approach, multivariate risk assessments. The aim of our study was to compare the three risk stratification approaches recommended by the COFN for management of chorioamnionitis-exposed infants.

METHODS

Retrospective study of 1,521 infants born ≥35 weeks to mothers with chorioamnionitis. Management recommendations of the SRC were compared to the recommendations of categorical risk assessment and risk assessment based on clinical condition (CCA).

RESULTS

Hypothetical application of SRC and CCA resulted in 79.6% and 76.8-85.1% respectively fewer infants allocated empiric antibiotic therapy. While CCA recommended enhanced observation for all chorioamnionitis-exposed infants, SRC recommended routine care without enhanced observation in 44.3% infants. For the six infants (0.39%) with EOS, SRC and CCA recommended empiric antibiotics only for three symptomatic infants.

CONCLUSION

The SRC and CCA can reduce antibiotic use but potentially delay antibiotic treatment. The SRC does not recommend enhanced observation with frequent and prolonged vital signs for >44% of chorioamnionitis-exposed infants.

Digital health screening tool for identification of elder mistreatment

PURPOSE

It is estimated that 15.7% of people aged 60 years and older were subjected to some form of Elder Mistreatment (EM) globally (Yon et al., 2017). In the USA, as many as 1 in 24 EM cases are left unidentified by professionals, with a 300% increased mortality risk for older adults who do not receive help (National Center on Elder Abuse, n.d.; Dong, 2009). Current methods of screening tend to miss less obvious signs of EM and may discourage older adults from disclosing EM, due to either a lack of understanding of what constitutes mistreatment or fear of retaliation from the perpetrator.

METHOD

Our approach shifts the focus of EM identification to the older adults themselves through an automated tablet-based tool. The Virtual cOaching in making Informed Choices on Elder Mistreatment Self-Disclosure (VOICES) tool includes various multimedia components such as videos, audio, and animations designed to educate and enhance screening. Patients screened as positive are guided through a Brief Negotiated Interview (BNI) utilizing motivational interviewing to assist in self-identification (recognize that they are experiencing elder mistreatment) or self-disclosure (inform others about their elder mistreatment experiences). During tool development, we conducted a qualitative study to evaluate the perceived value and likelihood of adopting a tablet-based approach to facilitate screening and self-disclosure of EM in the ED. We held 3 focus groups with stakeholders, including 24 adults 60 years or over, 2 social workers, 2 caregivers, and 2 ED clinicians. We used the findings from the focus groups and User-Centered Design approach (UCD) to develop the tablet-based screening tool. Once the tool was ready, we tested its usability and acceptability with 14 older adults.

RESULTS AND DISCUSSION

Focus group participants supported use of a tablet-based tool to screen for EM, indicating that digital screening benefits from feelings of privacy and anonymity. On a 7-point Likert scale ranging from "1=Very Comfortable" to "7=Very Uncomfortable", older adults scored 2.8 on average for whether they would feel comfortable using a tablet device to screen for EM. Prominent suggestions made by older adults included using a female voice for the tool narrator, larger font size, more multimedia, headphones for privacy; and having someone available during screening for assistance if needed. Participants indicated that it is difficult for older adults experiencing EM to ask for help and that any type of mistreatment screening would be helpful. They also highlighted the need to explain community resources available to older adults once EM is disclosed, especially resources offering help to the caregiver. Participants of the usability evaluation rated the tool a mean score of 86.6 (median= 88.8, iQR =18.1) on the System Usability Scale (SUS), far above the benchmark SUS score of 68, which indicates that the system is "good" or "acceptable" (Bangor et al., 2008). Shifting the focus from the provider to the older adult may encourage self-disclosure of EM by addressing major barriers to traditional screening processes. In summary, this study supported the use of self-administered automated tablet-based screening for EM. Participants generally believed that the use of digital health tools to facilitate the screening process would be beneficial in the ED setting.

THU0586 ESTABLISHING THE KEY COMPONENTS OF A EULAR PORTFOLIO FOR TRAINING IN RHEUMATOLOGY: A EULAR SCHOOL OF RHEUMATOLOGY INITIATIVE

Background:

In clinical training, a portfolio is expected to stimulate learning and encourage critical reflection. Some, but not all, European countries use a portfolio in rheumatology training, and their scope varies widely. A EULAR portfolio for Rheumatology trainees could contribute to improve overall training, raise educational standards, foster the setting of common goals and harmonize rheumatology training across countries.

Objectives:

Develop key components that should be included in a EULAR portfolio of Rheumatology.

Methods:

A working group (WG) composed of 9 rheumatologists and 1 educationalist was established. A systematic literature review (SLR) was conducted in November 2018, according to the PIM structure: Population: trainees; Instrument of interest: portfolio; Measurement of properties of interest: content portfolio. A survey was disseminated among the WG group and WG members of the EMerging EUlar NETwork (EMEUNET), inquiring about the content and structure of existing national portfolios. Portfolio materials of selected countries were reviewed. Last, the WG elected the key components of the portfolio.

Results:

13/2,034 articles were included in the SLR (12 high/1 moderate risk of bias). Information on direct observation of procedural skills (DOPS) (9/13), personal reflections (8/13), learning goals (5/13) and multisource feedback (5/13) were most often included in the portfolio. Twenty-five respondents filled out the survey (response rate ≈ 50%). Reflective writing (n=7), learning goals (n=4) and feedback (n=4) were considered the most useful components of a portfolio. About half indicated that a portfolio was a bureaucratic burden; 4 respondents mentioned lack of feedback by supervisors as a barrier. Portfolio materials of 7 European countries were reviewed. Several portfolios (Germany, Italy, Greece and Spain) were logbooks, i.e. a record of clinical activities. Other portfolios (UK, Denmark, The Netherlands) also included information on workplace-based assessments, learning goals, and personal reflections. The proposed key components of the portfolio are included in Table 1.

Table 1.

Key components of the EULAR portfolio of Rheumatology.

Key componentContentCurriculum vitaePersonal record of achievements, experiences, knowledge and skillsPersonal Development PlanLearning goals and action planClinical workInformation on managing patients (e.g. rheumatoid arthritis)Skills (e.g. joint aspiration)Assessments (summative and formative)Personal reflectionsProfessional behaviourMultisource feedbackPersonal reflectionsEducationContinuing professional development, list of formal and non-formal learning activitiesAssessments (e.g. teaching assessment, evidence based medicine assignment)Personal reflectionsResearchList of abstracts, published articlesInformation on research funding, scholarships, bursaries, academic posts

Conclusion:

This initiative resulted in the establishment of a list of key components to be included in a EULAR portfolio of Rheumatology. Assessment forms for each key portfolio component are currently being developed. Portfolio implementation, particularly in countries that do not use it yet, may contribute significantly to promote a higher standard of patient care across Europe.

Disclosure of Interests:

Marloes van Onna: None declared, Sofia Ramiro Grant/research support from: MSD, Consultant of: Abbvie, Lilly, Novartis, Sanofi Genzyme, Speakers bureau: Lilly, MSD, Novartis, Catherine Haines: None declared, M. Holland-Fischer: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Jean Dudler: None declared, Christopher Edwards Grant/research support from: Abbvie, Biogen, Roche, Consultant of: Abbvie, Samsung, Speakers bureau: Abbvie, BMS, Biogen, Celgene, Fresenius, Gilead, Janssen, Lilly, Mundipharma, Pfizer, MSD, Novartis, Roche, Samsung, Sanofi, UCB,

Alessia Alunno: None declared, Elena Nikiphorou: None declared, L. Falzon: None declared, Francisca Sivera: None declared

OP0179 USEFUL STUDY I: A MULTICENTRE LONGITUDINAL STUDY TO TEST WHETHER ULTRASOUND CAN IDENTIFY PATIENTS WITH MUSCULOSKELETAL SYMPTOMS OF LUPUS WITH BETTER RESPONSE TO THERAPY

Background:

In SLE, musculoskeletal manifestations impact on quality of life and trial outcomes. We previously showed that assessments based on joint swelling lack sensitivity, specificity and responsiveness compared to ultrasound (US).

Objectives:

To determine clinical features predicting US synovitis and whether patients with US synovitis respond better to therapy

Methods:

SLE patients were recruited if the referring physician deemed they had inflammatory pain warranting treatment. Swollen joints were not required. At baseline, physicians recorded features of inflammation, concurrent fibromyalgia and osteoarthritis. Stable doses of prednisolone (≤5mg/day), antimalarials or immunosuppressants were allowed. Participants received depomedrone 120mg IM then were assessed at 0, 2 and 6 weeks for 66/68 swollen and tender joint counts, BILAG-2004, SLEDAI-2K, physician global and MSK-VAS, inflammatory markers, patient pain and disease activity-VAS, HAQ-DI, LupusQoL, US of hands and wrists (blinded to patient and clinical assessor). An internal pilot determined the primary endpoint:(Early Morning stiffness-VAS (EMS-VAS) at 2 weeks (adjusted for baseline) between patients with US-synovitis (GS≥2 or PD≥1 in ≥1 joint) vs. normal US at baseline. 20% difference was considered clinically meaningful. Sensitivity analyses adjusted for prednisolone and immunosuppressants.

Results:

122/133 patients completed all visits. There was significant disagreement between clinical examination and US. 78/133 had US synovitis; 68% of these had ≥1 swollen joint. Of 66/133 patients with ≥ 1 swollen joint, 20% had normal US. US-synovitis was more likely with joint swelling, a symmetrical small joint distribution and active serology. Physician-determined EMS, other lupus features or prior response to therapy were not associated. Fibromyalgia or osteoarthritis did not reduce the probability of US synovitis.

In the full analysis set (n=133) there was no difference in EMS VAS at 2 weeks according to US synovial status at baseline (difference -8mm, 95% CI -19, 4mm, p=0.178). 32 patients had fibromyalgia. After excluding them, we found a statistically and clinically significantly better clinical response to depomedrone in patients with US-synovitis at baseline (baseline-adjusted EMS VAS at 2 weeks -12mm, 95% CI -24, 0mm, p=0.049). This difference was greater in the treatment-adjusted sensitivity analysis (-12.8 (95% CI -22, -3mm), p=0.007) and the per-protocol-adjusted sensitivity analysis (-14.8mm (95% CI -20.8, -8.8mm), p<0.001). Patient with US synovitis had higher rates of improvement in the MSK BILAG-2004 (56% vs. 26%, p=0.09) and SLEDAI-2K (37% vs. 15%, p=0.03).

Conclusion:

In lupus arthritis, distribution and serology, but not other features, help identify US-synovitis. US-synovitis was independent of features of fibromyalgia, but fibromyalgia confounded assessment of clinical response. US should be used to select SLE arthritis patients for therapy and clinical trials, especially when there are inflammatory symptoms without swollen joints.

Acknowledgments:

The Project was funded by Lupus-UK

Disclosure of Interests:

Khaled Mahmoud: None declared, Ahmed Zayat: None declared, Md Yuzaiful Md Yusof: None declared, Katherine Dutton: None declared, Lee-Suan Teh: None declared, Chee-Seng Yee: None declared, David d’cruz Grant/research support from: GlaxoSmithKline, Nora Ng: None declared, David Isenberg Consultant of: Study Investigator and Consultant to Genentech, Coziana Ciurtin Grant/research support from: Pfizer, Consultant of: Roche, Modern Biosciences, Philip G Conaghan Consultant of: AbbVie, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, GSK, Novartis, Pfizer, Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor), Christopher Edwards Grant/research support from: Abbvie, Biogen, Roche, Consultant of: Abbvie, Samsung, Speakers bureau: Abbvie, BMS, Biogen, Celgene, Fresenius, Gilead, Janssen, Lilly, Mundipharma, Pfizer, MSD, Novartis, Roche, Samsung, Sanofi, UCB, Elizabeth Hensor: None declared, Edward Vital Grant/research support from: AstraZeneca, Roche/Genentech, and Sandoz, Consultant of: AstraZeneca, GSK, Roche/Genentech, and Sandoz, Speakers bureau: Becton Dickinson and GSK

FRI0599 USEFUL II: DERIVATION OF THE LUPUS ARTHRITIS AND MUSCULOSKELETAL DISEASE ACTIVITY SCORE (LAMDA) USING DATA FROM A MULTICENTRE LONGITUDINAL STUDY

Background:

Musculoskeletal (MSK) disease is the commonest manifestation of SLE. We showed that the MSK components of the BILAG index and SLEDAI have limited sensitivity, specificity and responsiveness compared to ultrasound (US) synovitis. The USEFUL study evaluated response to glucocorticoids in SLE patients with inflammatory pain.

Objectives:

To develop a disease activity tool for lupus MSK manifestations that is continuous, responsive, sensitive, and correlates with US-synovitis

Methods:

133 patients who received depomedrone 120mg IM were assessed at 0, 2 and 6 weeks for 66/68 swollen and tender joint counts, BILAG2004 index, SLEDAI-2K, physician global and MSK-VAS, inflammatory markers, patient pain and disease activity-VAS. Total US score (OMERACT-EULAR) in the hands and wrists was calculated blinded to patient and clinical assessor. Patients reported overall response using a Likert scale.

The LAMDA was developed by modelling a core set of clinical variables against total US score using penalized (Lasso) regression. Responsiveness was compared between LAMDA and other variables at week 6 using effect sizes. Minimum clinically important difference (MCID) was explored using the SEM and minimal disease activity threshold using ROC.

Results:

The variables selected for the LAMDA score were swollen joint count, patient MSK pain VAS, physician MSK disease activity VAS and ESR. A continuous score was derived. This had a theoretical range from 0 to 26.5 based on maximum ESR of 100. The highest value observed in USEFUL was 15. LAMDA was significantly higher in patients with active US (mean (SD) 5.71 (2.67), n=78) compared to patients with normal US (3.27 (1.77), n=55; difference (95% CI) -2.45 (-3.26, -1.63), t=-5.93, p<0.001). This difference remained significant in patients with no swollen joints (difference (95% CI) -0.71 (-1.40, -0.02), t=-2.06, p=0.044).

Effect size was greater for the LAMDA (0.37) than the BILAG-MSK (0.31), SLEDAI-MSK (0.27) and total US score (0.33). In patients with active US at baseline, LAMDA’s effect size was 0.42.

The MCID was 0.71 and correlated with patient-reported change in pain. A threshold for minimal disease activity of 3.23 optimized sensitivity (0.77 (0.65, 0.89)) and specificity (0.80 (0.68, 0.92)) against US score >0.

Conclusion:

The LAMDA score is a novel continuous disease activity instrument for MSK manifestations of SLE derived from variables familiar to rheumatologists. The LAMDA score is sensitive to imaging detected synovitis without swelling and more responsive than other instruments. . LAMDA may improve the ability of clinicians to accurately determine therapeutic efficacy in clinical trials and practice. Future work will validate the LAMDA score in independent cohorts and randomized trials.

Acknowledgements:

This project was funded by Lupus UK

Disclosure of Interests:

Khaled Mahmoud: None declared, Ahmed Zayat: None declared, Md Yuzaiful Md Yusof: None declared, Coziana Ciurtin Grant/research support from: Pfizer, Consultant of: Roche, Modern Biosciences, Chee-Seng Yee: None declared, David Isenberg Consultant of: Study Investigator and Consultant to Genentech, Lee-Suan Teh: None declared, Katherine Dutton: None declared, David d’cruz Grant/research support from: GlaxoSmithKline, Nora Ng: None declared, Philip G Conaghan Consultant of: AbbVie, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, GSK, Novartis, Pfizer, Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor), Christopher Edwards Grant/research support from: Abbvie, Biogen, Roche, Consultant of: Abbvie, Samsung, Speakers bureau: Abbvie, BMS, Biogen, Celgene, Fresenius, Gilead, Janssen, Lilly, Mundipharma, Pfizer, MSD, Novartis, Roche, Samsung, Sanofi, UCB, Elizabeth Hensor: None declared, Edward Vital Grant/research support from: AstraZeneca, Roche/Genentech, and Sandoz, Consultant of: AstraZeneca, GSK, Roche/Genentech, and Sandoz, Speakers bureau: Becton Dickinson and GSK

THU0134 COGNITIVE IMPAIRMENT IN RHEUMATOID ARTHRITIS

Background:

Increasing evidence suggests that systemic inflammation may be associated with an increased risk of developing cognitive dysfunction and Alzheimer’s disease (AD). Some studies have found an association between rheumatoid arthritis (RA) and neurodegeneration with several finding increased incidence of mild cognitive impairment (MCI) in those with RA compared to healthy controls.

Objectives:

This study aims to use preliminary data from theRheumatoid arthritis, medication and memorystudy (RESIST) to investigate the prevalence of MCI in a population of patients with RA and explore the relationship between MCI and specific demographic and clinical characteristics.

Methods:

The Montreal Cognitive Assessment (MoCA) was used as a cognitive screening tool and was administered to subjects ≥55 years of age who had been diagnosed with RA according to the ACR/EULAR criteria. Demographic and clinical data was recorded at screening in face-to-face interviews and included age, gender, date of RA diagnosis and RA medication. RA disease activity score from 28 joints (DAS28), rheumatoid factor (RF) level, anti-cyclic citrullinated peptide (anti-CCP) level, erythrocyte sedimentation rate (ESR) were recorded. 260 participants completed both screening and baseline visits as part of the RESIST longitudinal study, MoCA scores from baseline were analysed for these participants. Statistical analysis was used to provide descriptive statistics and explore possible predictors of cognitive impairment.

Results:

A total of 636 participants (mean age 68.1 yrs, female 67.5%) were screened between May 2018 and December 2019. The mean MoCA for screened participants was 25.4; 45.3% scored <26 in the MoCA and were considered to have mild cognitive impairment. Age was negatively correlated with MoCA score and was the only significant predictor of cognitive impairment. For each year of increase in age the MoCA score reduced by a mean of 0.08 points (p<0.05). There was little evidence of a difference in mean MoCA score by gender, RA medication, duration of disease, DAS28 score, ESR, anti-CCP or RF levels. The mean MoCA scores increased by 0.4 points between screening and baseline (P<0.001).

Conclusion:

A large proportion of participants scored below the proposed cut-off for normal cognition in the MoCA suggesting a high prevalence of MCI in adults >55 years with moderately active RA. This provides further support for the role of chronic inflammation in cognitive dysfunction and AD. Screening for MCI in rheumatology clinics might be clinically useful.

DemographicsOutcomeAge mean years (+/-SD) (n=633)68.1 (8.01)Gender (n=636)Female n (%)429 (67.5)RA Medication (n=636)csDMARD n (%)TNFi n (%)368 (57.9)268 (42.1)Duration of RA mean years (+/-SD) (n=484)14.4 (13.9)DAS28 mean (+/-SD) (n=306)3.5 (2.04)ESR mean (+/-SD) (n=501)23.4 (22.0)Anti-CCP (n=387)Positive n (%)236 (61)Rheumatoid Factor (n=377)Positive n (%)277 (73.5)MoCA Score points (n=636)≥26, n (%)<26 n (%)348 (54.7)288 (45.3)Subjective memory concerns (n=430)Yes n (%)No n (%)95 (22.1)335 (77.9)

Disclosure of Interests:

Christopher Edwards Grant/research support from: Abbvie, Biogen, Roche, Consultant of: Abbvie, Samsung, Speakers bureau: Abbvie, BMS, Biogen, Celgene, Fresenius, Gilead, Janssen, Lilly, Mundipharma, Pfizer, MSD, Novartis, Roche, Samsung, Sanofi, UCB

, Bethany McDowell: None declared, Chris Holroyd: None declared, Chris Cardwell: None declared, Michelle McHenry Speakers bureau: Novartis, Pfizer, AbbVie, Celgene, Lilly, Gary Meenagh: None declared, Clive Holmes: None declared, Bernadette McGuiness: None declared

72 Prevalence of Reported and Unreported Vertebral Fractures in Ctpas in Older Adults Above 75 Years

Introduction

Identifying vertebral fractures is prudent in the diagnosis of osteoporosis as they occur early in this hidden condition. Unfortunately, due to their unspecific presentation, only 25% are clinically recognised. Computerised Tomography Pulmonary Angiogram (CTPA) are frequently requested to confirm pulmonary thromboembolisms, but could also aid in detecting clinically silent vertebral fractures. Current literature suggests that less than one-third of incidental vertebral fractures are reported. The aim of this study is to measure the prevalence of vertebral fractures in CTPA and its relevance to clinical outcomes.

Methods

This is retrospective observational study based on the analysis of existing CTPA for acutely unwell patients admitted to medical assessment unit or A & E across three acute sites within Aneurin Bevan University Health board, Wales, UK between January and December 2015. All CTPA reports were reviewed for fragility factures and CTPA images were reassessed for any unreported vertebral fractures. Age and gender were recorded for all patients. Analysis was done for all patients in respect to subsequent fragility fractures and mortality. Difference of proportion test was used to compare two groups with and without vertebral fractures.

Results

179 CTPA were reviewed, 161 patients were included for further analysis. 14.3% (n=23/161) were reported to have a vertebral fracture, however only 8.7% (n=14/161) of reports used the correct terminology of ‘fracture’. On subsequent review, an additional 24.2% (n=39/161) vertebral fractures were noted. Therefore, overall prevalence of vertebral fractures was 38.5% (n=62/161). Only 9.1% (n=9/99) of patients without a vertebral fracture developed a subsequent fragility fracture. In comparison, 22.5% (n=14/62) of patients with a previous vertebral fracture sustained a new fragility fracture over next 4 years and this was significantly higher (p = 0.017). Overall mortality over 4 years follow-up was significantly higher for patients with vertebral fractures (64.5%, n=40/62) as compared to those without fractures (43.4%, n=43/99, p = 0.009). Only 48.4% (n=30/62) received osteoporosis treatment.

Conclusions

Vertebral fractures could be underreported by radiologists, likely due to human factors as they might be concentrating on the clinical scenario to exclude a pulmonary embolism. However, considering a significant higher mortality in patients with underlying vertebral fracture, it justifies that radiologists could be asked to examine sagittal view in the bone window for possible underlying vertebral fractures, to ensure osteoporosis is treated to guidance.

Automatic Quality Assessment of Transperineal Ultrasound Images of the Male Pelvic Region, Using Deep Learning

Ultrasound guidance is not in widespread use in prostate cancer radiotherapy workflows. This can be partially attributed to the need for image interpretation by a trained operator during ultrasound image acquisition. In this work, a one-class regressor, based on DenseNet and Gaussian processes, was implemented to automatically assess the quality of transperineal ultrasound images of the male pelvic region. The implemented deep learning approach was tested on 300 transperineal ultrasound images and it achieved a scoring accuracy of 94%, a specificity of 95% and a sensitivity of 92% with respect to the majority vote of 3 experts, which was comparable with the results of these experts. This is the first step toward a fully automatic workflow, which could potentially remove the need for ultrasound image interpretation and make real-time volumetric organ tracking in the radiotherapy environment using ultrasound more appealing.

Exploring pressures, tissue reperfusion and body positioning: a pilot evaluation

OBJECTIVE

To assess the relationship in healthy adults and critically ill patients between: patient position, body mass index (BMI), patient body temperature, interface pressure (IP) and tissue reperfusion (TR). Also to determine the relationship in critically ill patients between: Sequential Organ Failure Assessment (SOFA) score, Braden Scale score for predicting pressure injury risk, Acute Physiology and Chronic Health Evaluation II (APACHE II) severity of disease classification score, IP and TR.

METHODS

This study took place in a 27-bed intensive care unit (ICU) of an Australian tertiary hospital. IP and TR outcomes were measured at the sacrum and greater trochanter. Repeated measures analyses of variance (ANOVAs) and doubly multivariate repeated measures ANOVAs were conducted using peak pressure index (PPI), peak time (PT), settled time constant (STC) and normalised hyperaemic area (NHA) measures of TR as outcomes. Participant type, body mass index (BMI), Braden and APACHE II scores and patient body temperature were considered as between-groups factors and covariates.

RESULTS

We recruited 23 low- and high-acuity ICU patients and nine healthy adult volunteers. Not all IP readings could be obtained from ICU patients. TR readings were collected from all recruited patients, but not all TR measurements were mutually uncorrelated. Controlling for age, PPI readings differed between participant types (p=0.093), with the highest values associated with high-acuity patients and the lowest with healthy adults; the association was not substantive when controlling for age and BMI. Age was a significant variable (p=0.008), with older participants having higher scores than younger ones. No statistically significant associations between any measured parameter and TR variables were observed. However, temperature was revealed to be related to TR (p=0.091).

CONCLUSIONS

Although not powered to detect significant effects, this pilot analysis has determined several associations of importance, with differences in outcomes observed between low- and high-acuity ICU patients; and between ICU patients and healthy volunteers.

Enhancing photocatalytic degradation of the cyanotoxin microcystin-LR with the addition of sulfate-radical generating oxidants

This study investigated the coupling of sulfate radical generating oxidants, (persulfate, PS and peroxymonosulfate, PMS) with TiO₂ photocatalysis for the degradation of microcystin-LR (MC-LR). Treatment efficiency was evaluated by estimating the electrical energy per order (E_EO). Oxidant addition at 4 mg/L reduced the energy requirements of the treatment by 60% and 12% for PMS and PS, respectively compared with conventional photocatalysis. Quenching studies indicated that both sulfate and hydroxyl radicals contributed towards the degradation of MC-LR for both oxidants, while Electron Paramagnetic Resonance (EPR) studies confirmed that the oxidants prolonged that lifetime of both radicals (concentration maxima shifted from 10 to 20 min), allowing for bulk diffusion and enhancing cyanotoxin removal. Structural identification of transformation products (TPs) formed during all treatments, indicated that early stage degradation of MC-LR occurred mainly on the aromatic ring and conjugated carbon double bonds of the ADDA amino acid. In addition, simultaneous hydroxyl substitution of the aromatic ring and the conjugated double carbon bonds of ADDA (m/z = 1027.5) are reported for the first time. Oxidant addition also increased the rates of formation/degradation of TPs and affected the overall toxicity of the treated samples. The detoxification and degradation order of the treatments was UVA/TiO₂/PMS > UVA/TiO₂/PS>> UVA/TiO₂.