Reducing Firearm Access for Suicide Prevention: Implementation Evaluation of the Web-Based "Lock to Live" Decision Aid in Routine Health Care Encounters

Background

"Lock to Live" (L2L) is a novel web-based decision aid for helping people at risk of suicide reduce access to firearms. Researchers have demonstrated that L2L is feasible to use and acceptable to patients, but little is known about how to implement L2L during web-based mental health care and in-person contact with clinicians.

Objective

The goal of this project was to support the implementation and evaluation of L2L during routine primary care and mental health specialty web-based and in-person encounters.

Methods

The L2L implementation and evaluation took place at Kaiser Permanente Washington (KPWA)-a large, regional, nonprofit health care system. Three dimensions from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) model-Reach, Adoption, and Implementation-were selected to inform and evaluate the implementation of L2L at KPWA (January 1, 2020, to December 31, 2021). Electronic health record (EHR) data were used to purposefully recruit adult patients, including firearm owners and patients reporting suicidality, to participate in semistructured interviews. Interview themes were used to facilitate L2L implementation and inform subsequent semistructured interviews with clinicians responsible for suicide risk mitigation. Audio-recorded interviews were conducted via the web, transcribed, and coded, using a rapid qualitative inquiry approach. A descriptive analysis of EHR data was performed to summarize L2L reach and adoption among patients identified at high risk of suicide.

Results

The initial implementation consisted of updates for clinicians to add a URL and QR code referencing L2L to the safety planning EHR templates. Recommendations about introducing L2L were subsequently derived from the thematic analysis of semistructured interviews with patients (n=36), which included (1) "have an open conversation," (2) "validate their situation," (3) "share what to expect," (4) "make it accessible and memorable," and (5) "walk through the tool." Clinicians' interviews (n=30) showed a strong preference to have L2L included by default in the EHR-based safety planning template (in contrast to adding it manually). During the 2-year observation period, 2739 patients reported prior-month suicide attempt planning or intent and had a documented safety plan during the study period, including 745 (27.2%) who also received L2L. Over four 6-month subperiods of the observation period, L2L adoption rates increased substantially from 2% to 29% among primary care clinicians and from <1% to 48% among mental health clinicians.

Conclusions

Understanding the value of L2L from users' perspectives was essential for facilitating implementation and increasing patient reach and clinician adoption. Incorporating L2L into the existing system-level, EHR-based safety plan template reduced the effort to use L2L and was likely the most impactful implementation strategy. As rising suicide rates galvanize the urgency of prevention, the findings from this project, including L2L implementation tools and strategies, will support efforts to promote safety for suicide prevention in health care nationwide.

Suicide Screening, Risk Assessment, and Lethal Means Counseling During Zero Suicide Implementation

OBJECTIVE

The authors measured implementation of Zero Suicide (ZS) clinical practices that support identification of suicide risk and risk mitigation, including screening, risk assessment, and lethal means counseling, across mental health specialty and primary care settings.

METHODS

Six health care systems in California, Colorado, Michigan, Oregon, and Washington participated. The sample included members ages ≥13 years from 2010 to 2019 (N=7,820,524 patients). The proportions of patients with suicidal ideation screening, suicide risk assessment, and lethal means counseling were estimated.

RESULTS

In 2019, patients were screened for suicidal ideation in 27.1% (range 5.0%-85.0%) of mental health visits and 2.5% (range 0.1%-35.0%) of primary care visits among a racially and ethnically diverse sample (44.9% White, 27.2% Hispanic, 13.4% Asian, and 7.7% Black). More patients screened positive for suicidal ideation in the mental health setting (10.2%) than in the primary care setting (3.8%). Of the patients screening positive for suicidal ideation in the mental health setting, 76.8% received a risk assessment, and 82.4% of those identified as being at high risk received lethal means counseling, compared with 43.2% and 82.4%, respectively, in primary care.

CONCLUSIONS

Six health systems that implemented ZS showed a high level of variation in the proportions of patients receiving suicide screening and risk assessment and lethal means counseling. Two opportunities emerged for further study to increase frequency of these practices: expanding screening beyond patients with regular health care visits and implementing risk assessment with lethal means counseling in the primary care setting directly after a positive suicidal ideation screening.

The Fragility of Scientific Rigour and Integrity in "Sped up Science": Research Misconduct, Bias, and Hype and in the COVID-19 Pandemic

During the early years of the COVID-19 pandemic, preclinical and clinical research were sped up and scaled up in both the public and private sectors and in partnerships between them. This resulted in some extraordinary advances, but it also raised a range of issues regarding the ethics, rigour, and integrity of scientific research, academic publication, and public communication. Many of the failures of scientific rigour and integrity that occurred during the pandemic were exacerbated by the rush to generate, disseminate, and implement research findings, which not only created opportunities for unscrupulous actors but also compromised the methodological, peer review, and advisory processes that would usually identify sub-standard research and prevent compromised clinical or policy-level decisions. While it would be tempting to attribute these failures of science and its translation solely to the "unprecedented" circumstances of the COVID-19 pandemic, the reality is that they preceded the pandemic and will continue to arise once it is over. Existing strategies for promoting scientific rigour and integrity need to be made more rigorous, better integrated into research training and institutional cultures, and made more sophisticated. They might also need to be modified or supplemented with other strategies that are fit for purpose not only in public health emergencies but in any research that is sped-up and scaled up to address urgent unmet medical needs.

Examining infants' visual paired comparison performance in the US and rural Malawi

Measures of attention and memory were evaluated in 6- to 9-month-old infants from two diverse contexts. One sample consisted of African infants residing in rural Malawi (N = 228, 118 girls, 110 boys). The other sample consisted of racially diverse infants residing in suburban California (N = 48, 24 girls, 24 boys). Infants were tested in an eye-tracking version of the visual paired comparison procedure and were shown racially familiar faces. The eye tracking data were parsed into individual looks, revealing that both groups of infants showed significant memory performance. However, how a look was operationally defined impacted some-but not other-measures of infant VPC performance. RESEARCH HIGHLIGHTS: In both the US and Malawi, 6- to 9-month-old infants showed evidence of memory for faces they had previously viewed during a familiarization period. Infant age was associated with peak look duration and memory performance in both contexts. Different operational definitions of a look yielded consistent findings for peak look duration and novelty preference scores-but not shift rate. Operationalization of look-defined measures is an important consideration for studies of infants in different cultural contexts.

Gamma knife capsulotomy for intractable OCD: Neuroimage analysis of lesion size, location, and clinical response

Obsessive-compulsive disorder (OCD) affects 2-3% of the population. One-third of patients are poorly responsive to conventional therapies, and for a subgroup, gamma knife capsulotomy (GKC) is an option. We examined lesion characteristics in patients previously treated with GKC through well-established programs in Providence, RI (Butler Hospital/Rhode Island Hospital/Alpert Medical School of Brown University) and São Paulo, Brazil (University of São Paolo). Lesions were traced on T1 images from 26 patients who had received GKC targeting the ventral half of the anterior limb of the internal capsule (ALIC), and the masks were transformed into MNI space. Voxel-wise lesion-symptom mapping was performed to assess the influence of lesion location on Y-BOCS ratings. General linear models were built to compare the relationship between lesion size/location along different axes of the ALIC and above or below-average change in Y-BOCS ratings. Sixty-nine percent of this sample were full responders (≥35% improvement in OCD). Lesion occurrence anywhere within the targeted region was associated with clinical improvement, but modeling results demonstrated that lesions occurring posteriorly (closer to the anterior commissure) and dorsally (closer to the mid-ALIC) were associated with the greatest Y-BOCS reduction. No association was found between Y-BOCS reduction and overall lesion volume. GKC remains an effective treatment for refractory OCD. Our data suggest that continuing to target the bottom half of the ALIC in the coronal plane is likely to provide the dorsal-ventral height required to achieve optimal outcomes, as it will cover the white matter pathways relevant to change. Further analysis of individual variability will be essential for improving targeting and clinical outcomes, and potentially further reducing the lesion size necessary for beneficial outcomes.

Crevasse refreezing and signatures of retreat observed at Kamb Ice Stream grounding zone

Ice streams flowing into Ross Ice Shelf are presently responsible for around 10% of the mass flux from West Antarctica, with the noteworthy exception of Kamb Ice Stream, which stagnated in the late 1800s. The subsequent reduction in ice supply led to grounding-line retreat at the coastal margin where Kamb transitions into the floating Ross Ice Shelf. Grounding-line migration is linked to broader changes in ice-sheet mass balance and sea level, but our understanding of related ice, ocean and seafloor interactions is limited by the difficulty in accessing these remote regions. Here we report in situ observations from an underwater vehicle deployed at Kamb that show how fine-scale variability in ice and ocean structure combine to influence a diversity of ice-ocean interactions. We found a stratified water column within a tenth of a degree of freezing at the ice base and mapped basal crevasses with supercooled water and active marine ice formation. At the seafloor, we interpret parallel ridges as crevasse impressions left as the ice lifted off during grounding-line retreat. These observations from a recently ungrounded sub-shelf environment illuminate both the geomorphological signatures of past grounding-line retreat and the fine-scale sensitivity of ongoing ice-ocean interactions to ice topography.

Molecular and clinical diversity in primary central nervous system lymphoma

BACKGROUND

Primary central nervous system lymphoma (PCNSL) is a rare and distinct entity within diffuse large B-cell lymphoma presenting with variable response rates probably to underlying molecular heterogeneity.

PATIENTS AND METHODS

To identify and characterize PCNSL heterogeneity and facilitate clinical translation, we carried out a comprehensive multi-omic analysis [whole-exome sequencing, RNA sequencing (RNA-seq), methylation sequencing, and clinical features] in a discovery cohort of 147 fresh-frozen (FF) immunocompetent PCNSLs and a validation cohort of formalin-fixed, paraffin-embedded (FFPE) 93 PCNSLs with RNA-seq and clinico-radiological data.

RESULTS

Consensus clustering of multi-omic data uncovered concordant classification of four robust, non-overlapping, prognostically significant clusters (CS). The CS1 and CS2 groups presented an immune-cold hypermethylated profile but a distinct clinical behavior. The 'immune-hot' CS4 group, enriched with mutations increasing the Janus kinase (JAK)-signal transducer and activator of transcription (STAT) and nuclear factor-κB activity, had the most favorable clinical outcome, while the heterogeneous-immune CS3 group had the worse prognosis probably due to its association with meningeal infiltration and enriched HIST1H1E mutations. CS1 was characterized by high Polycomb repressive complex 2 activity and CDKN2A/B loss leading to higher proliferation activity. Integrated analysis on proposed targets suggests potential use of immune checkpoint inhibitors/JAK1 inhibitors for CS4, cyclin D-Cdk4,6 plus phosphoinositide 3-kinase (PI3K) inhibitors for CS1, lenalidomide/demethylating drugs for CS2, and enhancer of zeste 2 polycomb repressive complex 2 subunit (EZH2) inhibitors for CS3. We developed an algorithm to identify the PCNSL subtypes using RNA-seq data from either FFPE or FF tissue.

CONCLUSIONS

The integration of genome-wide data from multi-omic data revealed four molecular patterns in PCNSL with a distinctive prognostic impact that provides a basis for future clinical stratification and subtype-based targeted interventions.

Nature-positive goals for an organization's food consumption

Organizations are increasingly committing to biodiversity protection targets with focus on 'nature-positive' outcomes, yet examples of how to feasibly achieve these targets are needed. Here we propose an approach to achieve nature-positive targets with respect to the embodied biodiversity impacts of an organization's food consumption. We quantify these impacts using a comprehensive database of life-cycle environmental impacts from food, and map exploratory strategies to meet defined targets structured according to a mitigation and conservation hierarchy. By considering the varying needs and values across the organization's internal community, we identify a range of targeted approaches towards mitigating impacts, which balance top-down and bottom-up actions to different degrees. Delivering ambitious nature-positive targets within current constraints will be challenging, particularly given the need to mitigate cumulative impacts. Our results evidence that however committed an organization is to being nature positive in its food provision, this is unachievable in the absence of systems change.

NB housing study protocol: investigating the relationship between subsidized housing, mental health, physical health and healthcare use in New Brunswick, Canada

BACKGROUND

Income and housing are pervasive social determinants of health. Subsidized housing is a prominent affordability mechanism in Canada; however, waitlists are lengthy. Subsidized rents should provide greater access to residual income, which may theoretically improve health outcomes. However, little is known about the health of tenants who wait for and receive subsidized housing. This is especially problematic for New Brunswick, a Canadian province with low population density, whose inhabitants experience income inequality, social exclusion, and challenges with healthcare access.  METHODS: This study will use a longitudinal, prospective matched cohort design. All 4,750 households on New Brunswick's subsidized housing wait list will be approached to participate. The survey measures various demographic, social and health indicators at six-month intervals for up to 18 months as they wait for subsidized housing. Those who receive housing will join an intervention group and receive surveys for an additional 18 months post-move date. With consent, participants will have their data linked to a provincial administrative database of medical records.  DISCUSSION: Knowledge of housing and health is sparse in Canada. This study will provide stakeholders with a wealth of health information on a population that is historically under-researched and underserved.

Rapid synthesis of drug-encapsulated films by evaporation-induced self-assembly for highly-controlled drug release from biomaterial surfaces

Infection at the surgical site for dental implants results in failed procedures, patient pain, burdensome economic impact, and the over-prescription of prophylactic antibiotics. Mesoporous silica films as coatings for implants may provide an ideal antimicrobial drug storage and local release vector to the site of infection, however traditional drug loading techniques result in insufficient drug load and short-term release kinetics. In this work, we have applied a method to use a surfactant-antimicrobial drug octenidine dihydrochloride (OCT) as a template for mesostructured silica, to demonstrate silica-OCT composite films. The films are synthesized by evaporation induced self-assembly (EISA) and we explore the effects of synthesis parameters on porous film structure, OCT incorporation, and OCT drug release rates. Drug micelle incorporation into the silica mesostructure was highly dependent on silica precursor pre-reaction to form silica oligomers before film spin-casting. The OCT drug concentration of the synthesis solution dictated the time required for effective incorporation (without phase separation), with total loading in the film of up to 90% by mass. The OCT content in the films was found to directly determine the timescale of drug release, from 2 to 8 h for a single layer film. The total release timescale was increased by the addition of multiple layers of OCT-silica films to nearly 2 weeks. Drug release from films completely inhibited Streptococcus mutans (UA159) growth, while drug-free porous silica films showed no increase in bacterial growth over non-porous control. These OCT-silica films have a significant potential to store and release antimicrobial drugs from dental implant surfaces.

Frequency of Small Fish Consumption Is Associated With Improved Iron and Hemoglobin in Young Malawian Children

Objectives

Our objective was to assess whether fish and meat consumption over 6mo was associated with plasma ferritin, soluble transferrin receptor (sTfR), hemoglobin (Hb), iron deficiency (ID), and anemia in a population of young Malawian children with a high (&gt;50%) prevalence of iron deficiency anemia.

Methods

This secondary data analysis includes 585 Malawian infants, age 6–9mo, from a 6mo egg feeding trial. At enrollment and 6mo follow-up, 24hr dietary recalls and blood draws were conducted. Days with any small fish, large fish, or meat consumption were reported weekly in 7-day food frequency questionnaires. The % of days with flesh food consumption were totaled for each child. Plasma ferritin, sTfR, and Hb were assessed for associations with the % of days with small fish, large fish, and meat intake using linear regression. Prevalence ratios (PR) of ID (ferritin &lt; 12µg/L or sTfR &gt; 8.3 mg/L) and anemia (Hb&lt; 11g/dL) were compared for each flesh food category using log binomial or modified Poisson regression.

Results

The % of children with observed intake of small fish (4%), large fish (1%), and meat (2%) from 24-hr recalls at enrollment increased to 40%, 12%, and 9%, respectively, at the 6mo follow-up. Over 6mo, children averaged consumption of small fish, large fish, and meat on 25%, 8%, and 6% of days, respectively. More frequent intake of small fish was associated with higher Hb [geometric mean ratio (95% CI) per 10 percentage point difference: 1.01 g/dL (1.00, 1.01)] and lower sTfR [0.98 mg/L (0.96, 1.00)] but was not associated with ferritin concentration [1.03 µg/L (0.99, 1.07)]; nor was it associated with the prevalence of ID [PR (95% CI): 0.99 (0.97, 1.01)] or anemia [0.94 (0.88, 1.01)]. More frequent consumption of large fish was associated with a higher prevalence of anemia [1.09 per 10 percentage point difference in frequency, (1.00, 1.18)] but was not associated with ID [0.96 (0.92, 1.00)]. Meat consumption was predominantly chicken and not associated with iron or anemia indices.

Conclusions

Small fish are a primary contributor to total flesh food intake of young Malawian children and may provide modest improvements to iron status and hemoglobin. Meat and large fish were infrequently consumed and not associated with ID.

Funding Sources

Bill & Melinda Gates Foundation.

Associations of Maternal and Child Fatty Acid Status With Child Growth and Development Outcomes in Ghana

Objectives

Maintaining adequate fatty acid intake during pregnancy and lactation is necessary to support fetal and infant growth. Low maternal intake may lead to decreased transfer of fatty acids to the fetus. Our objective was to examine associations of individual fatty acid status at three different time points with child growth and development outcomes at 18 months.

Methods

A cohort of 1,320 women were enrolled in the International Lipid-Based Nutrient Supplements Dyad Ghana trial (iLiNS-DYAD-G). Fatty acids were measured in maternal plasma at 36 weeks gestation (n = 130), maternal breast milk six months postpartum (n = 303), and child plasma at 18 months (n = 369) and quantified as weight percentage of total identified fatty acids of the sample (% weight). We examined correlations between time points (maternal, breastmilk, and child) for five indicators of fatty acid status: % weight of four individual fatty acids (alpha-linolenic acid, ALA; linolenic acid, LA; docosahexaenoic acid, DHA; arachidonic acid, AA) and the n6: n3 ratio (ratio of LA & AA to ALA, DHA & EPA). We then examined whether each fatty acid indicator was associated with child growth (head circumference for age, length for age, weight for length z-scores) or developmental outcomes (motor, language, and social-emotional scores) at 18 months. Adjusted regressions included child sex, food insecurity scores, socioeconomic status, intervention group, and years of maternal education.

Results

Maternal plasma and breast milk were positively correlated for % weight AA, LA, and n6: n3 ratio. Maternal and child plasma were positively correlated for % weight DHA and n6: n3 ratio. Breast milk and child plasma fatty acids were positively correlated for % weight AA, ALA, DHA, and n6: n3 ratio. Associations of fatty acid status indicators with child growth and developmental outcomes were not significant after correcting for multiple comparisons.

Conclusions

Although maternal fatty acid status was associated with breastmilk and child fatty acid status, maternal and child fatty acid status was not generally associated with child growth and development at 18 months of age in this sample of mother-child dyads in Ghana.

Funding Sources

Bill & Melinda Gates Foundation; National Institute of Child Health and Human Development & Fogarty International Center R01HD099811.

Remote Assessment of Disease and Relapse in Major Depressive Disorder (RADAR-MDD): Recruitment, retention, and data availability in a longitudinal remote measurement study

Introduction

Major Depressive Disorder (MDD) is prevalent, often chronic, and requires ongoing monitoring of symptoms to track response to treatment and identify early indicators of relapse. Remote Measurement Technologies (RMT) provide an exciting opportunity to transform the measurement and management of MDD, via data collected from inbuilt smartphone sensors and wearable devices alongside app-based questionnaires and tasks.

Objectives

To describe the amount of data collected during a multimodal longitudinal RMT study, in an MDD population.

Methods

RADAR-MDD is a multi-centre, prospective observational cohort study. People with a history of MDD were provided with a wrist-worn wearable, and several apps designed to: a) collect data from smartphone sensors; and b) deliver questionnaires, speech tasks and cognitive assessments and followed-up for a maximum of 2 years.

Results

A total of 623 individuals with a history of MDD were enrolled in the study with 80% completion rates for primary outcome assessments across all timepoints. 79.8% of people participated for the maximum amount of time available and 20.2% withdrew prematurely. Data availability across all RMT data types varied depending on the source of data and the participant-burden for each data type. We found no evidence of an association between the severity of depression symptoms at baseline and the availability of data. 110 participants had > 50% data available across all data types, and thus able to contribute to multiparametric analyses.

Conclusions

RADAR-MDD is the largest multimodal RMT study in the field of mental health. Here, we have shown that collecting RMT data from a clinical population is feasible.

Disclosure

No significant relationships.

Face-to-face versus online clinically integrated EBM teaching in an undergraduate medical school: a pilot study

OBJECTIVES

The aim of this study was to test the feasibility and effectiveness of two models (face-to-face vs online teaching) of clinically integrating evidence-based medicine (EBM) teaching in an undergraduate medical school.

DESIGN AND SETTING

A pilot study of face-to-face versus online EBM teaching.

PARTICIPANTS

This study focused on undergraduate medical students who entered the University of Buckingham Medical School MBChB course in 2016 (n=65). Of the 65 students, 45 received face-to-face teaching, while 20 received online teaching.

MAIN OUTCOME MEASURES

Feasibility was assessed by the ability to deliver the content, students' engagement during teaching and their completion rates in formative assessments-Assessing Competency in EBM (ACE) tool, and educational prescriptions (EPs). Effectiveness of teaching for the two models was compared by evaluating students' performance in the formative assessments and in the summative final professional examination and final year EBM objective structured clinical examination (OSCE).

RESULTS

We had similar students' engagement and completion rates in formative assessments in both models. Students receiving face-to-face teaching performed better in EPs (mean difference=-2.28, 95% CI: -4.31 to -0.26). There was no significant difference in performances in the ACE tool (mean difference=-1.02, 95% CI: -2.20 to 0.16); the written final professional exams (mean difference=-0.11, 95% CI: -0.65 to 0.44) and the EBM OSCE station (mean difference=-0.81, 95% CI: -2.38 to 0.74).

CONCLUSIONS

It was feasible to deliver both models of clinically integrated EBM teaching. While students in the face-to-face model scored higher in EPs; there was no significant difference between the two models of teaching as measured by performances in the ACE tool or the summative assessments.

61 Use of Ketamine Sedation for the Treatment of Minor Plastic Surgery Procedures in the Paediatric Emergency Department

Aim

To determine if ketamine sedation is a safe and cost-effective way of treating paediatric patients presenting with minor injuries, requiring plastic surgery procedures, in the emergency department.

Method

A retrospective cohort study was carried out over a 9-month period in children between ages 18 months and 16 years old, presenting to the paediatric emergency department at Chelsea and Westminster Hospital with minor injuries requiring plastic surgery input. The data collected included previously validated co-primary outcome measures of surgical site infection at 7 days and cosmetic appearance summary score at a minimum of 4 months. Parental satisfaction surveys were completed at 4 months to assess perceived quality of treatment. A cost analysis comparison against procedures completed under general anaesthetic was also undertaken.

Results

During the 9-month period of study, 24 minor procedures were performed under ketamine in the paediatric emergency department. There were no serious adverse events recorded. Three cases exceeded the recommended 20-minute maximum procedure duration, but there was no associated adverse outcome. No cases required further procedures under general anaesthesia and there were no cases of surgical site infections at 7 days. Parents reported extremely favourable outcomes using this technique, with an average overall satisfaction score of 9.2 (assessed over a number of parameters, where 10 is complete satisfaction).

Conclusions

Ketamine procedural sedation in the paediatric population is a safe and cost-effective method for the treatment of minor plastic surgery procedures, with low risk for surgical site infection post-operatively, and high parent satisfaction rates

Distressing psychotic-like experiences, cognitive functioning and early developmental markers in clinically referred young people aged 8-18 years

PURPOSE

Neurocognitive difficulties and early childhood speech/motor delays are well documented amongst older adolescents and young adults considered at risk for psychosis-spectrum diagnoses. We aimed to test associations between unusual or psychotic-like experiences (PLEs), co-occurring distress/emotional symptoms, current cognitive functioning and developmental delays/difficulties in young people (aged 8-18 years) referred to Child and Adolescent Mental Health Services in South London, UK.

METHODS

Study 1 examined receptive language, verbal learning and caregiver-reported speech and motor delays/difficulties in a sample of 101 clinically-referred children aged 8-14 years, comparing those reporting no PLEs (n = 19), PLEs without distress (n = 16), and PLEs with distress (n = 66). Study 2 tested associations of severity of distressing PLEs with vocabulary, perceptual reasoning, word reading and developmental delays/difficulties in a second sample of 122 adolescents aged 12-18 years with distressing PLEs.

RESULTS

In Study 1, children with distressing PLEs had lower receptive language and delayed recall and higher rates of developmental delays/difficulties than the no-PLE and non-distressing PLE groups (F values: 2.3-2.8; p values: < 0.005). Receptive language (β = 0.24, p = 0.03) and delayed recall (β = - 0.17, p = 0.02) predicted PLE distress severity. In Study 2, the cognitive-developmental variables did not significantly predict PLE distress severity (β values = 0.01-0.22, p values: > 0.05).

CONCLUSION

Findings may be consistent with a cognitive-developmental model relating distressing PLEs in youth with difficulties in cognitive functioning. This highlights the potential utility of adjunctive cognitive strategies which target mechanisms associated with PLE distress. These could be included in cognitive-behavioural interventions offered prior to the development of an at-risk mental state in mental health, educational or public health settings.

1111 Shifting the Paradigm of Abscess Treatment – From Theatre to Clinic

Aim

Treatment of skin and soft tissue abscesses forms a substantial part of the emergency general surgery workload. Abscesses account for approximately 2% of presentations to Accident and Emergency, with 0.9% of patients requiring surgical intervention. Incision and drainage is often performed in theatre and may necessitate admission to hospital, impacting bed space and theatre availability. This study aims to identify if the introduction of a clinic-based abscess service could reduce the number of abscess drainages in theatre without compromise to clinical outcomes.

Method

Retrospective data was collected for patients undergoing abscess treatment at Musgrove Park Hospital (Taunton) in September 2019. Subsequently, a Nurse-led abscess drainage pathway was initiated in Emergency Surgery Ambulatory Clinic (ESAC) encompassing initial assessment and drainage at the bedside. Prospective data was then collected for abscesses drained in theatre and ESAC during September 2020 and compared with data from 2019.

Result

22 abscess drainages were performed in September 2019 vs 25 in September 2020. 8 cases were carried out in theatre during September 2020, with the rest being treated in ESAC. Of those who were treated in clinic (n = 17), admission was prevented in 16 patients. Readmission rates were similar between ESAC (16%) and theatre (18.1%).

Conclusions

A clinic-based abscess service is achievable and prevents unnecessary use of theatres and hospital admissions, with comparable re-presentation rates. A nurse led approach also relieves pressure on Doctors during busy surgical on calls. Nonetheless, a larger data set would be needed to consolidate the findings from this study.

Self-reported Access to Firearms Among Patients Receiving Care for Mental Health and Substance Use

Question

Did patients respond to a standard question about firearm access on a mental health questionnaire, and, if so, how did they respond?

Findings

In this cross-sectional study of 128 802 patients receiving care for mental health and substance use, 83% of primary care patients answered a standard question about firearm access and 21% reported access. In mental health clinics, 92% of patients answered the question and 15% reported access.

Meaning

In this study, most patients reported firearm access on standard questionnaires; this screening practice may improve efforts to identify and engage patients at risk of suicide in discussions about securing firearms.

Importance

Firearms are the most common method of suicide, one of the “diseases of despair” driving increased mortality in the US over the past decade. However, routine standardized questions about firearm access are uncommon, particularly among adult populations, who are more often asked at the discretion of health care clinicians. Because standard questions are rare, patterns of patient-reported access are unknown.

Objective

To evaluate whether and how patients self-report firearm access information on a routine mental health monitoring questionnaire and additionally to examine sociodemographic and clinical associations of reported access.

Design, Setting, and Participants

Cross-sectional study of patients receiving care for mental health and/or substance use in primary care or outpatient mental health specialty clinics of Kaiser Permanente Washington, an integrated health insurance provider and care delivery system.

Main Outcomes and Measures

Electronic health records were used to identify patients who completed a standardized self-reported mental health monitoring questionnaire after a single question about firearm access was added from January 1, 2016, through December 31, 2019. Primary analyses evaluated response (answered vs not answered) and reported access (yes vs no) among those who answered, separately for patients seen in primary care and mental health. These analyses also evaluated associations between patient characteristics and reported firearm access. Data analysis took place from February 2020 through May 2021.

Results

Among patients (n = 128 802) who completed a mental health monitoring questionnaire during the study period, 74.4% (n = 95 875) saw a primary care clinician and 39.3% (n = 50 631) saw a mental health specialty clinician. The primary care and mental health samples were predominantly female (63.1% and 64.9%, respectively) and White (75.7% and 77.0%), with a mean age of 42.8 and 51.1 years. In primary care, 83.4% of patients answered the question about firearm access, and 20.9% of patients who responded to the firearm question reported having access. In mental health, 91.8% of patients answered the question, and 15.3% reported having access.

Conclusions and Relevance

In this cross-sectional study of adult patients receiving care for mental health and substance use, most patients answered a question about firearm access on a standardized mental health questionnaire. These findings provide a critical foundation to help advance understanding of the utility of standardized firearm access assessment and to inform development of practice guidelines and recommendations. Responses to standard firearm access questions used in combination with dialogue and decision-making resources about firearm access and storage may improve suicide prevention practices and outcomes.

Evaluation of One Egg per Day on Iron and Anemia Status Among Young Malawian Children: A Randomized Controlled Trial

Objectives

Young children with complementary feeding diets that lack diversity and have low micronutrient density are at risk of iron deficiency anemia. Our objectives were to determine the impact of supplementing diets with 1 egg/day on: (1) plasma ferritin, soluble transferrin receptor (sTfR), and hemoglobin (Hb) concentrations; and (2) the prevalence of iron deficiency (ID), anemia, and iron deficiency anemia (IDA).

Methods

Children age 6–9mo in the Mangochi District of Malawi were individually randomized to receive 1 egg/day for 6mo (n = 331) or continue their usual diet (n = 329). Venous blood samples were collected at enrollment and a 6mo follow-up by assessors masked to group assignment. Plasma ferritin, sTfR, c-reactive protein (CRP), and α1-acid glycoprotein (AGP) were assessed using ELISA and hemoglobin was measured using Hemocue analyzers. Ferritin and sTfR were corrected for inflammation using CRP and AGP in linear regression models. Ferritin, sTfR, and hemoglobin concentrations were compared between groups using linear regression models, adjusting for baseline values. The prevalence ratios (PR) of ID (fer &lt; 12μg/L,  sTfR &gt;8.3mg/L,  or total body iron&lt; 0mg/kg),  anemia (Hb&lt; 11g/dL),  and IDA (Hb &lt; 11g/dL and ID) were compared between egg and control groups using binomial or Poisson regression models.

Results

A total of 585 children were included in this analysis (Egg: n = 286; Control: n = 299). At enrollment, the prevalence of anemia and IDA was 61% and 55%. At the 6mo follow-up, there was no difference between groups in inflammation-adjusted ferritin (geometric mean [95% CI]; Egg: 6.52µg/L [5.98,7.10];  Control: 6.82 [6.27, 7.42]) or sTfR (Egg: 11.34mg/L [10.92,11.78];  Control:  11.46 [11.04,11.89]) concentrations. There was also no difference in mean hemoglobin concentration between groups (mean [95%CI]; Egg: 11.0g/L [10.8,11.1];  Control:11.1 [11.0,11.3]). Overall, 43% of children had anemia, 89% had ID, and 40% had IDA. No group-level differences were observed in the prevalence of anemia [PR: 1.15 (95% CI: 0.96, 1.38)], ID [PR: 0.99 (0.94, 1.05)], or IDA [PR: 1.12 (0.92, 1.36)].

Conclusions

Iron and anemia indices did not differ between the egg intervention group and control group. Other interventions are needed to address the high prevalence of iron deficiency and anemia among young, Malawian children.

Funding Sources

Bill & Melinda Gates Foundation.

Eggs Introduced Early in Complementary Feeding and Egg Specific IgE Antibodies: A Randomized Controlled Trial in Ecuador

Objectives

The purpose of the study was to assess the safety of using eggs as a nutritional intervention for stunting in infants living in a rural indigenous community in Ecuador and to further understand the prevalence of egg allergy in this population.

Methods

The Lulun Project was a randomized controlled trial conducted in a rural indigenous population in Ecuador. Infants age 6–9 months were recruited and randomly assigned to the intervention (1 egg/day; n = 80) or control (no intervention, n = 83) group. At baseline and end line, enumerators collected anthropometric, dietary intake, morbidity, and sociodemographic data along with blood samples. Symptoms of allergies were assessed, including rash, congestion, coughing or wheezing, and diarrhea. Children in the intervention group were monitored by the study team for allergy symptoms during consumption of the first study egg. All children were monitored for illness and allergy symptoms throughout the study. We used ELISA assays to determine serum anti-ovomucoid and ovalbumin IgE levels, a validated approach to identify “risk of” egg allergy.

Results

131 of the children had a sufficient serum sample to be analyzed for IgE levels. Ovomucoid levels were &lt;0.35 kUA/L in all children. 57 paired samples were available, 1 of 51 in the control and 2 of 56 in the intervention group developed increased responses to ovalbumin during the study (0.51−1.04 kUA/L). For unpaired endline samples (n = 51), 3 of 25 in the control group and 2 of 26 in the egg group had increased ovalbumin responses (0.6–1.36 kUA/L). No child was removed from the study due to a reaction to eggs.

Conclusions

These findings support the use of eggs as a safe option to improve growth and reduce stunting in this community in Ecuador. Our study's findings are in alignment with current guidelines that recommend introducing eggs early in the complementary feeding period, and the evidence that doing so does not increase the risk of developing an egg allergy.

Funding Sources

The Mathile Institute for Human Nutrition, The Bill and Melinda Gates Foundation, and the Washington University in St. Louis Institute for Public Health Summer Research Program funded this study.

The Association of Plasma Choline With Growth and Development Among Young Malawian Children Enrolled in an Egg Intervention Trial

Objectives

Choline has been positively associated with child growth and development, but few studies have been in areas of high stunting and low choline intake. This secondary analysis examines the association of plasma choline with growth/development in Malawian children enrolled in a randomized trial of 1 egg/day versus nonintervention control.

Methods

Venous blood, anthropometric, and developmental measures were collected at enrollment (at age 6–9 mos) and at endline 6 mos later. Plasma choline, betaine, dimethylglycine, and trimethylamine N-oxide were measured using untargeted metabolomics among 400 children. Length, weight, and head circumference were converted to z-scores using WHO Growth Standards. Developmental measures

included fine and gross motor, personal social, and language skills (measured and normed using the Malawi Developmental Assessment Tool), memory (elicited imitation [endline only] and visual paired comparison tasks), and attention (Infant Orienting with Attention [IOWA] task). Generalized linear models, adjusted for covariates including group assignment, were used to examine the association of plasma choline with growth/developmental outcomes.

Results

In cross-sectional models including both time points (baseline, endline) and adjusting for repeated measures, a 1 SD-unit increase in plasma choline was negatively associated with length-for-age z-score (–0.11 SD [95% CI: –0.20, –0.02]) and positively associated with IOWA reaction time (8.8 ms [1.7, 16.0]), meaning slower shifts in attention with higher plasma choline. In predictive models, higher baseline plasma choline predicted lower endline fine motor z-scores (–0.13 SD [–0.22, –0.04]). There were no associations of plasma choline with weight-for-age, head-circumference-for-age, weight-for-length, or the other developmental outcomes. Analysis of other biomarkers revealed few significant associations with growth/development.

Conclusions

Plasma choline was not strongly associated with growth or development in this sample of Malawian children. The few significant associations suggested poorer growth/development with higher plasma choline. Further research in various contexts is needed.

Funding Sources

Bill and Melinda Gates Foundation; Egg Nutrition Center.

815 The Impact and Implications for The Workload for Vascular Surgery as A Result of the COVID-19 Lockdown

Introduction

The emergence of the coronavirus pandemic and subsequent UK lockdown resulted in a significant reduction in elective vascular surgery to increase critical care capacity. We aimed to ascertain the impact of lockdown on the workload of a busy vascular surgical unit.

Method

Data on all major vascular procedures performed between March 2020 and June 2020 were collected prospectively. Comparison to the same time period over the last 6 years was performed using a prospectively maintained database.

Results

92 major cases were performed, a reduction of 30% compared with cases performed during similar periods (803 cases total, mean 133), with an increased proportion of unplanned & emergency cases(35.9% & 31.5% vs 31.4% & 20.5%).

There was a significant reduction in aortic procedures (19 vs mean 36). Despite the reduction in cases there was a similar number of amputations performed (9 vs mean 10).

Conclusions

The lockdown period resulted in a 30% reduction in cases performed with far fewer aortic procedure performed and a similar number of amputations. These pending cases will need consideration, especially with critical care capacity to ensure they are completed within a timely period. Considerations for capacity are also pertinent given the approach of winter and the possibility of a second wave.

Development and evaluation of a spiral model of assessing EBM competency using OSCEs in undergraduate medical education

BACKGROUND

Medical students often struggle to understand the relevance of Evidence Based Medicine (EBM) to their clinical practice, yet it is a competence that all students must develop prior to graduation. Objective structured clinical examinations (OSCEs) are a valued assessment tool to assess critical components of EBM competency, particularly different levels of mastery as they progress through the course. This study developed and evaluated EBM based OSCE stations with an aim to establish a spiral approach for EBM OSCE stations for undergraduate medical students.

METHODS

OSCE stations were developed with increasingly complex EBM tasks. OSCE stations were classified according to the classification rubric for EBP assessment tools (CREATE) framework and mapped against the recently published core competencies for evidence-based practice (EBP). Performance data evaluation was undertaken using Classical Test Theory analysing mean scores, pass rates, and station item total correlation (ITC) using SPSS.

RESULTS

Six EBM based OSCE stations assessing various stages of EBM were created for use in high stakes summative OSCEs for different year groups across the undergraduate medical degree. All OSCE stations, except for one, had excellent correlation coefficients and hence a high reliability, ranging from 0.21-0.49. The domain mean score ranged from 13.33 to 16.83 out of 20. High reliability was demonstrated for the each of the summative OSCE circuits (Cronbach's alpha = 0.67-0.85). In the CREATE framework these stations assessed knowledge, skills, and behaviour of medical students in asking, searching, appraising, and integrating evidence in practice. The OSCE stations were useful in assessing six core evidence-based practice competencies, which are meant to be practiced with exercises. A spiral model of OSCEs of increasing complexity was proposed to assess EBM competency as students progressed through the MBChB course.

CONCLUSIONS

The use of the OSCEs is a feasible method of authentically assessing leaner EBM performance and behaviour in a high stakes assessment setting. Use of valid and reliable EBM-based OSCE stations provide evidence for continued development of a hierarchy of assessing scaffolded learning and mastery of EBM competency. Further work is needed to assess their predictive validity.

Examination of a blood-brain barrier targeting β-galactosidase-monoclonal antibody fusion protein in a murine model of GM1-gangliosidosis

GM1-gangliosidosis is a lysosomal disease resulting from a deficiency in the hydrolase β-galactosidase (β-gal) and subsequent accumulation of gangliosides, primarily in neuronal tissue, leading to progressive neurological deterioration and eventually early death. Lysosomal diseases with neurological involvement have limited non-invasive therapies due to the inability of lysosomal enzymes to cross the blood-brain barrier (BBB). A novel fusion enzyme, labeled mTfR-GLB1, was designed to act as a ferry across the BBB by fusing β-gal to the mouse monoclonal antibody against the mouse transferrin receptor and tested in a murine model of GM1-gangliosidosis (β-gal^-/-). Twelve hours following a single intravenous dose of mTfR-GLB1 (5.0 mg/kg) into adult β-gal^-/- mice showed clearance of enzyme activity in the plasma and an increase in β-gal enzyme activity in the liver and spleen. Long-term efficacy of mTfR-GLB1 was assessed by treating β-gal^-/- mice intravenously twice a week with a low (2.5 mg/kg) or high (5.0 mg/kg) dose of mTfR-GLB1 for 17 weeks. Long-term studies showed high dose mice gained weight normally compared to vehicle-treated β-gal^-/- mice, which are significantly heavier than heterozygous controls. Behavioral assessment at six months of age using the pole test showed β-gal^-/- mice treated with mTfR-GLB1 had improved motor function. Biochemical analysis showed an increase in β-gal enzyme activity in the high dose group from negligible levels to 20% and 11% of heterozygous levels in the liver and spleen, respectively. Together, these data show that mTfR-GLB1 is a catalytically active β-gal fusion enzyme in vivo that is readily taken up into tissues. Despite these indications of bioactivity, behavior tests other than the pole test, including the Barnes maze, inverted screen, and accelerating rotarod, showed limited or no improvement of treated mice compared to β-gal^-/- mice receiving vehicle only. Further, administration of mTfR-GLB1 was insufficient to create measurable increases in β-gal enzyme activity in the brain or reduce ganglioside content (biochemically and morphologically).

Clinico-radiological findings of neuroendocrine tumour metastases to the orbit

Purpose: We present the clinico-radiological findings of neuroendocrine tumour metastases to the orbit.Methods: This was a multicentre, retrospective study of patients with neuroendocrine tumour metastases to the orbit. Data was collected from medical records across five different sites within Australia and the United Kingdom.Results: Nine patients (eleven lesions) were identified. The most common presenting complaint was diplopia (5/9, 56%). Disease occurred bilaterally in two patients. Seven patients (78%) had extraocular muscle involvement. The lateral recti (4/9, 44%) and superior recti (2/9, 22%) were the most commonly affected. Ocular presentation preceded primary tumour diagnosis in three patients (33%). On orbital imaging, metastases were most commonly reported as well circumscribed, ovoid or round, heterogeneous, contrast-enhancing masses. Features of intralesional haemorrhage and bony invasion are uncommonly reported.Conclusions: Neuroendocrine tumour metastasis to the orbit is uncommon. Metastases have a propensity for the extraocular muscles, commonly presenting as heterogeneous, well circumscribed, contrast-enhancing lesions on neuroimaging. New ocular symptoms, a history of neuroendocrine tumours, and these radiological findings, should lead to high clinical suspicion of metastatic disease. Atypical findings warrant biopsy to exclude other causes of orbital lesions.

Provider Contributions to Disparities in Mental Health Care

OBJECTIVE

Disparities in diagnosis of mental health problems and in access to treatment among racial-ethnic groups are apparent across different behavioral conditions, particularly in the quality of treatment for depression. This study aimed to determine how much disparities differ across providers.

METHODS

Bayesian mixed-effects models were used to estimate whether disparities in patient adherence to antidepressant medication (N=331,776) or psychotherapy (N=275,095) were associated with specific providers. Models also tested whether providers who achieved greater adherence to treatment, on average, among non-Hispanic white patients than among patients from racial-ethnic minority groups attained lower disparities and whether the percentage of patients from racial-ethnic minority groups in a provider caseload was associated with disparities.

RESULTS

Disparities in adherence to both antidepressant medication and psychotherapy were associated with the provider. Provider performance with non-Hispanic white patients was negatively correlated with provider-specific disparities in adherence to psychotherapy but not to antidepressants. A higher proportion of patients from racial-ethnic minority groups in a provider's caseload was associated with lower adherence among non-Hispanic white patients, lower disparities in adherence to psychotherapy, and greater disparities in adherence to antidepressant medication.

CONCLUSIONS

Adherence to depression treatment among a provider's patients from racial-ethnic minority groups was related to adherence among that provider's non-Hispanic white patients, but evidence also suggested provider-specific disparities. Efforts among providers to decrease disparities might focus on improving the general skill of providers who treat more patients from racial-ethnic minority groups as well as offering culturally based training to providers with notable disparities.

An Egg Feeding Intervention Increased Protein Quantity and Quality Among Young Malawian Children

Objectives

Adequate protein quantity and quality are necessary for child health, growth and development, but may be lacking in complementary feeding diets with limited variety and few animal source foods. We assessed the impact of an egg feeding intervention on protein quality and quantity among rural Malawian children aged 9 to 15 months.

Methods

We enrolled 660 children into a 6-month trial to test the effect of eggs on child growth. Children were randomly assigned to the egg group (n = 331), who received one egg per day, or the control group (n = 329). Dietary intake data were collected at 3-month midline (9–12 months old) and 6-month endline visits (12–15 months old) by 24-hour recall interview with the primary caregiver. Repeat recalls were collected in a subsample at each timepoint. Crude protein intakes were calculated using local recipe and food composition tables. Breast milk intake was estimated as the difference between the estimated energy requirement and energy intake from complementary diet. Protein intakes were adjusted using the Digestible Indispensible Amino Acid Score (DIAAS), which weighs crude amino acid intakes against amino acid requirements. Treatment group differences in DIAAS were tested with ANCOVA. Group differences in adjusted total protein intakes from complementary diet and breastfeeding were tested using the National Cancer Institute method for estimating usual mean intakes with bootstrap standard errors. Adequacy was assessed using World Health Organization protein requirements.

Results

The egg intervention improved protein quality of the complementary feeding diet (DIAAS of 79 egg v 61 control at midline, 86 v 72 at endline, P &lt; .0001). Inclusion of breast milk in the DIAAS increased mean scores in both groups; total protein quality remained higher in the egg group. Total quality-adjusted protein intakes were 15.4 ± 0.3 g (mean ± standard error) in the egg group v 12.7 ± 0.3 g in the control group at midline and 17.1 ± 0.3 g egg group v 14.6 ± 0.3 g control at endline (P &lt; .0001). Inadequacy of protein intake was lower in the egg group than the control group at midline (2% v 15%, P &lt; 0.01) and very low in both groups at endline (&lt;1% egg v 2% control, P &gt; 0.05).

Conclusions

The egg intervention increased quantity and quality of protein intakes among young Malawian children, though protein inadequacy was uncommon.

Funding Sources

The Bill and Melinda Gates Foundation.

The Effect of Providing Eggs Early in Complementary Feeding on Energy Intake and Dietary Diversity: The Mazira Project Randomized Controlled Trial

Objectives

Complementary feeding diets in low- and middle-income countries are usually inadequate to meet requirements for healthy growth and development. Food-based interventions may prevent nutrient inadequacies provided they do not replace other nutrient-rich foods. They may also be more sustainable than manufactured food supplements. We describe the contribution of daily egg supplementation to usual energy intake, usual energy intake by food group, and minimum dietary diversity of rural Malawian infants and young children.

Methods

We conducted a randomized controlled trial in rural Malawi in which 660 children aged 6 to 9 months were randomly allocated to receive an egg a day for 6 months or to a control group. Dietary intake of foods and drinks was assessed at baseline, 3-month midline, and 6-month endline visits using a tablet-based mulitpass 24-hour recall. Up to two repeat recalls were collected at each timepoint in a subsample of 100 children per intervention group.

Results

The intervention resulted in an increased usual energy intake in the intervention group of 30 kcal at midline (P = 0.128) and 36 kcal at endline (P = 0.087). It also resulted in a 7 kcal displacement of legumes and nuts in children at endline (P = 0.059). At midline and endline, usual energy intake from eggs was about 30 kcal higher in the egg group compared to controls (P &lt; 0.0001). Compared to controls, children in the egg group were over 9 times more likely to consume eggs at midline and endline. At midline and endline more than 80% of children in the egg group consumed a minimally diverse diet compared to 53% at midline and 60% at endline in the control group.

Conclusions

Mothers in the egg group fed eggs to young children on a regular basis without substantial displacement of other nutrient-rich complementary foods. The intervention resulted in higher energy intake from eggs, greater dietary diversity, and an increased percentage of children meeting a minimum dietary diversity cutoff.

Funding Sources

Bill & Melinda Gates Foundation.

Intake of Free Sugars Among Young Children in Rural Malawi

Objectives

The World Health Organization (WHO) recommends intake of free sugars to not exceed 10% of energy in children. The objectives of this study are to (1) estimate the proportion of infants in rural Malawi who exceed the recommended intake of free sugars and (2) describe the sources of free sugars in infant diets.

Methods

Among children enrolled in a randomized controlled trial of an egg feeding intervention, a secondary analysis was conducted using endline dietary data from a single 24-hour recall among 12- to 15-month-old children (n = 590). Free sugars in home-prepared foods were estimated using the gram weight of table sugar and honey in standardized local recipes. Free sugars from commercial foods were estimated using food composition data from the Nutrition Data System for Research. Foods and beverages containing free sugars were classified into seven food categories: maize porridge, sweetened tea, sweetened dairy, candy or table sugar, juice or soda, pastries, and cookies. The total grams of free sugars and grams of free sugars by food category and by commercial or home preparation were summed for each child. Breastmilk intake was not directly assessed, so total energy intake was assumed equal to the estimated energy requirement when assessing proportion of energy intake from free sugars.

Results

The mean intake of free sugars was 10.7 ± 13.1 g (6% of estimated energy requirement), and 22% of children exceeded recommended energy intake from free sugars. The majority of free sugars were consumed in maize porridge (5.1 g, 48% of total free sugars) followed by sweetened tea (2.0 g, 18%), sweetened dairy (1.7 g, 16%), candy or table sugar (1.0 g, 9%), juice or soda (0.3 g, 3%), pastries (0.3 g, 3%), and cookies (0.3 g, 3%). The average intake of free sugars from commercial foods or beverages was 3.5 ± 8.5 g (33% of total free sugar intake), whereas the average intake from home-prepared foods or beverages was 7.1 ± 9.4 g (67%).

Conclusions

Free sugar consumption exceeded WHO recommendations in approximately one-fifth of this sample of rural Malawian children. This data suggests the greatest opportunity for reducing free sugar consumption among young children in rural villages is by targeting sugars added to home-prepared foods and beverages.

Funding Sources

Bill and Melinda Gates Foundation.

Choline Intake in Malawian Children Aged 6–9 and 12–15 Months in an Egg Intervention Trial

Objectives

Choline is an essential nutrient which may be important for child growth and development; however, data on intake among children in low and middle income countries are scarce. We aimed to describe choline intake among Malawian children age 6–9 and 12–15 months enrolled in an egg intervention trial.

Methods

The Mazira Project was a randomized controlled trial of the effect of daily egg consumption on growth and development in Malawian children. Children 6–9 months old were randomized to the intervention group, which received one egg/day for 6 months, or to the control group, which did not receive eggs. Data on children's complementary food intake were collected by 24-hour recall interview with the primary caregiver at baseline (6–9 months of age; n = 659) and at endline (12–15 months of age; n = 595). Choline from complementary foods was calculated based on local recipe and food composition tables. Breastmilk intake was approximated as the child's estimated energy requirement minus energy from complementary foods, and then multiplied by an assumed choline concentration. Total choline intake was compared to the Adequate Intake (AI) level. Contribution to choline intake by food source was calculated at each time point. Since eggs are high in choline, analysis was stratified by group at endline.

Results

The median (IQR) total choline intake at 6–9 months was 98.2 (77.7–120.6) mg. Breastmilk was the top contributor (80% of total choline), followed by maize (10%). At 12–15 months, median (IQR) choline intake in the egg group was 126.2 (91.9–166.2) mg and the main contributors were breastmilk (40%), eggs (29%) and maize (10%). Choline intake in the control group was lower, at 94.3 (63.3–118.1) mg, and was mainly from breastmilk (53%) and maize (15%). Median intake was below the AI at both ages; however, at 12–15 months, median intake was 65% of the AI in the egg group and only 47% in the control group.

Conclusions

Choline intake is low among the Malawian children in this sample, potentially putting them at risk for poor development. The egg intervention increased choline intake, specifically from eggs, but the median intake in this group was still below the AI.

Funding Sources

The Bill and Melinda Gates Foundation, Egg Nutrition Center.

A novel non-agonist c-Met antibody drug conjugate with superior potency over a c-Met tyrosine kinase inhibitor in c-Met amplified and non-amplified cancers

c-Met is a well-characterized oncogene that is associated with poor prognosis in many solid tumor types. While responses to c-Met inhibitors have been observed in clinical trials, activity appears to be limited to those with MET gene amplifications or mutations. We developed a c-Met targeted antibody-drug conjugate (ADC) with preclinical activity in the absence of MET gene amplification or mutation, and activity even in the context of moderate protein expression. The ADC utilized a high-affinity c-Met antibody (P3D12), that induced c-Met degradation with minimal activation of c-Met signaling, or mitogenic effect. P3D12 was conjugated to the tubulin inhibitor toxin MMAF via a cleavable linker (vc-MMAF). P3D12-vc-MMAF demonstrated potent in vitro activity in c-Met protein-expressing cell lines regardless of MET gene amplification or mutation status, and retained activity in cell lines with medium-low c-Met protein expression. In contrast, the c-Met tyrosine kinase inhibitor (TKI) PHA-665752 slowed tumor cell growth in vitro only in the context of MET gene amplification or very high protein expression. This differential activity was even more marked in vivo. P3D12-vc-MMAF demonstrated robust inhibition of tumor growth in the MET gene amplified MKN-45 xenograft model, and similar results in H1975, which expresses moderate levels of wild type c-Met without genomic amplification. By comparison, the c-Met TKI, PHA-665752, demonstrated modest tumor growth inhibition in MKN-45, and no inhibition at all in H1975. Taken together, these data suggest that P3D12-vc-MMAF may have a superior clinical profile in treating c-Met positive malignancies in contrast to c-Met pathway inhibitors.

Ten years of enzyme replacement therapy in paediatric onset mucopolysaccharidosis II in England

The outcome of 110 patients with paediatric onset mucopolysaccharidosis II (MPS II) since the commercial introduction of enzyme replacement therapy (ERT) in England in 2007 is reported. Median length of follow up was 10 years 3 months (range = 1 y 2 m to 18 years 6 month). 78 patients were treated with ERT, 18 had no ERT or disease modifying treatment 7 had haematopoietic stem cell transplant, 4 experimental intrathecal therapy and 3 were lost to follow up. There is clear evidence of improved survival (median age of death of ERT treated (n = 16) = 15.13 years (range = 9.53 to 20.58 y), and untreated (n = 17) = 11.43 y (0.5 to 19.13 y) p = .0005). Early introduction of ERT improved respiratory outcome at 16 years, the median FVC (% predicted) of those in whom ERT initiated <8 years = 69% (range = 34-86%) and 48% (25-108) (p = .045) in those started >8 years. However, ERT appears to have minimal impact on hearing, carpal tunnel syndrome or progression of cardiac valvular disease. Cardiac valvular disease occurred in 18/46 (40%), with progression occurring most frequently in the aortic valve 13/46 (28%). The lack of requirement for neurosurgical intervention in the first 8 years of life suggests that targeted imaging based on clinical symptomology would be safe in this age group after baseline assessments. There is also emerging evidence that the neurological phenotype is more nuanced than the previously recognized dichotomy of severe and attenuated phenotypes in patients presenting in early childhood.

Chronic pain diagnoses and opioid dispensings among insured individuals with serious mental illness

BACKGROUND

Individuals with major depressive disorder (MDD) and bipolar disorder (BD) have particularly high rates of chronic non-cancer pain (CNCP) and are also more likely to receive prescription opioids for their pain. However, there have been no known studies published to date that have examined opioid treatment patterns among individuals with schizophrenia.

METHODS

Using electronic medical record data across 13 Mental Health Research Network sites, individuals with diagnoses of MDD (N = 65,750), BD (N = 38,117) or schizophrenia or schizoaffective disorder (N = 12,916) were identified and matched on age, sex and Medicare status to controls with no documented mental illness. CNCP diagnoses and prescription opioid medication dispensings were extracted for the matched samples. Multivariate analyses were conducted to evaluate (1) the odds of receiving a pain-related diagnosis and (2) the odds of receiving opioids, by separate mental illness diagnosis category compared with matched controls, controlling for age, sex, Medicare status, race/ethnicity, income, medical comorbidities, healthcare utilization and chronic pain diagnoses.

RESULTS

Multivariable models indicated that having a MDD (OR = 1.90; 95% CI = 1.85-1.95) or BD (OR = 1.71; 95% CI = 1.66-1.77) diagnosis was associated with increased odds of a CNCP diagnosis after controlling for age, sex, race, income, medical comorbidities and healthcare utilization. By contrast, having a schizophrenia diagnosis was associated with decreased odds of receiving a chronic pain diagnosis (OR = 0.86; 95% CI = 0.82-0.90). Having a MDD (OR = 2.59; 95% CI = 2.44-2.75) or BD (OR = 2.12; 95% CI = 1.97-2.28) diagnosis was associated with increased odds of receiving chronic opioid medications, even after controlling for age, sex, race, income, medical comorbidities, healthcare utilization and chronic pain diagnosis; having a schizophrenia diagnosis was not associated with receiving chronic opioid medications.

CONCLUSIONS

Individuals with serious mental illness, who are most at risk for developing opioid-related problems, continue to be prescribed opioids more often than their peers without mental illness. Mental health clinicians may be particularly well-suited to lead pain assessment and management efforts for these patients. Future research is needed to evaluate the effectiveness of involving mental health clinicians in these efforts.

Egg intervention effect on linear growth no longer present after two years

The Lulun Project, a randomized controlled trial conducted in 2015, found that one egg per day for 6 months during early complementary feeding reduced stunting by 47% and increased linear growth by 0.63 length‐for‐age Z (LAZ). This follow‐up cohort study (Lulun Project II) aimed to test whether the growth effect remained in the egg intervention group compared with the control group after approximately 2 years. Mothers or caregivers from the Lulun Project were recontacted and recruited for this study. Enumerators collected data on socio‐economic and demographic factors, 24‐hr frequency of dietary intakes, morbidities, and anthropometric measures of height, weight, and head circumference using World Health Organization protocols. Statistical analyses followed the same analytical plan as Lulun Project, applying generalized linear models and regression modelling to test group differences in height‐for‐age z (HAZ) from LAZ at Lulun Project endline, and structural equation modelling for mediation. One hundred thirty‐five mother–child dyads were included in Lulun II, with 11% losses to follow‐up from endline Lulun Project. Growth faltering across all children was evident with HAZ −2.07 ± 0.91 and a stunting prevelance of 50%. Regression modelling showed no difference between egg and control groups for the HAZ outcome and other anthropometric outcomes, and significant declines in HAZ from endline Lulun Project in the egg intervention are compared with control groups. Current dietary egg intake, however, was associated with reduced growth faltering in HAZ from Lulun Project endline to Lulun Project II, independent of group assignment and through mediation, explaining 8.8% of the total effect. Findings suggest the need for a longer intervention period and ongoing nutrition support to young children during early childhood.

TR1801-ADC: a highly potent cMet antibody-drug conjugate with high activity in patient-derived xenograft models of solid tumors

cMet is a well‐characterized oncogene that is the target of many drugs including small molecule and biologic pathway inhibitors, and, more recently, antibody–drug conjugates (ADCs). However, the clinical benefit from cMet‐targeted therapy has been limited. We developed a novel cMet‐targeted ‘third‐generation’ ADC, TR1801‐ADC, that was optimized at different levels including specificity, stability, toxin–linker, conjugation site, and in vivo efficacy. Our nonagonistic cMet antibody was site‐specifically conjugated to the pyrrolobenzodiazepine (PBD) toxin–linker tesirine and has picomolar activity in cancer cell lines derived from different solid tumors including lung, colorectal, and gastric cancers. The potency of our cMet ADC is independent of MET gene copy number, and its antitumor activity was high not only in high cMet‐expressing cell lines but also in medium‐to‐low cMet cell lines (40 000–90 000 cMet/cell) in which a cMet ADC with tubulin inhibitor payload was considerably less potent. In vivo xenografts with low–medium cMet expression were also very responsive to TR1801‐ADC at a single dose, while a cMet ADC using a tubulin inhibitor showed a substantially reduced efficacy. Furthermore, TR1801‐ADC had excellent efficacy with significant antitumor activity in 90% of tested patient‐derived xenograft models of gastric, colorectal, and head and neck cancers: 7 of 10 gastric models, 4 of 10 colorectal cancer models, and 3 of 10 head and neck cancer models showed complete tumor regression after a single‐dose administration. Altogether, TR1801‐ADC is a new generation cMet ADC with best‐in‐class preclinical efficacy and good tolerability in rats.

Setting research priorities on multiple micronutrient supplementation in pregnancy

Prenatal micronutrient deficiencies are associated with negative maternal and birth outcomes. Multiple micronutrient supplementation (MMS) during pregnancy is a cost-effective intervention to reduce these adverse outcomes. However, important knowledge gaps remain in the implementation of MMS interventions. The Child Health and Nutrition Research Initiative (CHNRI) methodology was applied to inform the direction of research and investments needed to support the implementation of MMS interventions for pregnant women in low- and middle-income countries (LMIC). Following CHNRI methodology guidelines, a group of international experts in nutrition and maternal health provided and ranked the research questions that most urgently need to be resolved for prenatal MMS interventions to be successfully implemented. Seventy-three research questions were received, analyzed, and reorganized, resulting in 35 consolidated research questions. These were scored against four criteria, yielding a priority ranking where the top 10 research options focused on strategies to increase antenatal care attendance and MMS adherence, methods needed to identify populations more likely to benefit from MMS interventions and some discovery issues (e.g., potential benefit of extending MMS through lactation). This exercise prioritized 35 discrete research questions that merit serious consideration for the potential of MMS during pregnancy to be optimized in LMIC.

Patterns of Health Care Utilization Before First Episode Psychosis in Racial and Ethnic Groups

Objective

To compare patterns of health care utilization associated with first presentation of psychosis among different racial and ethnic groups of patients.

Design

The study was a retrospective observational design.

Setting

The study was conducted in five health care systems in the western United States. All sites were also part of the National Institute of Mental Health-funded Mental Health Research Network (MHRN).

Participants

Patients (n = 852) were aged 15 - 59 years (average 26.9 ± 12.2 years), 45% women, and primarily non-Hispanic White (53%), with 16% Hispanic, 10% non-Hispanic Black, 6% Asian, 1% Native Hawaiian/Pacific Islander, 1% Native American/ Alaskan Native, and 12% unknown race/ethnicity.

Main Outcome Measures

Variables examined were patterns of health care utilization, type of comorbid mental health condition, and type of treatment received in the three years before first presentation of psychosis.

Methods

Data abstracted from electronic medical records and insurance claims data were organized into a research virtual data warehouse (VDW) and used for analysis.

Results

Compared with non-Hispanic Whites, Asian patients (16% vs 34%; P=.007) and non-Hispanic Black patients (20% vs 34%; P=.009) were less likely to have a visit with specialty mental health care before their first presentation of psychosis.

Conclusions

Early detection of first episode psychosis should start with wider screening for symptoms outside of any indicators for mental health conditions for non-Hispanic Black and Asian patients.

Pain in older adults with dementia : A survey across Europe on current practices, use of assessment tools, guidelines and policies

BACKGROUND

We aimed to explore the existing use of pain assessment tools and guidelines, and develop understanding of the practical considerations required to facilitate their use within the nursing home, hospital and community settings.

METHODS

A self-administered web-based survey was conducted with nurses, health and social care workers with an interest in the assessment of pain in older adults with cognitive impairment. The survey was distributed to participants in Austria, Belgium, Denmark, Germany, The Netherlands, Switzerland and United Kingdom.

RESULTS

Only a minority of staff reported use of (inter-)national or local standards or specific pain assessment tools in daily practice. A range of tools were reported as being used, which varied across country. While participants generally reported that these pain assessment tools were easy/very easy to use, many participants reported that they were difficult to interpret. Assessment is generally performed whilst providing nursing care. This was highlighted in 70-80% of all participating countries. While many of these tools rely on facial expression of pain, facial expressions were considered to be the least useful in comparison to other items. Furthermore findings showed that nurses employed in long-term care settings did not feel that they were educated enough in pain assessment and management.

CONCLUSION

Our findings suggest that pain education is required across all countries surveyed. This should include a focus on guidelines and standards for assessment and subsequent management of pain. Findings suggest that clinical staff find interpreting facial expressions in relation to pain more difficult.

A review of the law of consent in dentistry

The development of the law of consent has led to much discussion within the dental literature as to how these changes might impact practice. The move from a practitioner-focused standard of consent to a patient-focused standard has altered the nature of the framework required to support a patient's decision-making to avoid an allegation or finding of a negligent consent process. Contrastingly, there has been little in the way of exploration as to how the law of battery (in civil matters) and assault (in criminal cases), where consent is entirely absent, might apply to dentistry and the practice of the profession. This article considers the law of consent, using several key examples from dentistry, as well as providing an update of recent case law of relevance to dental practice.

Are wishes for death or suicidal ideation symptoms of depression in older adults?

OBJECTIVE

Clinicians may question whether thoughts of being better off dead are normal consequences of aging or symptoms of depression. We examine whether thoughts of suicide are as strongly linked to depression severity in older adults as they are in other age groups.

METHODS

Cross-sectional cohort study. Participants included 509,945 outpatients >18 years old from four large integrated healthcare systems in the Mental Health Research Network who completed 1.2 million Patient Health Questionnaires (PHQ) and had data to calculate Charlson Comorbidity Index scores from 2010 through 2012. The PHQ8 estimated depression severity, while suicidal ideation was measured using the 9th item of the PHQ. Data were abstracted from a Virtual Data Warehouse.

RESULTS

In older adult patients, suicidal ideation was strongly associated with depression severity. Older adults who had at least moderately-severe depression (PHQ8 ≥15) were 48 times more likely (95% CI: 42.8-53.8) to report suicidal ideation than those with minimal or mild symptoms of depression (PHQ8 <10) after adjustment for all other variables in the model, including medical comorbidity burden.

CONCLUSIONS

Depression severity was by far the strongest predictor of suicidal ideation in older adult patients. Older patients with suicidal ideation should be screened for depression.

Mucosal lactoferrin response to genital tract infections is associated with iron and nutritional biomarkers in young Burkinabé women

BACKGROUND/OBJECTIVES

The iron-binding affinity of vaginal lactoferrin (Lf) reduces iron available to genital pathogens. We describe host reproductive, nutritional, infection and iron biomarker profiles affecting vaginal Lf concentration in young nulliparous and primigravid women in Burkina Faso.

SUBJECTS/METHODS

Vaginal eluates from women who had participated in a randomized, controlled periconceptional iron supplementation trial were used to measure Lf using a competitive double-sandwich ELISA. For this analysis samples from both trial arms were combined and pregnant and non-pregnant cohorts compared. Following randomization Lf was measured after 18 months (end assessment) for women remaining non-pregnant, and at two antenatal visits for those becoming pregnant. Associations between log Lf levels and demographic, anthropometric, infection and iron biomarker variables were assessed using linear mixed models.

RESULTS

Lf samples were available for 712 non-pregnant women at end assessment and for 303 women seen at an antenatal visit. Lf concentrations of pregnant women were comparable to those of non-pregnant, sexually active women. Lf concentration increased with mid-upper-arm circumference, (P = 0.047), body mass index (P = 0.018), Trichomonas vaginalis (P < 0.001) infection, bacterial vaginosis (P < 0.001), serum C-reactive protein (P = 0.048) and microbiota community state types III/IV. Adjusted Lf concentration was positively associated with serum hepcidin (P = 0.047), serum ferritin (P = 0.018) and total body iron stores (P = 0.042). There was evidence that some women maintained persistently high or low Lf concentrations from before, and through, pregnancy.

CONCLUSION

Lf concentrations increased with genital infection, higher BMI, MUAC, body iron stores and hepcidin, suggesting nutritional and iron status influence homeostatic mechanisms controlling vaginal Lf responses.

The WASH Benefits and SHINE Trials. Interpretation of Findings on Linear Growth and Diarrhoea and Implications for Policy: Perspective of the Investigative Teams (P10-136-19)

Objectives

We recently completed 3 efficacy trials (Bangladesh, Kenya, Zimbabwe) testing the independent and combined effects of improved complementary feeding (CF) and intensive household water quality, sanitation, and hygiene (WASH) on child diarrhea and length-for-age-Z-score (LAZ) at 18 to 24 mo. Intervention uptake was high. In all three trials: CF increased LAZ but WASH had no effect on LAZ. WASH reduced diarrhea in Bangladesh but not in Kenya or Zimbabwe. We present a synthesis of trial findings and their implications.

Methods

Reviews of the literature and reanalyses of trial data were conducted.

Results

WASH and stunting: Copious observational studies have demonstrated a strong association between household-level WASH and child LAZ. We conducted an observational anlaysis (nested birth cohort) from our control arms. In adjusted analyses of all three trials, having an improved latrine when the pregnant woman was enrolled was associated with ∼0.2LAZ increase in her child at 18–24 mo. The frequently reported association between household WASH indicators and child growth may be confounded and drawing causal inferance misguided.

WASH and diarrhea: Promoters visited intervention households 6 times per month in Bangladesh and monthly in Kenya and Zimbabwe. We conducted a systematic literature review: virtually all evidence that household water chlorination and handwashing reduce diarrhea comes from studies with daily to fortnightly intervention contact. In studies with follow-up after the trial ending, behaviors steeply declined and the effect on child diarrhea disappeared. Household water chlorination and handwashing promotion implemented through sporadic message delivery may not reduce child diarrhea.

Enteropathogen transmission: Despite achieving substantial contrast between WASH and non-WASH households, children in the WASH arms still experienced high enteropathogen transmission, illustrating the recalcitrance of pervasive fecal contamination in rural low-income communities to even intense intervention.

Conclusions

Household WASH interventions are unlikely to reduce child stunting and may not reduce child diarrhea. We call for substantial investment in research to identify and in programming to deliver much more efficacious interventions.

Funding Sources

Bill & Melinda Gates Foundation, USAID, DFID/UKAID, Wellcome Trust.

Hemoglobin Concentration and Memory Development in Malawian Children Aged 12–15 Months (P10-093-19)

Objectives

Multiple studies have found associations between hemoglobin concentration (Hb) and cognitive development in children under age 2 y, including development of language and motor skills; however, its association with early memory development is less well studied. Our objective was to assess whether hemoglobin concentration was associated with scores on a memory task in a sample of children aged 12–15 months in Malawi.

Methods

This analysis includes a subset of children (n = 450) from an ongoing trial evaluating eggs during complementary feeding in 660 Malawian children. Hb was measured using the HemoCue 201 Analyser at baseline, when children were 6–9 months old, and at endline 6 months later. The elicited imitation test, a nonverbal measure of memory, was administered at endline. In the test, children were shown eight novel objects. After a period of spontaneous interaction, children were shown a two-action sequence for each object and asked to imitate it, either immediately or after a delay of 10 minutes. Children were scored on their ability to perform the actions in any order (total actions score, 0–16) and to complete the sequences correctly (total sequences score, 0–8). The association of Hb at each time point with total actions was examined using multiple linear regression and with total sequences, categorized (<2 or ≥2 sequences), using multiple logistic regression. Both models controlled for the spontaneous actions produced, baseline Home Observation for the Measurement of the Environment score, maternal education, maternal age, and household asset index, and endline child age and the Family Care Indicators score.

Results

The mean (SD) Hb at baseline was 10.4 (1.6) g/dL and at endline was 11.1 (1.3) g/dL. The mean (SD) total actions score was 6.8 (3.5), and 52.7% of the children had a sequences score below two. Total actions score was not significantly associated with Hb at either time point (baseline: P = 0.99; endline: P = 0.15). Total sequences score <2 was also not associated with Hb (baseline: P = 0.90, endline: P = 0.14).

Conclusions

Hemoglobin concentration at 6–9 and 12–15 months of age was not associated with memory development at 12–15 months in this sample of Malawian children.

Funding Sources

The Bill and Melinda Gates Foundation; UC Davis Blum Center.

OpenDRS: An Open-source 24-hour Recall for Mobile Devices (P13-004-19)

Objectives

Our aim was to develop a 24-hour recall program using open-source language that can be readily adapted for use on multiple platforms and in different settings.

Methods

We developed the Open Dietary Recall System (OpenDRS), a multi-pass, 24-hour recall survey using the XLSForm programming language. XLSForm operates in Microsoft Excel and is used by several free or subscription-based electronic survey platforms that deploy forms via Android devices or online. The first pass collects a brief list of foods consumed, the second pass collects descriptive details and added ingredients for each food, and the third pass collects portion size estimates. The final pass reviews the recorded data with the option to edit or add foods. The program references external food and ingredient lists in .csv format. These food and ingredient lists are customizable for each survey setting, can be coded to match nutrient composition or recipe tables, and can be amended over the course of a study. Questions or response options can be added or edited to fit study-specific data collection methods. Photos can be incorporated for food identification or portion size estimation. Two case studies from adaptations in Malawi and Haiti will be presented.

Results

OpenDRS was used to collect 24-hour dietary intake data among 6- to 15-month-old children in Malawi, for a randomized, controlled complementary feeding trial. The median number of foods reported was 6, and the median survey duration was 9 minutes. For a national nutrition survey of 6- to 59-month-old children and their caregivers in Haiti, the program was expanded to record recipe data and to capture caregiver and child intakes in one electronic survey form. Recipes reported during the caregiver's recall can be linked to the child's recall if both consumed the same mixed dish.

Conclusions

OpenDRS is an open-source 24-hour recall program which has been used in low- and middle-income countries. The XLSForm program for data collection and Stata code for data formatting will be made available to researchers conducting nutrition surveys via the Open Science Framework.

Funding Sources

The Bill & Melinda Gates Foundation and GAIN.