Lessons Learned from COVID-19 Response in Correctional and Detention Facilities

The COVID-19 pandemic disproportionately affected persons held in and working in correctional and detention facilities, causing facilities' traditional priorities to shift when healthcare and public health needs temporarily drove many aspects of operations. During July-August 2022, we interviewed members of health departments and criminal justice organizations to document lessons learned from the COVID-19 response in correctional settings. Participants valued enhanced partnerships, flexibility, and innovation, as well as real-time data and corrections-specific public health guidance. Challenges included cross-sector collaborations, population density, scarcity of equipment and supplies, and mental health. Most participants reported improved relationships between criminal justice and public health organizations during the pandemic. Lessons from COVID-19 can be applied to everyday public health preparedness and emergency response in correctional facilities by ensuring representation of correctional health in public health strategy and practice and providing timely, data-driven, and partner-informed guidance tailored to correctional environments when public health needs arise.

Evidence-informed recommendations on managing breast screening atypia: perspectives from an expert panel consensus meeting reviewing results from the Sloane atypia project

Evidence-based clinical guidelines are essential to maximize patient benefit and to reduce clinical uncertainty and inconsistency in clinical practice. Gaps in the evidence base can be addressed by data acquired in routine practice. At present, there is no international consensus on management of women diagnosed with atypical lesions in breast screening programmes. Here, we describe how routine NHS breast screening data collected by the Sloane atypia project was used to inform a management pathway that maximizes early detection of cancer and minimizes over-investigation of lesions with uncertain malignant potential. A half-day consensus meeting with 11 clinical experts, 1 representative from Independent Cancer Patients' Voice, 6 representatives from NHS England (NHSE) including from Commissioning, and 2 researchers was held to facilitate discussions of findings from an analysis of the Sloane atypia project. Key considerations of the expert group in terms of the management of women with screen detected atypia were: (1) frequency and purpose of follow-up; (2) communication to patients; (3) generalizability of study results; and (4) workforce challenges. The group concurred that the new evidence does not support annual surveillance mammography for women with atypia, irrespective of type of lesion, or woman's age. Continued data collection is paramount to monitor and audit the change in recommendations.

Childhood bullying victimization, emotion regulation, rumination, distress tolerance, and depressive symptoms: A cross-national examination among young adults in seven countries

Existing research suggests a robust association between childhood bullying victimization and depressive symptoms in adulthood, but less is known about potential mediators of this link. Furthermore, there is limited cross-national research evaluating similarities and differences in bullying victimization and its associations with mental health. The current study addressed gaps in the literature by evaluating cognitive and affective responses to stress (i.e., emotion regulation, rumination, and distress tolerance) as potential mediators of the link between recalled bullying victimization and current depressive symptoms among 5909 (70.6% female) college students from seven countries. Results revealed specific indirect associations of bullying victimization through distress tolerance and three out of four facets of rumination, as well as a persistent direct association of childhood bullying on adulthood depression. Emotion regulation strategies were not significantly associated with bullying victimization and did not mediate its association with depressive symptoms. Constrained multigroup models indicated that results were invariant across country and gender. Findings provide evidence of statistical mediation in a cross-sectional sample and await replication in prospective studies. Rumination and distress tolerance may be promising targets for resilience-promoting interventions among children experiencing peer victimization. Ongoing research is needed to clarify cross-national patterns in childhood bullying, identify additional mediators accounting for the remaining direct association, and evaluate emotion regulation as a potential moderator of associations between bullying victimization and adult mental health.

Neonatal near-miss audits: a systematic review and a call to action

BACKGROUND

Neonatal near-miss (NNM) can be considered as an end of a spectrum that includes stillbirths and neonatal deaths. Clinical audits of NNM might reduce perinatal adverse outcomes. The aim of this review is to evaluate the effectiveness of NNM audits for reducing perinatal mortality and morbidity and explore related contextual factors.

METHODS

PubMed, Embase, Scopus, CINAHL, LILACS and SciELO were searched in February/2023. Randomized and observational studies of NNM clinical audits were included without restrictions on setting, publication date or language.

PRIMARY OUTCOMES

perinatal mortality, morbidity and NNM.

SECONDARY OUTCOMES

factors contributing to NNM and measures of quality of care. Study characteristics, methodological quality and outcome were extracted and assessed by two independent reviewers. Narrative synthesis was performed.

RESULTS

Of 3081 titles and abstracts screened, 36 articles had full-text review. Two studies identified, rated, and classified contributing care factors and generated recommendations to improve the quality of care. No study reported the primary outcomes for the review (change in perinatal mortality, morbidity and NNM rates resulting from an audit process), thus precluding meta-analysis. Three studies were multidisciplinary NNM audits and were assessed for additional contextual factors.

CONCLUSION

There was little data available to determine the effectiveness of clinical audits of NNM. While trials randomised at patient level to test our research question would be difficult or unethical for both NNM and perinatal death audits, other strategies such as large, well-designed before-and-after studies within services or comparisons between services could contribute evidence. This review supports a Call to Action for NNM audits. Adoption of formal audit methodology, standardised NNM definitions, evaluation of parent's engagement and measurement of the effectiveness of quality improvement cycles for improving outcomes are needed.

Robocasting of Ceramic Fischer-Koch S Scaffolds for Bone Tissue Engineering

Triply Periodic Minimal Surfaces (TPMS) are promising structures for bone tissue engineering scaffolds due to their relatively high mechanical energy absorption, smoothly interconnected porous structure, scalable unit cell topology, and relatively high surface area per volume. Calcium phosphate-based materials, such as hydroxyapatite and tricalcium phosphate, are very popular scaffold biomaterials due to their biocompatibility, bioactivity, compositional similarities to bone mineral, non-immunogenicity, and tunable biodegradation. Their brittle nature can be partially mitigated by 3D printing them in TPMS topologies such as gyroids, which are widely studied for bone regeneration, as evidenced by their presence in popular 3D-printing slicers, modeling systems, and topology optimization tools. Although structural and flow simulations have predicted promising properties of other TPMS scaffolds, such as Fischer-Koch S (FKS), to the best of our knowledge, no one has explored these possibilities for bone regeneration in the laboratory. One reason for this is that fabrication of the FKS scaffolds, such as by 3D printing, is challenged by a lack of algorithms to model and slice this topology for use by low-cost biomaterial printers. This paper presents an open-source software algorithm that we developed to create 3D-printable FKS and gyroid scaffold cubes, with a framework that can accept any continuous differentiable implicit function. We also report on our successful 3D printing of hydroxyapatite FKS scaffolds using a low-cost method that combines robocasting with layer-wise photopolymerization. Dimensional accuracy, internal microstructure, and porosity characteristics are also presented, demonstrating promising potential for the 3D printing of TPMS ceramic scaffolds for bone regeneration.

Room-Based Assessment of Mobile Air Cleaning Devices Using a Bioaerosol Challenge

Introduction

The widespread transmission of the SARS-CoV-2 virus has increased scientific and societal interest in air cleaning technologies, and their potential to mitigate the airborne spread of microorganisms. Here we evaluate room scale use of five mobile air cleaning devices.

Methods

A selection of air cleaners, containing high efficiency filtration, was tested using an airborne bacteriophage challenge. Assessments of bioaerosol removal efficacy were undertaken using a decay measurement approach over 3 h, with air cleaner performance compared with bioaerosol decay rate without an air cleaner in the sealed test room. Evidence of chemical by-product emission was also checked, as were total particle counts.

Results

Bioaerosol reduction, exceeding natural decay, was observed for all air cleaners. Reductions ranged between devices from <2-log per m³ room air for the least effective, to a >5-log reduction for the most efficacious systems. One system generated detectable ozone within the sealed test room, but ozone was undetectable when the system was run in a normally ventilated room. Total particulate air removal trends aligned with measured airborne bacteriophage decline.

Discussion

Air cleaner performance differed, and this could relate to individual air cleaner flow specifications as well as test room conditions, such as air mixing during testing. However, measurable reductions in bioaerosols, beyond natural airborne decay rate, were observed.

Conclusion

Under the described test conditions, air cleaners containing high efficiency filtration significantly reduced bioaerosol levels. The best performing air cleaners could be investigated further with improved assay sensitivity, to enable measurement of lower residual levels of bioaerosols.

Association of the origin of contamination and species of microorganisms with short-term survival in dogs with septic peritonitis

OBJECTIVE

To assess the association between anatomical location of contamination and mortality in dogs with gastrointestinal and biliary origin of septic peritonitis.

METHODS

Medical records at two private referral hospitals between 2003 and 2020 were retrospectively reviewed. Cases were included if the origin of contamination was confirmed intraoperatively within the gastrointestinal or biliary tract. Cases were excluded if the dog died or was euthanized intraoperatively or where the data regarding the origin of contamination were not available. The association of anatomical origin with survival was assessed specifying the locations as stomach, small intestine, large intestine and biliary tract. The gastrointestinal tract origin was further subdivided into pylorus, nonpylorus, duodenum, jejunum, ileum, caecum and colon.

RESULTS

The overall survival rate was 75.9% (n = 44/58). There were no significant differences in survival among different anatomical origins of contaminations before or after subdivision (P = 0.349 and 0.832, respectively). Also, there was no association between isolated microorganism species in microbiological culture and the anatomical origin (P = 0.951) and the microorganism species was not associated with survival (P = 0.674).

CONCLUSIONS

There was no association between anatomical location of leakage, microorganism species and survival although further studies are warranted to analyse the relationships between anatomical leakage site and microorganism species as well as microorganism species and mortality.

Validation of personal protective equipment ensembles, incorporating powered air-purifying respirators protected from contamination, for the care of patients with high-consequence infectious diseases

BACKGROUND

The UK High-Consequence Infectious Diseases (HCID) Network of high-level isolation units provides care for patients with contact- or airborne-transmissible highly infectious and highly dangerous diseases. In most HCID units, the healthcare workers (HCWs) wear personal protective equipment (PPE) ensembles incorporating a powered air-purifying respirator (PAPR) for head and respiratory protection. Some PAPRs have components worn outside/over other PPE, necessitating decontamination of re-usable elements. Two alternative PAPRs, with all re-usable elements worn under PPE, were trialled in this study.

AIM

To undertake scenario-based testing of PAPRs and PPE to determine usability, comfort and ability to remove contaminated PPE without personal cross-contamination.

METHODS

Trained healthcare volunteers (N=20) wearing PAPR/PPE ensembles were sprayed with ultraviolet fluorescent markers. They undertook exercises to mimic patient care, and subsequently, after doffing the contaminated PPE following an established protocol, any personal cross-contamination was visualized under ultraviolet light. Participants also completed a questionnaire to gauge how comfortable they found the PPE.

FINDINGS AND CONCLUSIONS

The ensembles were tested under extreme 'worst case scenario' conditions, augmented by physical and manual dexterity tests. Participating volunteers considered the exercise to be beneficial in terms of training and PPE evaluation. Data obtained, including feedback from questionnaires and doffing buddy observations, supported evidence-based decisions on the PAPR/PPE ensemble to be adopted by the HCID Network. One cross-contamination event was recorded in the ensemble chosen; this could be attributed to doffing error, and could therefore be eliminated with further practice.

The role of point-of-Care Musculoskeletal Ultrasound for Routine Joint evaluation and management in the Hemophilia Clinic - A Real World Experience

BACKGROUND

The use of musculoskeletal ultrasound (MSKUS) for point-of-care (POC) evaluation of hemophilic arthropathy is growing rapidly. However, the extent to which MSKUS influences clinical treatment decisions is unknown.

METHODS

We conducted a three-year, prospective, multi-center study at three hemophilia treatment centers in the United States to evaluate the utilization of POC-MSKUS for routine clinical decision-making in adult persons with hemophilic arthropathy. Bilateral elbows, knees and ankles were assessed clinically [Hemophilia Joint Health Score (HJHS)] and with POC-MSKUS by the Joint _TissueActivity and Damage Exam (JADE) protocol at baseline and approximately annually for two additional times. Treatment decisions, including physical therapy (PT) and "medical" (joint injections/aspirations, referrals to orthopedics, changes/adjustments of hemostatic plans, and use of oral anti-inflammatory medications) were recorded in relation to POC-MSKUS.

RESULTS

Forty-four persons [median age 37 years (IQR 29, 51)], mostly with severe Hemophilia A on clotting factor prophylaxis, completed 129 visits, yielding 792 joint exams by POC-MSKUS and HJHS [median at baseline 27 (IQR 18, 42)] over a median follow up of 584 days (range: 363 to 1072). Among 157 management decisions, 70% were related to PT plans (n = 110) and 30% were "medical". Point-of-care MSKUS influenced 47/110 (43%) PT plans, mostly informing treatment of specific arthropathic joints (45/47 plans) in patients with high HJHS. Physical therapy plans influenced by POC-MSKUS directed more manual therapy/therapeutic exercises, while plans based on physical exam were focused more on global exercises and wellness. Treatment decisions were mostly based on the identification of specific musculoskeletal abnormalities visualized by POC-MSKUS. Of note 20/47 (43%) POC-MSKUS plans included de-escalation strategies, thereby reducing exercise intensity, mostly for joint instability and subclinical hemarthroses. Point-of-care MSKUS also informed 68% (32/47) of "medical" decisions, surprisingly mostly for injections/aspirations and referrals to orthopedics, and not for adjustments of hemostatic treatment. Although not formally studied, ultrasound images were used frequently for patient education.

CONCLUSION

Routine joint evaluations with POC-MSKUS resulted in few changes regarding medical management decisions but had a profound effect on the formulation of PT plans. Based on these findings, new studies are essential to determine the benefit of MSKUS-informed management plans on joint health outcomes.

Evaluation of Face Shields, Goggles, and Safety Glasses as a Virus Transmission Control Measure to Protect the Wearer Against Cough Droplets

Face shields (also referred to as visors), goggles and safety glasses have been worn during the COVID-19 pandemic as one measure to control transmission of the virus. However, their effectiveness in controlling facial exposure to cough droplets is not well established and standard tests for evaluating eye protection for this application are limited. A method was developed to evaluate face shields, goggles, and safety glasses as a control measure to protect the wearer against cough droplets. The method uses a semi-quantitative assessment of facial droplet deposition. A cough simulator was developed to generate droplets comparable to those from a human cough. The droplets consisted of a UV fluorescent marker (fluorescein) in water. Fourteen face shields, four pairs of goggles and one pair of safety glasses were evaluated by mounting them on two different sizes of breathing manikin head and challenging them with the simulated cough. The manikin head was positioned in seven orientations relative to the cough simulator to represent various potential occupational exposure scenarios, for example, a nurse standing over a patient. Droplet deposition in the eyes, nose and mouth regions were visualised following three 'coughs'. Face shields, goggles, and safety glasses reduced, but did not eliminate exposure to the wearer from droplets such as those produced by a human cough. The level of protection differed based on the design of the personal protective equipment and the relative orientation of the wearer to the cough. For example, face shields, and goggles offered the greatest protection when a cough challenge was face on or from above and the least protection when a cough challenge was from below. Face shields were also evaluated as source control to protect others from the wearer. Results suggested that if a coughing person wears a face shield, it can provide some protection from cough droplets to those standing directly in front of the wearer.

A-44 Experiences of Adversity and Validity of Baseline Concussion Testing

Purpose: This study examined the relationship between individual-level experiences of social adversity and baseline computerized concussion testing validity (Immediate Post-Concussion Assessment and Cognitive Testing; ImPACT). Methods: This study involved 6495 student-athletes born between 1995 and 2005 who completed a baseline ImPACT test between 10 and 18 years old and could be identified in the Child-Household Integrated Longitudinal Data (CHILD) System, a continuously updated integrated and comprehensive data system that captures detailed individual-level demographic, social service usage, and educational outcomes on every child born or living in Cuyahoga County, Ohio from 1989 to present. Multivariable logistic regression models were conducted with experiences of SNAP/TANF enrollment, substantiated abuse or neglect incidents, and extreme neighborhood deprivation occurring in the sensitive developmental periods of early childhood and adolescence as key predictors of baseline test validity. Results: Our findings suggest that social mobility may play an important role in baseline validity. Youth with upward social mobility (poverty or neighborhood deprivation in early childhood only) were not significantly different than youth without such experiences (OR = 0.91, p = 0.74). Youth with persistent adversity across childhood or downward social mobility (poverty or high neighborhood deprivation in adolescence only) had 50–72% lower odds of achieving a valid baseline test (persistent poverty: OR = 0.59, p = 0.05; adolescent poverty only: OR = 0.50, p = 0.004; adolescent neighborhood deprivation only: OR = 0.28, p &lt; 0.0001). Conclusions: These findings suggest certain patterns of social adversity may predispose youth to invalid computerized concussion baseline testing scores, potentially increasing their risk of inaccurate injury management and poor outcomes.

Impact of mapping technology on procedural characteristics during radiofrequency or cryoballoon pulmonary vein isolation for atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Cryoballoon ablation (CBA) is often associated with shorter procedure times along with tradeoffs such as increased fluoroscopy use compared to radiofrequency (RF) ablation of atrial fibrillation (AF), however the impact of mapping technology on these characteristics is not fully understood.

Purpose

To assess the effect of mapping technology on trends in fluoroscopy use and procedure times in AF pulmonary vein isolation (PVI) procedures with an RF or CBA catheter.

Methods

Acute procedure data from 210 de novo AF cases using a 3D mapping system was prospectively collected from 48 centers in eight countries. Choice of technology was left to physician discretion; a PVI only ablation strategy was utilized in all cases. Procedure data such as total procedure and fluoroscopy times from cases using either an RF or CBA catheter with either a grid-style mapping catheter (HD Grid) or circular mapping catheter (CMC) were compared.

Results

Of the 210 cases, RF ablation was used in 103 (49%), and CBA used in 107 (51%). In RF cases, a relatively even split between CMC and HD Grid use was observed (n=46, 45% vs. n=57, 55%), while a CMC was used in 100% of CBA cases (Figure 1). Across all cases, fluoroscopy and procedure times were significantly shorter when HD Grid was used (7.4±26.7 minutes; 108.2±46.3 minutes) compared to a CMC (20.4±17.6 minutes; 133.7±62.7) (p&lt;0.001; p=0.003). A similar trend was also observed in RF cases using HD Grid (7.4±26.7 minutes; 108.2±46.3 minutes) compared to a CMC (17.9±12.3 minutes; 175.1±50.5) (p=0.01; p&lt;0.001). Fluoroscopy times in RF cases with HD Grid (7.4±26.7 minutes) were significantly shorter compared to CBA cases with a CMC (21.5±19.4 minutes) (p&lt;0.001), while procedure times were similar (108.2±46.3 minutes; 116.0±59.2 minutes, p=0.20).

Conclusion(s)

Use of HD Grid resulted in significantly shorter procedure and fluoroscopy times compared to a CMC across all cases, including those using RF ablation. Fluoroscopy times were also significantly shorter in RF cases using HD Grid compared to CBA cases using a CMC, with similar procedure times. These observations suggest that use of HD Grid may better enable safer and more efficient PVI, specifically when employing RF ablation, in addition to safer and equally efficient RF PVI compared to CBA with a CMC. Further study in in a larger, randomized cohort may be necessary.

Global preferences in mapping technology and its impact on fluoroscopy and procedure times during catheter ablation of atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Choice in mapping technology may play a critical role in reducing fluoroscopy and procedure times during atrial fibrillation (AF) ablation, however this relationship is not well studied.

Purpose

To assess the impact of mapping technology on trends in fluoroscopy use and procedure times in AF ablation procedures.

Methods

Acute procedure data from 525 AF cases was prospectively collected from 68 centers in nine countries. Choice of technology and ablation strategy, including PVI and substrate modification, were left to physician discretion. Procedure data such as total procedure and fluoroscopy times from cases using a grid-style mapping catheter (HD Grid) were compared to those using a circular mapping catheter (CMC).

Results

Of the 525 cases, HD Grid was used in 230 (44%), and CMC was used in 295 (56%). HD Grid was routinely used for both de novo and redo procedures while CMC was used predominantly for de novo procedures (Table 1). Similar procedure times were noted in redo PAF and redo PersAF procedures, while significantly shorter procedure times were observed for the HD Grid group in both de novo PAF and PersAF (113.9±48.8 vs. 125.9±56.3 minutes, p=0.04; and 142.8±53.2 vs. 169.8±52.2 minutes, p=0.001).

Overall fluoroscopy times were significantly shorter using HD Grid compared to a CMC (9.0±19.6 minutes vs. 19.8±16.4 minutes, p&lt;0.001), including significantly shorter fluoroscopy times in de novo PAF, de novo PersAF, and redo PAF (Table 1). There were 155 cases completed without fluoroscopy use; zero fluoroscopy cases accounted for 50% (114/230) and 14% (41/295) of total cases completed with HD Grid and a CMC, respectively (p&lt;0.001).

Conclusion(s)

Use of HD Grid was observed in a significantly higher portion of zero fluoroscopy cases and resulted in significantly shorter procedure and fluoroscopy times in both de novo PAF and de novo PersAF and significantly shorter fluoroscopy times in redo PAF. These observations suggest that use of HD Grid may better enable faster and safer procedures in these specific AF types compared to CMCs, although further analysis in a larger, randomized cohort may be warranted.

Initial experience using a novel algorithm to calculate omnipolar electrograms using a high-density grid-style catheter

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

A novel mapping algorithm recently became available in Europe and select countries in the Asia Pacific region. EnSite Omnipolar Technology (OT) utilizes the Advisor HD Grid Mapping Catheter, Sensor Enabled (HD Grid) to calculate electrograms in 360 degrees from two bipolar and three unipolar electrograms acquired from a triangular set of three electrodes. This software also enables calculation of wavefront characteristics including maximum voltage, activation direction and wave speed. Procedural characteristics and clinical utilization of this novel software have not yet been reported.

Purpose

To examine the clinical utility and procedural characteristics associated with the use of this novel mapping algorithm among participating centers.

Methods

Acute procedural data were prospectively collected in 386 cases at 52 centers utilizing the newly approved mapping software in the initial phases of commercialization in Europe and the Asia Pacific region. Procedural characteristics recorded included indication for mapping/ablation, navigation mode, mapping reference, and maps and tools used to diagnose/locate ablation targets.

Results

A total of 14 indications for mapping and ablation were represented including AF, atypical flutter, and VT (Table 1). VoXel (magnetic primary) navigation mode was used in most cases (n=325, 84%). The CS catheter was used as the map reference in 280 cases (73%). A variety of workflows were used with OT to diagnose and locate ablation targets including voltage maps (n=275, 71%), LAT maps (n=226, 59%), OT activation vectors (n=124, 32%), propagation maps (n=94, 24%), and sparkle maps (n=69, 18%); note: total exceeds 100%, multiple workflows per case observed. EnSite LiveView Dynamic Display (LiveView) was used in 129 cases (33%) to diagnose and locate ablation targets, including 28 (22%) where OT activation vectors were used with LiveView. Several benefits of OT were reported including rapid identification of ablation target(s) (n=133, 35%), higher point density (n=82, 21%), better signals (n=69, 18%), and improved procedure efficiency (n=48, 12%).

Conclusion(s)

Initial experience with this novel mapping software in Europe and the Asia-Pacific region illustrated utility in a variety of arrhythmias to diagnose and locate ablation targets. The use of OT provided several benefits including rapid identification of ablation targets and higher point density, however further examination of its impact on procedural efficiencies and acute outcomes is likely warranted.

Validation of the Decontamination of a Specialist Transport System for Patients with High Consequence Infectious Diseases

When transferring highly infective patients to specialist hospitals, safe systems of work minimise the risk to healthcare staff. The EpiShuttle is a patient transport system that was developed to fit into an air ambulance. A validated decontamination procedure is required before the system can be adopted in the UK. Hydrogen peroxide (H2O2) vapour fumigation may offer better penetration of the inaccessible parts than the liquid disinfectant wiping that is currently suggested. To validate this, an EpiShuttle was fumigated in a sealed test chamber. Commercial bacterial spore indicators (BIs), alongside organic liquid suspensions and dried surface samples of MS2 bacteriophage (a safe virus surrogate), were placed in and around the EpiShuttle, for the purpose of evaluation. The complete kill of all of the BIs in the five test runs demonstrated the efficacy of the fumigation cycle. The log reduction of the MS2 that was dried on the coupons ranged from 2.66 to 4.50, but the log reduction of the MS2 that was in the organic liquids only ranged from 0.07 to 1.90, confirming the results of previous work. Fumigation with H2O2 alone may offer insufficient inactivation of viruses in liquid droplets, therefore a combination of fumigation and disinfectant surface wiping was proposed. Initial fumigation reducing contamination with minimal intervention allows disinfectant wipe cleaning to be completed more safely, with a second fumigation step inactivating the residual pathogens.

Combining modeling of drug uptake and release of cyclosporine in contact lenses to determine partition coefficient and diffusivity

Ophthalmic drug delivery via eye drops is inefficient because only about 1-5% of the drug permeates the cornea during the short residence time of a few minutes. Contact lenses are receiving considerable attention for delivering ophthalmic drugs because of higher bioavailability and the possibility of sustained release from hour to days, and possibly longer. The drug release durations from contact lenses are typically measured in vitro and it is challenging to relate the in vitro release to in vivo release, particularly for hydrophobic drugs which may not exhibit sink release in vitro and in vivo. The in vitro release can be fitted to diffusion equation to determine the partition coefficient and diffusivity, which can then be utilized to model in vivo release. The Higuchi equation is frequently used to model the short time release from a contact lens to determine diffusivity with the implicit assumption that the release is under sink conditions and the starting concentration in the lens was uniform. Both conditions may be violated when measuring release of hydrophobic drugs from contact lenses because the diffusivity and partition coefficient, and also the time needed for equilibrium are not known a priori. Here we develop a method to use the data for both loading and release of cyclosporine, which is a common hydrophobic ophthalmic drug, to determine the partition coefficient and diffusivity. The proposed approach does not require sink conditions and also does not require the lens to be fully equilibrated during loading, which may take almost a month for lenses considered here. The model is based on solving the diffusion equation in the gel along with a mass balance in the fluid. The model equations are solved numerically by finite difference. When the value of partition coefficient is high, such as it is for cyclosporine, the dynamic data is only sensitive to a ratio of partition coefficient and diffusivity, and this ratio had to first be determined from the loading data. Then the two unknown parameters were obtained by minimizing the error between the model prediction and experimental data. The method was used to determine D and K for several silicone hydrogel formulations with varying ratio of hydrogel and silicone fractions.

Mental health improvements after elective spine surgery: a Canadian Spine Outcome Research Network (CSORN) study

BACKGROUND CONTEXT

Spine patients have a higher rate of depression then the general population which may be caused in part by levels of pain and disability from their spinal disease.

PURPOSE

Determination whether improvements in health-related quality of life (HRQOL) resulting from successful spine surgery leads to improvements in mental health.

STUDY DESIGN/SETTING

The Canadian Spine Outcome Research Network prospective surgical outcome registry.

OUTCOME MEASURES

Change between preoperative and postoperative SF12 Mental Component Score (MCS). Secondary outcomes include European Quality of Life (EuroQoL) Healthstate, SF-12 Physical Component Score (PCS), Oswestry Disability Index (ODI), Patient Health Questionaire-9 (PHQ9), and pain scales.

METHODS

The Canadian Spine Outcome Research Network registry was queried for all patients receiving surgery for degenerative thoracolumbar spine disease. Exclusion criteria were trauma, tumor, infection, and previous spine surgery. SF12 Mental Component Scores (MCS) were compared between those with and without significant improvement in postoperative disability (ODI) and secondary measures. Multivariate analysis examined factors predictive of MCS improvement.

RESULTS

Eighteen hospitals contributed 3222 eligible patients. Worse ODI, EuroQoL, PCS, back pain and leg pain correlated with worse MCS at all time points. Overall, patients had an improvement in MCS that occurred within 3 months of surgery and was still present 24 months after surgery. Patients exceeding Minimally Clinically Important Differences in ODI had the greatest improvements in MCS. Major depression prevalence decreased up to 48% following surgery, depending on spine diagnosis.

CONCLUSIONS

Large scale, real world, registry data suggests that successful surgery for degenerative lumbar disease is associated with reduction in the prevalence of major depression regardless of the specific underlaying diagnosis. Worse baseline MCS was associated with worse baseline HRQOL and improved postoperatively with coincident improvement in disability, emphasizing that mental wellness is not a static state but may improve with well-planned spine surgery.

"We are in this together:" dyadic-level influence and decision-making among HIV serodiscordant couples in Tanzania receiving access to PrEP

BACKGROUND

A substantial number of new HIV infections in sub-Saharan Africa occur within stable couples. Biomedical prevention (pre-exposure prophylaxis, PrEP) and treatment (antiretroviral therapy, ART) can provide benefits to sexual partners and can be used to prevent infection within HIV serodiscordant couples. However, research is typically focused on individuals, not dyads, even when the intervention may directly or indirectly impact sexual partners. Gaps remain in understanding best practices for recruitment, informed consent, and intervention implementation in studies involving HIV prevention and treatment among heterosexual serodiscordant couples. This qualitative study was undertaken to understand and describe decision-making and dyadic-level influence among members of serodiscordant couples regarding (1) participation in a dyadic-based research study involving HIV self-testing and access to PrEP, and (2) utilization of PrEP and ART.

METHODS

This qualitative study was nested within an observational cohort study assessing the acceptability of home-based couples' HIV self-testing and uptake of dyadic care for serodiscordant couples involving facilitated referral for HIV-positive partners and access to PrEP for HIV-negative partners. Semi-structured in-depth interviews were conducted among a subset of study participants (n = 22) as well as individuals involved in serodiscordant relationships who chose not to participate (n = 9). Interviews focused on couples' decision-making regarding study participation and dyadic-level influence on medication use. Interviews were transcribed verbatim and translated from Kiswahili into English. Data were analyzed using thematic analysis.

RESULTS

Three major themes were identified: (1) HIV as "two people's secret" and the elevated role of partner support in serodiscordant relationships; (2) the intersectional role of HIV-status and gender on decision-making; (3) the relational benefits of PrEP, including psychosocial benefits for the couple that extend beyond prevention.

CONCLUSIONS

The study found that couples made joint decisions regarding study participation and uptake of HIV-related medication. Relational autonomy and dyadic-level influence should be considered within research and programs involving HIV serodiscordant couples.

The incidence, aetiology, and coagulation management of massive postpartum haemorrhage: a two-year national prospective cohort study

INTRODUCTION

Between 2017 and 2018 a national quality improvement initiative was introduced incorporating point-of-care viscoelastic haemostatic assays (VHA) to guide blood product transfusion. Laboratory coagulation profiles, use and results of VHA, and administration of blood products were investigated.

METHODS

A two-year prospective cohort study of maternal outcomes of women experiencing massive postpartum haemorrhage (PPH) >1000 mL in Wales. In this study, cases of massive PPH (≥2500 mL and/or ≥5 units red blood cell (RBC) transfusion) were identified.

RESULTS

Massive PPH occurred in 349 of 60 914 maternities (rate 5.7 per 1000). There were no deaths from PPH. Intensive care unit admission and/or hysterectomy occurred in 34/311 (10.9%) and 16/347 (4.6%), respectively. The leading cause of massive PPH was genital tract trauma (107/349, 30.6%). Two hundred and seventy-nine (80.6%) required RBC transfusion and 79/345 (22.9%) received at least one blood coagulation product. Results of VHA were recorded in 245/349 (70.2%), with 44/98 (44.9%) women tested in the first six months vs 63/77 (81.8%) in the final six months. Hypofibrinogenaemia (Clauss fibrinogen <2 g/L or FIBTEM A5 <12 mm) was observed in 56/328 (17.1%) of women, thrombocytopaenia (count <75 × 10⁹/L) in 17/334 (5.1%) and either PT or aPTT >1.5×reference range in 10/293 (3.4%).

CONCLUSION

In Wales, the use of VHA in cases of massive PPH increased over time, enabling clinicians to adopt a targeted, patient-specific approach to blood product administration, with only 22.9% of women receiving blood coagulation products and 17.1% having a documented clotting abnormality.

Review of Approaches for Increasing Ophthalmic Bioavailability for Eye Drop Formulations

Ophthalmic diseases represent a significant problem as over 2 billion people worldwide suffer from vison impairment and blindness. Eye drops account for around 90% of ophthalmic medications but are limited in success due to poor patient compliance and low bioavailability. Low bioavailability can be attributed to short retention times in the eye caused by rapid tear turnover and the difficulty of drug diffusion through the multi-layered structure of the eye that includes lipid-rich endothelial and epithelial layers as well as the stroma which is high in water content. In addition, there are barriers such as tight junctional complexes in the corneal epithelium, lacrimal turnover, nasolacrimal drainage, blinking reflexes, efflux transporters, drug metabolism by ocular enzymes, and drug binding to or repulsion from conjunctival mucins, tear proteins, and melanin. In order to maximize transport through the cornea while minimizing drug loss through other pathways, researchers have developed numerous methods to improve eye drop formulations including the addition of viscosity enhancers, permeability enhancers, mucoadhesives, and vasoconstrictors, or using formulations that include puncta occlusion, nanocarriers, or prodrugs. This review explains the mechanism behind each of these methods, examines their history, analyzes previous and current research, evaluates future applications, and discusses the pros and cons of each technique.

1517. Outcomes of Influenza Infection among Vaccinated and Un-Vaccinated Patients presenting to a Suburban hospital in Perth, Western Australia (WA), 2019 Southern Hemisphere Influenza Season

Background

Influenza season started in April, earlier than any previous season. WA immunization registry showed a higher than average vaccine uptake. By October 22,770 cases and 80 influenza related deaths were recorded (in 2018: 3,679 cases and 13 deaths). We aimed to characterize clinical presentation and outcomes of laboratory confirmed Influenza, comparing vaccinated with unvaccinated controls.Hypothesis; vaccination would result in less severe disease and better outcomes. Primary objective: length of stay (LOS); Secondary objective: prevalence of severe respiratory illness, ICU admission and death.

Methods

Retrospective study, April to October 2019. Eligible patients had a telephone-based questionnaire for clinical and immunization data verification. Excluded; &lt; 18 years; deceased; dementia; nursing home and unable to consent. Continuous and categorical data of cases (vaccinated) and controls (unvaccinated) were compared using Mann-Whitney U test (non parametric), student t-test (parametric). Correlation and multilinear regression analyses were undertaken to determine the effects of vaccination status and identified confounders on the primary outcome. Based on previous average LOS (5 days, SD 1.5) the sample required to detect a difference of 1 day with 80% power was 70 patients. This study was approved by the SJGHC HREC.

Results

Of 163 eligible, 83 completed the questionnaire. 8 were excluded. 75 underwent analysis (50 vaccinated and 25 unvaccinated). Median age was 75 (23-83) and 63 (33-70) respectively (p&lt; 0.01). 76% vs 48% reported &gt;1 comorbidity (p =0.02). 10% vs 0% were admitted to ICU (p =0.16). Higher vaccination uptake was seen in older patients and those with comorbid conditions. There was a strong correlation (Spearman r= 0.54 (0.34 to 0.68, p&lt; 0.001) between age and length of stay, but none was found between comorbidity or vaccination and length of stay. Neither age (p &gt;0.05), comorbidity status (yes/no; p=0.99), vaccination status (p=0.61) nor any combination of these variables were significantly associated with a dichotomised outcome of acute hospital stay &gt; 3 days.

Conclusion

Vaccination with the 2019 influenza vaccine had no significant effect on hospital length of stay, mortality or critical care requirement in patients admitted to hospital with influenza.

Disclosures

All Authors: No reported disclosures

A-03 SCAT5 Cognitive Screening Normative Data and Reliable Change Indices

Objective

This study provides normative data on the SCAT5 Cognitive Screening, establishes test-retest reliability, and creates clinically relevant cut points for low performance.

Method

The multisport baseline sample was composed of 727 uninjured college athletes (52% female) at a Division I university who were administered the SCAT5 before the 2017–2018 season. Descriptive statistics, including base rates of low performance, were calculated for SCAT5 indices. Repeat baseline testing was completed by 325 athletes (48% female) at 1 year (days M = 352.56;SD = 56.03) who were included in the test-retest reliability and practice effect analyses. Reliable change indices were calculated.

Results

Descriptive statistics for SCAT5 were computed for both baselines (Baseline 1: SAC total M = 35.15,SD = 4.93; immediate recall total M = 20.01,SD = 3.46; delayed recall total M = 6.43,SD = 1.75). A difference in descriptive statistics and practice effects by sex on the SCAT5 Cognitive Screening has been demonstrated (Bailey, Meyer, Tangen et al., under review). For female athletes, the 1st administration cutoff scores for abnormal performance (&lt;10th%ile) included SAC total score = 33, immediate recall score = 18, and delayed recall score = 6. For male athletes, the 1st administration cutoff scores for abnormal performance (&lt;10th%ile) included SAC total score = 30, immediate recall score = 17, and delayed recall score = 5. Test-retest reliability of the SAC was similar to previous versions but varied by sex. Reliable change indices (RCI) were created with cut points for significant change.

Conclusions

The present study provides clinically relevant normative data for the SCAT5 Cognitive Screening. Cut points for low performance on both reliable chance indices (RCIs) and normative performance reflected meaningful sex differences that could influence clinical interpretation.

Facilitators and barriers to general practitioner and general practice nurse participation in end-of-life care: systematic review

BACKGROUND

General practitioners (GPs) and general practice nurses (GPNs) face increasing demands to provide palliative care (PC) or end-of-life care (EoLC) as the population ages. To enhance primary EoLC, the facilitators and barriers to their provision need to be understood.

OBJECTIVE

To provide a comprehensive description of the facilitators and barriers to GP and GPN provision of PC or EoLC.

METHOD

Systematic literature review. Data included papers (2000 to 2017) sought from Medline, PsycInfo, Embase, Joanna Briggs Institute and Cochrane databases.

RESULTS

From 6209 journal articles, 62 reviewed papers reported the GP's and GPN's role in EoLC or PC practice. Six themes emerged: patient factors; personal GP factors; general practice factors; relational factors; co-ordination of care; availability of services. Four specific settings were identified: aged care facilities, out-of-hours care and resource-constrained settings (rural, and low-income and middle-income countries). Most GPs provide EoLC to some extent, with greater professional experience leading to increased comfort in performing this form of care. The organisation of primary care at practice, local and national level impose numerous structural barriers that impede more significant involvement. There are potential gaps in service provision where GPNs may provide significant input, but there is a paucity of studies describing GPN routine involvement in EoLC.

CONCLUSIONS

While primary care practitioners have a natural role to play in EoLC, significant barriers exist to improved GP and GPN involvement in PC. More work is required on the role of GPNs.

Extrachromosomal DNA-relieving heredity constraints, accelerating tumour evolution

Oncogene amplification on extrachromosomal DNA (ecDNA) provides a mechanism by which cancer cells can rapidly adapt to changes in the tumour microenvironment. These circular structures contain oncogenes and their regulatory elements, and, lacking centromeres, they are subject to unequal segregation during mitosis. This non-Mendelian mechanism of inheritance results in increased tumour heterogeneity with daughter cells that can contain increasingly amplified oncogene copy number. These structures also contain favourable epigenetic modifications including transcriptionally active chromatin, further fuelling positive selection. ecDNA drives aggressive tumour behaviour, is related to poorer survival outcomes and provides mechanisms of drug resistance. Recent evidence suggests one in four solid tumours contain cells with ecDNA structures. The concept of tumour evolution is one in which cancer cells compete to survive in a diverse tumour microenvironment under the Darwinian principles of variation and fitness heritability. Unconstrained by conventional segregation constraints, ecDNA can accelerate intratumoral heterogeneity and cellular fitness. In this review, we highlight some of the recent discoveries underpinning this process.

Performance Testing of a Venturi-Based Backpack Spray Decontamination System

Introduction

The performance of 2 disinfectant chemicals, peracetic acid (PAA) and hypochlorous acid (HOCl), was evaluated using a Venturi-nozzle-based light decontamination system (LDS) for delivery. The atomization equipment combined low-pressure air and disinfectant via a handheld lance, producing a fine, dense aerosol. A range of microorganisms, including Bacillus cereus and Bacillus anthracis (Vollum) spores, were used as test challenges to evaluate chemicals and equipment.

Methods

The tests undertaken included assessments over fixed and variable exposure times, use of multiple surface materials, and a live agent challenge.

Results

Over a fixed-time exposure of 60 minutes, aerosolized PAA gave 7- to 8-log reductions of all test challenges, but HOCl was less effective. Material tests showed extensive kill on most surfaces using PAA (≥6-log kill), but HOCl showed more variation (4- to 6-log). Testing using B. anthracis showed measurable PAA induced spore kill inside 5 minutes and >6-log kill at 5 minutes or over. HOCl was less effective.

Discussion

The results demonstrate the importance of testing decontamination systems against a range of relevant microbiological challenges. Disinfectant efficacy may vary depending on product choice, types of challenge microorganisms, and their position in a treated area. The most effective disinfectants demonstrate biocidal efficacy despite these factors.

Conclusion

The data confirmed PAA as an effective disinfectant capable of rapidly killing a range of microorganisms, including spores. HOCl was less effective. The LDS system successfully delivered PAA and HOCl over a wide area and could be suitable for a range of frontline biosecurity applications.

B-48 Effects of Anxiety on Response to a Subsymptom Threshold Exercise Program for Treatment of Persistent Post-Concussive Symptoms: A Pilot Randomized Clinical Trial

Objective

There is a growing literature to support the use of subsymptom threshold exercise for treatment of both acute and chronic post-concussion symptoms. The present study aimed to explore the influence of anxiety on response to exercise intervention for patients with persistent post-concussive symptoms.

Methods

Sixteen adolescents (ages 14-18) with persistent (>1 month) concussion symptoms were randomized into a light, home exercise group and a subsymptom threshold exercise group performed by PT’s (modeled after Leddy et al.,2019). Participants underwent intervention for 6 weeks and completed evaluations at Baseline, Mid-Point, and Follow-up after treatment; evaluations included State-Trait Anxiety Inventory (STAI), the Post-Concussive Scale-Revised (PCS-R), as well as additional measures of emotional functioning, balance disturbance, and neuropsychological functioning.

Results

Average PCS-R endorsement improved by 21 points from Baseline to Follow-up across treatment groups (PCS-R Total Change M = -21.29,SD = 13.54). There were meaningful Baseline differences between intervention groups in STAI state anxiety (p < .05) and STAI trait anxiety (p = 0.51); STAI variables were used as covariates in an ANOVA comparing mean PCS-R Percent Change between treatment and control groups. After removing the influence of anxiety, the intervention groups significantly differed and showed large effect (F(3,13) = 6.94,p < .05,partial eta2 = .41), with the intervention group improving (PCS-R Percent Change M = -63.3,SD = 17.4) more than the control group (PCS-R Percent Change M = -56.8,SD = 27.8).

Conclusion

Exercise intervention appears to be more effective than standard-of-care light activity in the treatment of persistent symptoms in adolescents; however, anxiety may alter response to intervention. Complimentary mental health treatment may augment response to exercise intervention and optimize concussion recovery trajectory in patients with persisting symptoms.

Effectiveness of Multimodal imaging for the Evaluation of Retinal oedema And new vesseLs in Diabetic retinopathy (EMERALD)

INTRODUCTION

Diabetic macular oedema (DMO) and proliferative diabetic retinopathy (PDR) are the major causes of sight loss in people with diabetes. Due to the increased prevalence of diabetes, the workload related to these complications is increasing making it difficult for Hospital Eye Services (HSE) to meet demands.

METHODS AND ANALYSIS

Effectiveness of Multimodal imaging for the Evaluation of Retinal oedema And new vesseLs in Diabetic retinopathy (EMERALD) is a prospective, case-referent, cross-sectional diagnostic study. It aims at determining the diagnostic performance, cost-effectiveness and acceptability of a new form of surveillance for people with stable DMO and/or PDR, which entails multimodal imaging and image review by an ophthalmic grader, using the current standard of care (evaluation of patients in clinic by an ophthalmologist) as the reference standard. If safe, cost-effective and acceptable, this pathway could help HES by freeing ophthalmologist time. The primary outcome of EMERALD is sensitivity of the new surveillance pathway in detecting active DMO/PDR. Secondary outcomes include specificity, agreement between new and the standard care pathway, positive and negative likelihood ratios, cost-effectiveness, acceptability, proportion of patients requiring subsequent full clinical assessment, unable to undergo imaging, with inadequate quality images or indeterminate findings.

ETHICS AND DISSEMINATION

Ethical approval was obtained for this study from the Office for Research Ethics Committees Northern Ireland (reference 17/NI/0124). Study results will be published as a Health Technology Assessment monograph, in peer-reviewed national and international journals and presented at national/international conferences and to patient groups.

TRIAL REGISTRATION NUMBER

NCT03490318 and ISRCTN:10856638.