Late-Onset Findings During Extended EEG Monitoring Are Rare in Critically Ill Children

PURPOSE

Electrographic seizures (ES) are common in critically ill children undergoing continuous EEG (CEEG) monitoring, and previous studies have aimed to target limited CEEG resources to children at highest risk of ES. However, previous studies have relied on observational data in which the duration of CEEG was clinically determined. Thus, the incidence of late occurring ES is unknown. The authors aimed to assess the incidence of ES for 24 hours after discontinuation of clinically indicated CEEG.

METHODS

This was a single-center prospective study of nonconsecutive children with acute encephalopathy in the pediatric intensive care unit who underwent 24 hours of extended research EEG after the end of clinical CEEG. The authors assessed whether there were new findings that affected clinical management during the extended research EEG, including new-onset ES.

RESULTS

Sixty-three subjects underwent extended research EEG. The median duration of the extended research EEG was 24.3 hours (interquartile range 24.0-25.3). Three subjects (5%) had an EEG change during the extended research EEG that resulted in a change in clinical management, including an increase in ES frequency, differential diagnosis of an event, and new interictal epileptiform discharges. No subjects had new-onset ES during the extended research EEG.

CONCLUSIONS

No subjects experienced new-onset ES during the 24-hour extended research EEG period. This finding supports observational data that patients with late-onset ES are rare and suggests that ES prediction models derived from observational data are likely not substantially underrepresenting the incidence of late-onset ES after discontinuation of clinically indicated CEEG.

Starting out rural: a qualitative study of the experiences of family physician graduates transitioning to practice in rural Ontario

BACKGROUND

New family medicine graduates are a promising group to recruit to underserved rural areas. This study aimed to understand the experiences of this group as they transitioned to practice in rural Ontario.

METHODS

We used a hermeneutic phenomenology approach. Purposive sampling was used to recruit participants who graduated from a Canadian family medicine residency program and worked in a rural community in Ontario (Rurality Index for Ontario score ≥ 40) for at least 1 year within the past 5 years. Participants completed an online demographic survey followed by a virtual semistructured interview (May-August 2022). Interviews were video recorded and transcribed. Two researchers reviewed transcripts for codes, and then codes were reviewed in an iterative process to create themes. Transcripts, codes and themes were reviewed by an independent researcher, and final themes were shared with participants to ensure reliability.

RESULTS

We included 18 family physicians in the study. We identified 8 themes and 18 subthemes. The themes identified as important to the experience of new graduates were as follows: choosing rural practice, preparedness for practice, navigating work-life balance, navigating transition to practice, challenges during transition to practice, successes during transition to practice, locuming and emergency medicine as part of rural generalist practice.

INTERPRETATION

Most physicians interviewed felt prepared for rural practice and enjoyed their work; however, they faced unique challenges associated with being an early-career physician in rural practice. This study identifies opportunities for improvements, which can guide medical educators, rural communities and their recruiters, new graduates and policy-makers.

Family role in paediatric safety incidents: a retrospective study protocol

INTRODUCTION

Healthcare-associated harm is an international public health issue. Children are particularly vulnerable to this with 15%-35% of hospitalised children experiencing harm during medical care. While many factors increase the risk of adverse events, such as children's dependency on others to recognise illness, children have a unique protective factor in the form of their family, who are often well placed to detect and prevent unsafe care. However, families can also play a key role in the aetiology of unsafe care.We aim to explore the role of families, guardians and parents in paediatric safety incidents, and how this may have changed during the pandemic, to learn how to deliver safer care and codevelop harm prevention strategies across healthcare settings.

METHODS AND ANALYSIS

This will be a retrospective study inclusive of an exploratory data analysis and thematic analysis of incident report data from the Learning from Patient Safety Events service (formerly National Reporting and Learning System), using the established PatIent SAfety classification system. Reports will be identified by using specific search terms, such as *parent* and *mother*, to capture narratives with explicit mention of parental involvement, inclusive of family members with parental and informal caregiver responsibilities.Paediatricians and general practitioners will characterise the reports and inter-rater reliability will be assessed. Exploratory descriptive analysis will allow the identification of types of incidents involving parents, contributing factors, harm outcomes and the specific role of the parents including inadvertent contribution to or mitigation of harm.

ETHICS AND DISSEMINATION

This study was approved by Cardiff University Research Ethics Committee (SMREC 22/32). Findings will be submitted to a peer-reviewed journal, presented at international conferences and presented at stakeholder workshops.

Uncertainty in low back pain care - insights from an ethnographic study

PURPOSE

To explore how uncertainty plays out in low back pain (LBP) care and investigate how clinicians manage accompanying emotions/tensions.

MATERIALS AND METHODS

We conducted ethnographic observations of clinical encounters in a private physiotherapy practice and a public multidisciplinary pain clinic. Our qualitative reflexive thematic analysis involved abductive thematic principles informed by Fox and Katz (medical uncertainty) and Ahmed (emotions).

RESULTS

We identified three themes. (1) Sources of uncertainty: both patients and clinicians expressed uncertainty during clinical encounters (e.g., causes of LBP, mismatch between imaging findings and presentation). Such uncertainty was often accompanied by emotions - anger, tiredness, frustration. (2) Neglecting complexity: clinicians often attempted to decrease uncertainty and associated emotions by providing narrow answers to questions about LBP. At times, clinicians' denial of uncertainty also appeared to deny patients the right to make informed decisions about treatments. (3) Attending to uncertainty?: clinicians attended to uncertainty through logical reasoning, reassurance, acknowledgement, personalising care, shifting power, adjusting language and disclosing risks.

CONCLUSIONS

Uncertainty pervades LBP care and is often accompanied by emotions, emphasising the need for a healthcare culture that recognises the emotional dimensions of patient-clinician interactions and prepares clinicians and patients to be more accepting of, and clearly communicate about, uncertainty.IMPLICATIONS FOR REHABILITATIONUncertainty pervades LBP care and is often accompanied by emotions.Neglecting complexity in LBP care may compromise person-centred care.Acknowledging uncertainty can enhance communication, balance patient-clinician relationships and address human aspects of care.

Widespread clinical implementation of the teen online problem-solving program: Progress, barriers, and lessons learned

Objective

We describe the clinical implementation in North America of Teen Online Problem Solving (TOPS), a 10+ session, evidence-based telehealth intervention providing training in problem-solving, emotion regulation, and communication skills.

Methods

Twelve children's hospitals and three rehabilitation hospitals participated, agreeing to train a minimum of five therapists to deliver the program and to enroll two patients with traumatic brain injuries (TBI) per month. Barriers to reach and adoption were addressed during monthly calls, resulting in expansion of the program to other neurological conditions and extending training to speech therapists.

Results

Over 26 months, 381 patients were enrolled (199 TBI, 182 other brain conditions), and 101 completed the program. A total of 307 therapists were trained, and 58 went on to deliver the program. Institutional, provider, and patient barriers and strategies to address them are discussed.

Conclusions

The TOPS implementation process highlights the challenges of implementing complex pediatric neurorehabilitation programs while underscoring potential avenues for improving reach and adoption.

294 INTEGRATION OF MUSIC THERAPY WITHIN A MULTIDISCIPLINARY TEAM FOR OLDER ADULTS IN AN ACUTE HOSPITAL

Background

Music Therapy (MT) is an evidence-based intervention in which a music therapist uses music within a therapeutic relationship to achieve targeted goals. Studies show that MT may improve patient communication, cognition and mood, and facilitate rehabilitation by improving motor skills, particularly in those with stroke and Parkinson’s disease. We aimed to integrate MT within our geriatric multidisciplinary team (MDT) by: (1) promoting knowledge of MT among MDT staff; and (2) developing and implementing a MT referral pathway for patients. Furthermore, we aimed to assess its overall impact.

Methods

Music therapists delivered oral presentations and experiential learning through creative workshops, collaboration and feedback to allied health therapists in our geriatric MDT. Criteria for referrals for MT and a referral pathway were developed. Data on patients who received MT was collated.

Results

There were 70 referrals for MT from our MDT. 61% were female, mean age 77 years. Referral sources were occupational therapists (45%), speech therapists (34%), medical social workers (13%), physiotherapists (8%). Patients included those with stroke (41%), general medical conditions (23%), dementia (16%), Parkinson's (11%) and mental health concerns (9%). There were 16 joint MDT sessions and a mean of 5 MT sessions per patient (about 40 minutes in duration). Interventions included: Melodic Intonation Therapy (MIT), singing and vocal exercises, Rhythmic Auditory Stimulation (RAS), Musical Neglect Training (MNT), Therapeutic Instrumental Musical Performance (TIMP), reminiscence and song-writing. Overall, we identified better engagement with rehabilitation and improvements in mood, speech (voice strength and verbal fluency) and upper and lower limb co-ordination.

Conclusion

MT was successfully integrated into a geriatric MDT and had beneficial effects on patient mood, speech, communication and motor function. Education of MDT members was crucial in achieving appropriate MT referrals. Joint MDT’s also facilitated individualised MT interventions. Findings strongly support our model that incorporates MT within an MDT.

301 BENEFITS OF ENVIRONMENTAL MUSIC THERAPY IN AN ACUTE HOSPITAL

Background

Environmental Music Therapy (EMT) uses live music played by a music therapist to enhance the surrounding environment and is increasingly used in clinical settings. Studies show that EMT may reduce anxiety, enhance wellbeing, promote better communication between patients and staff, and reduce patient perception of waiting times in hospital. We aimed to explore the benefit of EMT for older adults in a geriatric outpatient setting and on rehabilitation wards.

Methods

Harp music was played by a music therapist in the vicinity of ambulatory clinics and on rehabilitation wards for 4 hours per week (over a 2-day period) for 20 weeks. Music exposure on any given day was to an estimated 50 outpatients, as well as 50 people passing the vicinity or to about 30 patients on the rehabilitation ward. Music was selected and played in a dynamic process, responding to verbal and non-verbal reactions of patients, family, and staff. Voluntary responses were recorded and collated.

Results

There were 36 recorded responses and all reflected positively on EMT. Patients cited that the music created a welcoming space and stimulated interaction and conversation. Several patients waiting for their clinic appointment noted that it distracted from fearful expectation and was a source of comfort. Some commented that they felt more relaxed and that it reduced stress. On rehabilitation wards, patients found familiar music to be calming with nurses citing that it stimulated social interaction between patients, family and staff. Responses to EMT gave insights that resulted in patient referrals for music therapy.

Conclusion

Environmental music played by a music therapist was found to modify patient hospital experiences. In particular, it appeared to reduce self-perceived stress and stimulate positive social interaction and conversation. This supports the use of EMT to advance the integration of the arts for wellbeing in an acute hospital.

130 Surgical Repair of Cleft Lip: Comparison of Neonatal and Standard Time Repair

Aim

Cleft lip and palate (CLP) abnormalities are the most common congenital orofacial anomalies, affecting 1 in 700 live births per year in the United Kingdom. Cleft lip is present in approximately 55% of all CLP deformities. The aim of this study is to compare standard and neonatal cleft lip repair.

Method

Advanced literature searches were carried out using Medline ALL (1946 to date) and Embase (1974 to date), 11 articles were deemed relevant and included in this study.

Results

Aesthetic results showed excellent outcomes with neonatal repair with regards to the appearance of the scar, facial (lip and nasal) symmetry but those aesthetic results are no better than those achieved at standard time.

Conclusions

Early intervention can be beneficial as early repair takes place when the cleft is less severe and when the tissues are more malleable, making the surgery less challenging and when some aspects of foetal scar healing remain. Early repair has a positive impact on the development of the alveolar projections and can assist in reducing an alveolar cleft if present, improving the aesthetic outcome. Neonatal surgery carries with it no greater risk than surgery carried out at 6 months and will allow feeding to begin at an early stage promoting recovery. Early repair also brings with it a positive psychosocial impact where infants and mothers can build a normal relationship from an early stage. Later in life, children and adults will be less self-conscious following good aesthetic repair. In conclusion, neonatal repair may be recommended over standard time repair.

257 POSITIVE HEALTH AND AGING FOR OLDER IRISH TRAVELLERS AND OLDER PEOPLE WHO HAVE EXPERIENCED HOMELESSNESS: LIFE-COURSE MEANINGS AND DETERMINANTS

Background

The position of marginalized groups of older people remains neglected in positive health and aging (PHA) agendas, whether they concern healthy, active or positive aging. Questions exist around the meaning of such constructs, and the factors that enable disadvantaged populations to achieve equitable later-life experiences. In focusing on two such groups, this study investigates the constituent dimensions of PHA for older Irish Travellers and older people who have experienced homelessness, and the role of life-course and structural determinants in constructing PHA trajectories for these groups.

Methods

The study involves a multi-method qualitative, participatory voice-led methodology, but the analysis draws primarily on 49 in-depth life-course interviews with the populations.

Results

In addition to five interconnected dimensions of PHA, four determinants related to life-course experiences and structural factors are identified: social relations; material and accommodation circumstances; formal supports and systems; and critical transitions and resilience.

Conclusion

While illustrating the validity of PHA agendas for these groups when understood through their lived experiences, the findings highlight the significant deprivations and risks to rights that must be accounted for to secure meaningful gains in PHA for the groups.

187 A QUALITATIVE EXPLORATION OF PLACE AND PERSONHOOD IN DEMENTIA

Background

In dementia research, supporting personhood is seen as a corner stone of person-centred care. However, little is understood about how personhood is conceptualised in the context of the home and communities that people living with dementia reside within, and how place may constitute a key dimension of, or a determining factor of someone’s sense of self. This study seeks to explore these relationships by examining the intersection between place and personhood through the lens of Rowles (1983) work on place and personal identity in old age.

Methods

Qualitative secondary analysis of datasets from two separate studies was conducted. The first study examined the perspectives of people living with dementia on place across the life course, while the second study examined the perspectives of people living with dementia on personhood in formal care. In total, 15 interviews with people with dementia were analysed using theoretical framework analysis.

Results

Participants reflected on the meaning of place, and its iterative relationship with personhood across the life course. They used the residential life course, to convey and narrate their life story, locating themselves and major events in time and place. Participants also spoke about the impact of the physical environment on their sense of personhood, conceptualising personhood in relation to attachment to the physical landscape, location and their own homes. Finally, participants referred to the close link between place, relationships, and community. In particular, how important feelings of community and belonging to place are to their sense of personhood.

Conclusion

This research shows the role of place in interpreting understandings of personhood from the perspectives of people living with dementia. This is critical for understanding the nature and orientation of community-based interventions, and designing supports and services which appropriately harness place-based relationships of people living with dementia.

Executive Functioning and External Symbols: The Role of Symbolic Understanding and Psychological Distancing

Preschool children can use external symbols to aid their executive functioning (EF). The purpose of the current study was to investigate how symbols boost EF, specifically investigating the role of psychological distancing and symbolic understanding. Preschoolers were assessed on their level of symbolic understanding and completed two EF tasks. Half the children completed the first EF task using symbols, and all children completed the second EF task without the aid of symbols. Results indicated that children in the symbol group at first did significantly worse while they were using the symbols compared to the control group, though their performance improved over time. Control group performance was significantly worse in the second EF task. Symbolic understanding was sometimes related to EF performance for children in the symbol group but not the control group. The current research highlights the complexity of symbol use to influence cognitive functioning.

Medication Errors in Adolescents Using Asthma Controller Medications

The purpose of this study was to describe the number and types of errors that adolescents and caregivers report making when using asthma controller medications. A total of 319 adolescents ages 11 to 17 with persistent asthma and their caregivers participated in this cross-sectional study. Adolescent and caregiver reports of asthma medication use were compared to the prescribed directions in the medical record. An error was defined as discrepancies between reported use and the prescribed directions. About 38% of adolescents reported 1 error in using asthma controller medications, 16% reported 2 errors, and 5% reported 3 or more errors. About 42% of caregivers reported 1 error in adolescents using asthma controller medications, 14% reported 2 errors, while 6% reported 3 or more errors. The type of error most frequently reported by both was not taking the medication at all. Providers should ask open-ended questions of adolescents with asthma during visits so they can detect and educate families on how to overcome errors in taking controller medication use.

The role of clonal haematopoiesis in cardiovascular diseases: epidemiology and experimental studies

Clonal haematopoiesis results from acquired mutations in haematopoietic stem and progenitor cells (HSPCs). These mutations can confer the HSPC with a competitive advantage, leading to their clonal expansion within the limiting bone marrow niche. This process is often insufficient to produce a haematologic malignancy; however, the expanding HSPC clones increasingly give rise to progeny leucocytes whose phenotypes can be altered by the somatic mutations that they harbour. Key findings from multiple human studies have shown that clonal haematopoiesis in the absence of overt haematologic alterations is common amongst the ageing population and associated with mortality and cardiovascular disease. Key findings from experimental studies have provided evidence for a causative role for clonal haematopoiesis in cardiovascular diseases, and aspects of these mechanisms have been elucidated. Whilst our understanding of the impact and biology of clonal haematopoiesis is in its infancy, analyses of some of the most commonly mutated driver genes suggest promising clinical scenarios involving the development of personalized therapies with immunomodulatory drugs that exploit the perturbation caused by the particular mutation. Herein, we review the accumulating epidemiological and experimental evidence, and summarize our current understanding of the importance of clonal haematopoiesis as a new causal risk factor for atherosclerotic cardiovascular disease and heart failure.

Concentration and composition of bioaerosol emissions from intensive farms: Pig and poultry livestock

Intensive farming is widespread throughout the UK and yet the health effects of bioaerosols which may be generated by these sites are currently not well researched. A scoping study was established to measure bioaerosols emitted from intensive pig (n = 3) and poultry farms (n = 3) during the period 2014-2015. The concentration of culturable mesophilic bacteria, Gram-negative bacteria, Staphylococcus spp., and fungi selecting for presumptive Aspergillus fumigatus were measured using single-stage impaction Andersen samplers, whilst endotoxin and (1 → 3)-β-D-glucan was undertaken using inhalable personal samplers. Particulate matter concentration was determined using an optical particulate monitor. Results showed that culturable bacteria, fungi, presumptive Staphylococcus aureus (confirmed only as Staphylococcus spp.) and endotoxin concentrations were elevated above background concentrations for distances of up to 250 m downwind of the source. Of all the culturable bioaerosols measured, bacteria and Staphylococcus spp. were identified as the most significant, exceeding published or proposed bioaerosol guidelines in the UK. In particular, culturable Staphylococcus spp. downwind was at least 61 times higher than background at the boundary and at least 8 times higher 70m downwind on the four farms tested. This research represents a novel dataset of intensive farm emissions within the UK. Future research should exploit the use of innovative culture-independent methods such as next generation sequencing to develop deeper insights into the make-up of microbial communities emitted from intensive farming facilities and which would better inform species of interest from a public health perspective.

P333Left atrial function by echocardiography is independent of degree of left atrial electrical scar

Introduction

Assessment of left atrial function via transthoracic echocardiography (TTE) is performed most commonly by measuring the transmitral A wave in sinus rhythm. Left atrial (LA) fibrosis plays an important role in the pathogenesis and perpetuation of Atrial Fibrillation (AF). It may be identified by bipolar voltage (BiV) mapping, which can easily be performed at the beginning of a Pulmonary Vein Isolation (PVI) procedure. The relationship between the degree of LA fibrosis, characterised with mapping, and LA function, determined by echocardiography, has not previously been elucidated.

Methods

Patients were enrolled in a project to evaluate the degree of fibrosis during PVI procedures. Pre-procedure TTEs of those presenting in sinus rhythm were assessed and the transmitral A wave was measured and compared to the degree of scarring seen. The high density electroanatomic maps (HD-EAMs) created during the PVIs were analysed using a novel VHA algorithm after the procedure. All points with voltages < 0.5mV were defined to have electrical scar. Patients were classified into 4 quartiles based on the levels of scar seen (Figure 1).

Results

39 patients were included in the evaluation. Average age was 60.6 +/- 13.2 years. 32 (82.0%) of the patients were male. Mean CHADS2VASc score was 1.5. The mean percentage of scar was calculated as 19.6 +/- 15.9%. The average A wave was 0.62 +/- 0.18 ms-1. Pearson’s correlation coefficient showed no relationship between LA scar and either A wave velocities (r = 0.26, p = 0.11) or E:A ratio (r=-0.02, p = 0.91). A significant correlation between A wave velocity and CHADS2VASc was observed (r = 0.49, p = 0.001).

Conclusion

Our study demonstrates no relationship between degree of LA scarring and reduced LA function on TTE as assessed by the A wave. It has been established that structural remodelling in AF (such as atrial dilatation) may occur independently of the electrical remodelling. A potential explanation for our findings is that the electrical scarring in AF, which results in alterations in refractory periods, precedes the negative remodelling which ultimately results in reduced atrial function. This hypothesis would need to be further evaluated in larger studies.

Abstract Figure 1

0967 Clinical Characteristics of Children With Sleep Problems and Comorbid Psychiatric Disorders

Introduction

Anxiety and Attention Deficit Hyperactive Disorder (ADHD) are common psychiatric comorbidities in children with sleep disorders. It is known that comorbid psychiatric disorders increase the risk of sleep problems. However, no study has compared the clinical characteristics of children presenting with sleep problems and various common psychiatric disorders.

Methods

Retrospective chart review of all children presenting to the sleep clinic for sleep problems between March 2016 to June 2017 was performed. Demographics, sleep intake patient questionnaires, polysomnograms and ICD-9/10 codes for comorbidities and sleep diagnoses were collected. In children with diagnoses of anxiety (ICD-9 300/ICD-10 F41) and ADHD (ICD-9 314/ICD-10 F90), demographics, presenting symptoms, Epworth sleepiness scores and prevalence of sleep comorbidities were compared. T-test (continuous) and Chi Square (categorical) were used. Unadjusted odds ratio was calculated for presenting symptoms and sleep comorbidities. P value of <0.05 was considered significant.

Results

250 (F=145, 58%) children were evaluated. 71.2% children were diagnosed with anxiety and 28.8% diagnosed with ADHD. Mean age at presentation was 8.53 ± 4.2 years. Age, gender and race of children presenting with sleep problems and comorbid anxiety/ADHD were statistically similar. Children with anxiety spent less time in stage N3 sleep (25.2% ± 9.1 versus 28.6% ± 9.2) and had lower arousal indices (7.19 ± 3.8 versus 8.86 ± 5.5) compared to children with ADHD. Children with anxiety were more likely to present with chief complaint of “feeling tired or sleepy during the day” (OR:2.38, 1.32-4.37) and were more likely to have a diagnosis of hypersomnia (OR: 11.67, 3.19-42.75) versus children with ADHD.

Conclusion

Children with psychiatric comorbidities have distinct polysomnographic characteristics. Children with anxiety are more likely to present with daytime sleepiness and have a significantly higher prevalence of hypersomnia compared to children with ADHD.

Support

None

High Burden of Non-communicable Diseases among a Young Slum Population in Haiti

The objective of this study was to characterize the demographics and population health of four slum communities in Port-au-Prince, Haiti, including population density and the burden of communicable and non-communicable diseases. Four urban slums were surveyed using a population-representative design between July and October 2016. A multistage cluster area random sampling process was used to identify households and individuals for the survey. Household surveys included rosters of residents, household characteristics, adult and child deaths in the past year, child health, and healthcare access and utilization. Individual surveys of two randomly sampled adults from each household included sociodemographic data, maternal health, and adult health. Additionally, blood pressure, height, weight, and psychological distress were measured by study staff. Data were weighted for complex survey design and non-response. A total of 525 households and 894 individuals completed the survey (96% household and 90% individual response rate, respectively). The estimated population density was 58,000 persons/km². Across slums, 55% of all residents were female, and 38% were adolescents and youth 10-24 years. Among adults, 58% were female with median age 29 years (22-38). The most common adult illnesses were severe psychological distress (24%), hypertension (20%), history of physical injury/trauma (10%), asthma (7%), history of cholera (4%), and history of tuberculosis (3%). Ten percent of adults had obesity (BMI > 30 kg/m²), and 7% currently smoked. The most common under-5 diseases during the last 3 months were respiratory and gastrointestinal illnesses (50% and 28%, respectively). One-third of households reported needing medical care for a child in the past year but not being able to access it, largely due to financial constraints. Unique features of these slums are a population structure dominated by adolescents and youth, a high proportion of females, and a high burden of non-communicable diseases including hypertension and psychological distress. Screening, diagnostic, and disease management interventions are urgently needed to protect and promote improved population health outcomes in these slum communities.

A prospective multi-center quality improvement initiative (NINJA) indicates a reduction in nephrotoxic acute kidney injury in hospitalized children

Nephrotoxic medication (NTMx) exposure is a common cause of acute kidney injury (AKI) in hospitalized children. The Nephrotoxic Injury Negated by Just-in time Action (NINJA) program decreased NTMx associated AKI (NTMx-AKI) by 62% at one center. To further test the program, we incorporated NINJA across nine centers with the goal of reducing NTMx exposure and, consequently, AKI rates across these centers. NINJA screens all non-critically ill hospitalized patients for high NTMx exposure (over three medications on the same day or an intravenous aminoglycoside over three consecutive days), and then recommends obtaining a daily serum creatinine level in exposed patients for the duration of, and two days after, exposure ending. Additionally, substitution of equally efficacious but less nephrotoxic medications for exposed patients starting the day of exposure was recommended when possible. The main outcome was AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) serum creatinine criteria (increase of 50% or 0.3 mg/dl over baseline). The primary outcome measure was AKI episodes per 1000 patient-days. Improvement was defined by statistical process control methodology and confirmed by Autoregressive Integrated Moving Average (ARIMA) modeling. Eight consecutive bi-weekly measure rates in the same direction from the established baseline qualified as special cause change for special process control. We observed a significant and sustained 23.8% decrease in NTMx-AKI rates by statistical process control analysis and by ARIMA modeling; similar to those of the pilot single center. Thus, we have successfully applied the NINJA program to multiple pediatric institutions yielding decreased AKI rates.

New insights on lake sediment DNA from the catchment: importance of taphonomic and analytical issues on the record quality

Over the last decade, an increasing number of studies have used lake sediment DNA to trace past landscape changes, agricultural activities or human presence. However, the processes responsible for lake sediment formation and sediment properties might affect DNA records via taphonomic and analytical processes. It is crucial to understand these processes to ensure reliable interpretations for “palaeo” studies. Here, we combined plant and mammal DNA metabarcoding analyses with sedimentological and geochemical analyses from three lake-catchment systems that are characterised by different erosion dynamics. The new insights derived from this approach elucidate and assess issues relating to DNA sources and transfer processes. The sources of eroded materials strongly affect the “catchment-DNA” concentration in the sediments. For instance, erosion of upper organic and organo-mineral soil horizons provides a higher amount of plant DNA in lake sediments than deep horizons, bare soils or glacial flours. Moreover, high erosion rates, along with a well-developed hydrographic network, are proposed as factors positively affecting the representation of the catchment flora. The development of open and agricultural landscapes, which favour the erosion, could thus bias the reconstructed landscape trajectory but help the record of these human activities. Regarding domestic animals, pastoral practices and animal behaviour might affect their DNA record because they control the type of source of DNA (“point” vs. “diffuse”).

P1613Brown adipose tissue dysfunction has a critical role for the development of heart failure in murine pressure overload model

Prognosis of severe heart failure is unacceptably high, and it is our urgent task to find therapies for this critical condition. It has been reported that low body temperature predicts poor clinical outcomes in patients with heart failure, however, underlying mechanisms and pathological implications are largely unknown. Brown adipose tissue (BAT) was initially characterized as a heat generating organ, and studies suggest that BAT has crucial roles for the maintenance of systemic metabolic health. Here we show that BAT dysfunction develops in a murine thoracic aortic constriction (TAC) model, and has a causal role for promoting pathologies in failing heart. TAC operation led to a significant reduction both in intraperitoneal and subcutaneous temperature. TUNEL-positive cells significantly increased in BAT during left ventricular (LV)-pressure overload, and in-vitro studies with differentiated brown adipocytes suggested that the chronic activation of adrenergic signaling promotes apoptosis in these cells. Gain of BAT function model, generated with BAT implantation into peritoneal cavity, improved thermogenesis and ameliorated cardiac dysfunction in TAC. In contrast, genetic model of BAT dysfunction promoted cardiac dysfunction. Metabolomic analyses showed that BAT dysfunction led to an increase of oxidized choline that promoted metabolic dysfunction in the failing heart. Electron microscope study showed that oxidized choline induced mitochondrial dysfunction in vitro as well as in vivo settings. Extracellular flux analyzerindicated that oxidized choline suppresses oxidative phosphorylation in mitochondria. We found that dilated cardiomyopathy patients have lower body temperature, and confirmed by metabolomic study that both choline and oxidized choline are increased in circulation. Maintenance of BAT homeostasis and suppression of oxidized choline would become a novel therapeutic target for heart failure.

Commotio Cordis Caused During Hurling Game

A teenage boy had a cardiac arrest following a blow to the chest from a hurling ball (sliotar). Prompt resuscitation and automated external defibrillation enabled a full recovery. This is the first reported case of commotio cordis caused by a sliotar although it is described in other sports. Primary prevention of commotio cordis (CC) and secondary prevention of cardiac death are discussed.

AMEE Guide No. 123 - How to read studies of educational costs

Healthcare and health professions education share many of the same problems in decision making. In both cases, there is a finite amount of resources, and so choices need to be made between alternatives. To navigate the options available requires effective decision making. Choosing one option requires consideration of its opportunity cost - the benefit forgone of the other competing options. The purpose of this abridged AMEE guide is to introduce educational decision-makers to the economic concept of cost, and how to read studies about educational costs to inform effective cost-conscious decision-making. This guide leads with a brief review of study designs commonly utilized in this field of research, followed by an overview of how study findings are commonly presented. The tutorial will then offer a four-step model for appraising and considering the results of an economic evaluation. It asks the questions: (1) Can I trust the results? (2) What are the results telling me? (3) Could the results be transferred to my context? (4) Should I change my practice?

Polypharmacy Rates among Patients over 45 years

Polypharmacy, defined as receipt of ≥5 medications in any one month, is often associated with potentially inappropriate prescribing and adverse drug interactions. High levels of polypharmacy have been observed internationally and in Ireland. The Health Service Executive Primary Care Reimbursement Services (HSE-PCRS) pharmacy claims database for the GMS eligible population was used. We conducted Chi-square tests to determine the statistical significance of perceived differences in medication use among patients aged ³ 45 years. Our results establish a national benchmark for polypharmacy in gender and various age categories in the HSE-PCRS. Of the 794,628 individuals aged ≥45 years with at least one claim in 2013, 64.3% (510,946) had polypharmacy, with higher rates among women (67.0% - 293,886 - compared to 60.8% of men - 216,444). Patients aged 45-54 years were less likely to have polypharmacy (38.6% - 69,934) compared to those aged 75 years old (82.6% - 197,565). The high levels of polypharmacy are of interest, and suggest that monitoring and evaluation of patients’ medication regimes may be required to ensure appropriateness.

Autonomic dysfunction: Diagnosis and management

The autonomic nervous system is designed to maintain physiologic homeostasis. Its widespread connections make it vulnerable to disruption by many disease processes including primary etiologies such as Parkinson's disease, multiple system atrophy, dementia with Lewy bodies, and pure autonomic failure and secondary etiologies such as diabetes mellitus, amyloidosis, and immune-mediated illnesses. The result is numerous symptoms involving the cardiovascular, gastrointestinal, and urogenital systems. Patients with autonomic dysfunction (AUD) often have peripheral and/or cardiac denervation leading to impairment of the baroreflex, which is known to play a major role in determining hemodynamic outcome during orthostatic stress and low cardiac output states. Heart rate and plasma norepinephrine responses to orthostatic stress are helpful in diagnosing impairment of the baroreflex in patients with orthostatic hypotension (OH) and suspected AUD. Similarly, cardiac sympathetic denervation diagnosed with MIBG scintigraphy or ¹⁸F-DA PET scanning has also been shown to be helpful in distinguishing preganglionic from postganglionic involvement and in diagnosing early stages of neurodegenerative diseases. In this chapter, we review the causes of AUD, the pathophysiology and resulting cardiovascular manifestations with emphasis on the diagnosis and treatment of OH.

Practice of therapy acquired regulatory skills and depressive relapse/recurrence prophylaxis following cognitive therapy or mindfulness based cognitive therapy

BACKGROUND

To investigate whether usage of treatment-acquired regulatory skills is associated with prevention of depressive relapse/recurrence.

METHOD

Remitted depressed outpatients entered a 24-month clinical follow up after either 8 weekly group sessions of cognitive therapy (CT; N = 84) or mindfulness-based cognitive therapy (MBCT; N = 82). The primary outcome was symptom return meeting the criteria for major depression on Module A of the SCID.

RESULTS

Factor analysis identified three latent factors (53% of the variance): decentering (DC), distress tolerance (DT), and residual symptoms (RS), which were equivalent across CT and MBCT. Latent change score modeling of factor slopes over the follow up revealed positive slopes for DC (β = .177), and for DT (β = .259), but not for RS (β = -.017), indicating posttreatment growth in DC and DT, but no change in RS. Cox regression indicated that DC slope was a significant predictor of relapse/recurrence prophylaxis, Hazard Ratio (HR) = .232 90% Confidence Interval (CI) [.067, .806], controlling for past depressive episodes, treatment group, and medication. The practice of therapy-acquired regulatory skills had no direct effect on relapse/recurrence (β = .028) but predicted relapse/recurrence through an indirect path (β = -.125), such that greater practice of regulatory skills following treatment promoted increases in DC (β = .462), which, in turn, predicted a reduced risk of relapse/recurrence over 24 months (β = -.270).

CONCLUSIONS

Preventing major depressive disorder relapse/recurrence may depend upon developing DC in addition to managing residual symptoms. Following the acquisition of therapy skills during maintenance psychotherapies, DC is strengthened by continued skill utilization beyond treatment termination. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Outcomes across the tuberculosis care continuum among adolescents in Haiti

Setting: GHESKIO (Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes) clinic, Port-au-Prince, Haiti. Objective: To evaluate tuberculosis (TB) care continuum outcomes among adolescents. Design: Among a retrospective cohort of 10-24 year olds diagnosed with active TB, we report completion of the following steps of the TB care continuum stratified by human immunodeficiency virus (HIV) status: diagnosis of microbiologically confirmed TB, initiation of anti-tuberculosis treatment, retention in care at 2 months on anti-tuberculosis treatment, and TB treatment success. Factors associated with attrition at each step were identified using multivariable regression. Results: A total of 1005 adolescents were diagnosed with active TB; 74 (7%) were HIV-positive at the time of TB diagnosis. HIV-positive patients had poorer outcomes than non-HIV-infected patients: 73% vs. 85% initiated anti-tuberculosis treatment (P < 0.01), 46% vs. 74% were retained in care at 2 months (P < 0.01), and 41% vs. 68% achieved TB treatment success (P < 0.01). Among those who initiated treatment, same-day initiation resulted in less treatment failure. Attrition before treatment initiation was associated with female sex and HIV coinfection. Attrition after treatment initiation was associated with age ⩾16 years and HIV coinfection. Conclusion: Outcomes across the TB care continuum are suboptimal among adolescents, with only two thirds of patients achieving treatment success. Interventions tailored to adolescents are needed to improve retention in care, particularly for those who are co-infected with HIV.

Treatment correlates of successful outcomes in pulmonary multidrug-resistant tuberculosis: an individual patient data meta-analysis

BACKGROUND

Treatment outcomes for multidrug-resistant tuberculosis remain poor. We aimed to estimate the association of treatment success and death with the use of individual drugs, and the optimal number and duration of treatment with those drugs in patients with multidrug-resistant tuberculosis.

METHODS

In this individual patient data meta-analysis, we searched MEDLINE, Embase, and the Cochrane Library to identify potentially eligible observational and experimental studies published between Jan 1, 2009, and April 30, 2016. We also searched reference lists from all systematic reviews of treatment of multidrug-resistant tuberculosis published since 2009. To be eligible, studies had to report original results, with end of treatment outcomes (treatment completion [success], failure, or relapse) in cohorts of at least 25 adults (aged >18 years). We used anonymised individual patient data from eligible studies, provided by study investigators, regarding clinical characteristics, treatment, and outcomes. Using propensity score-matched generalised mixed effects logistic, or linear regression, we calculated adjusted odds ratios and adjusted risk differences for success or death during treatment, for specific drugs currently used to treat multidrug-resistant tuberculosis, as well as the number of drugs used and treatment duration.

FINDINGS

Of 12 030 patients from 25 countries in 50 studies, 7346 (61%) had treatment success, 1017 (8%) had failure or relapse, and 1729 (14%) died. Compared with failure or relapse, treatment success was positively associated with the use of linezolid (adjusted risk difference 0·15, 95% CI 0·11 to 0·18), levofloxacin (0·15, 0·13 to 0·18), carbapenems (0·14, 0·06 to 0·21), moxifloxacin (0·11, 0·08 to 0·14), bedaquiline (0·10, 0·05 to 0·14), and clofazimine (0·06, 0·01 to 0·10). There was a significant association between reduced mortality and use of linezolid (-0·20, -0·23 to -0·16), levofloxacin (-0·06, -0·09 to -0·04), moxifloxacin (-0·07, -0·10 to -0·04), or bedaquiline (-0·14, -0·19 to -0·10). Compared with regimens without any injectable drug, amikacin provided modest benefits, but kanamycin and capreomycin were associated with worse outcomes. The remaining drugs were associated with slight or no improvements in outcomes. Treatment outcomes were significantly worse for most drugs if they were used despite in-vitro resistance. The optimal number of effective drugs seemed to be five in the initial phase, and four in the continuation phase. In these adjusted analyses, heterogeneity, based on a simulated I² method, was high for approximately half the estimates for specific drugs, although relatively low for number of drugs and durations analyses.

INTERPRETATION

Although inferences are limited by the observational nature of these data, treatment outcomes were significantly better with use of linezolid, later generation fluoroquinolones, bedaquiline, clofazimine, and carbapenems for treatment of multidrug-resistant tuberculosis. These findings emphasise the need for trials to ascertain the optimal combination and duration of these drugs for treatment of this condition.

FUNDING

American Thoracic Society, Canadian Institutes of Health Research, US Centers for Disease Control and Prevention, European Respiratory Society, Infectious Diseases Society of America.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Nitrous oxide may interfere with the reconsolidation of drinking memories in hazardous drinkers in a prediction-error-dependent manner

Weakening drinking-related reward memories by blocking their reconsolidation is a potential novel strategy for treating alcohol use disorders. However, few viable pharmacological options exist for reconsolidation interference in humans. We therefore examined whether the NMDA receptor antagonising gas, Nitrous Oxide (N₂O) could reduce drinking by preventing the post-retrieval restabilisation of alcohol memories in a group of hazardous drinkers. Critically, we focussed on whether prediction error (PE; a key determinant of reconsolidation) was experienced at retrieval. Sixty hazardous drinkers were randomised to one of three groups that retrieved alcohol memories either with negative PE (Retrieval + PE), no PE (Retrieval no PE) or non-alcohol memory retrieval with PE (No-retrieval +PE). All participants then inhaled 50% N₂O for 30 min. The primary outcome was change in beer consumption and alcohol cue-driven urge to drink from the week preceding manipulation (baseline) to the week following manipulation (test). The manipulation did not affect drinking following the intended retrieval+/- PE conditions However, a manipulation check, using a measure of subjective surprise, revealed that the group-level manipulation did not achieve the intended differences in PE at retrieval. Assessment of outcomes according to whether alcohol-relevant PE was actually experienced at retrieval, showed N₂O produced reductions in drinking in a retrieval and PE-dependent fashion. These preliminary findings highlight the importance of directly testing assumptions about memory reactivation procedures in reconsolidation research and suggest that N₂O should be further investigated as a potential reconsolidation-blocking agent.

Dual endothelin-1 receptor antagonism attenuates platelet-mediated derangements of blood coagulation in Eisenmenger syndrome

Essentials Eisenmenger syndrome is characterised by thrombotic and hemorrhagic risks of unclear aetiology. Calibrated automated thrombography was used to assess these coagulation derangements. Platelet activity supported abnormalities in procoagulant and anticoagulant pathway function. Endothelin-1 antagonism appeared to ameliorate these derangements.

SUMMARY

Aims The mechanisms underlying the competing thrombotic and hemorrhagic risks in Eisenmenger syndrome are poorly understood. We aimed to characterize derangements of blood coagulation and to assess the effect of dual endothelin-1 receptor antagonism in modulating hemostasis in this rare disorder. Methods In a 10-month recruitment period at a tertiary cardiology referral center, during which time there were over 14 000 outpatient consultations, consecutive subjects with Eisenmenger syndrome being considered for macitentan therapy (n = 9) and healthy volunteers (n = 9) were recruited. Plasma thrombin generation in platelet-rich and platelet-poor plasma was assessed by calibrated automated thrombography prior to and following therapy. Results Median peak plasma thrombin generation was higher in platelet-rich plasma obtained from Eisenmenger syndrome subjects relative to controls (median peak thrombin [25th-75th percentile]: 228.3 [206.5-258.6] nm vs. 169.9 [164.3-215.8] nm), suggesting a critical mechanistic role for platelets in supporting abnormal hypercoagulability in Eisenmenger syndrome. Abnormal enhanced sensitivity to the anticoagulant activity of activated protein C was also observed in platelet-rich plasma in Eisenmenger syndrome, suggesting that derangements of platelet activity may influence the activity of anticoagulant pathways in a manner that might promote bleeding in this disease state. Following 6 months of macitentan therapy, attenuations in the derangements in both procoagulant and anticoagulant pathways were observed. Conclusions Abnormal platelet activity contributes to derangements in procoagulant and anticoagulant pathways in Eisenmenger syndrome. Therapies targeting the underlying vascular pathology appear to ameliorate these derangements and may represent a novel strategy for the management of the competing prothrombotic and hemorrhagic tendencies in this disorder.

Use of dispersion modelling for Environmental Impact Assessment of biological air pollution from composting: Progress, problems and prospects

With the increase in composting asa sustainable waste management option, biological air pollution (bioaerosols) from composting facilities have become a cause of increasing concern due to their potential health impacts. Estimating community exposure to bioaerosols is problematic due to limitations in current monitoring methods. Atmospheric dispersion modelling can be used to estimate exposure concentrations, however several issues arise from the lack of appropriate bioaerosol data to use as inputs into models, and the complexity of the emission sources at composting facilities. This paper analyses current progress in using dispersion models for bioaerosols, examines the remaining problems and provides recommendations for future prospects in this area. A key finding is the urgent need for guidance for model users to ensure consistent bioaerosol modelling practices.