A guide for a student-led doctoral-level qualitative methods short course in epidemiology: faculty and student perspectives

Qualitative research and mixed methods are core competencies for epidemiologists. In response to the shortage of guidance on graduate course development, we wrote a course development guide aimed at faculty and students designing similar courses in epidemiology curricula. The guide combines established educational theory with faculty and student experiences from a recent introductory course for epidemiology and biostatistics doctoral students at the University of Zurich and Swiss Federal Institute of Technology, Zurich. We propose a student-centred course with inverse classroom teaching and practice exercises with faculty input. Integration of student input during the course development process helps align the course syllabus with student needs. The proposed course comprises six sessions that cover learning outcomes in comprehension, knowledge, application, analysis, synthesis and evaluation. Following an introductory session, the students engage in face-to-face interviews, focus group interviews, observational methods, analysis and how qualitative and quantitative methods are integrated in mixed methods. Furthermore, the course covers interviewer safety, research ethics, quality in qualitative research and a practice session focused on the use of interview hardware, including video and audio recorders. The student-led teaching characteristic of the course allows for an immersive and reflective teaching-learning environment. After implementation of the course and learning from faculty and student perspectives, we propose these additional foci: a student project to apply learned knowledge to a case study; integration in mixed-methods; and providing faculty a larger space to cover theory and field anecdotes.

What is public trust in national electronic health record systems? A scoping review of qualitative research studies from 1995 to 2021

Objective

Public trust in national electronic health record systems is essential for the successful implementation within a healthcare system. Research investigating public trust in electronic health records is limited, leading to a lack of conceptual clarity. In response, the objective of this study is to gain a clearer understanding on the conceptualizations of public trust in electronic health records, which can support the implementation of national electronic health record systems.

Methods

Guided by the PRISMA-ScR checklist, a scoping review of 27 qualitative studies on public trust in electronic health records found between January 2022 and June 2022 was conducted using an inclusive search method. In an iterative process, conceptual themes were derived describing the promoters and outcomes of public trust in electronic health records.

Results

Five major conceptual themes with 15 sub-themes were present across the literature. Comprehension, autonomy, and data protection promote public trust in electronic health record; while personal and system benefits are the outcomes once public trust in electronic health records exists. Additional findings highlight the pivotal role of healthcare actors for the public trust building process.

Conclusions

The results underscore comprehension, autonomy, and data protection as important themes that help ascertain and solidify public trust in electronic health records. As well, health system actors have the capacity to promote or hinder national electronic health record implementation, depending on their actions and how the public perceives those actions. The findings can assist researchers, policymakers, and other health system actors in attaining a better understanding of the intricacies of public trust in electronic health records.

What does it take to create a European Health Data Space? International commitments and national realities

Public health concerns in Europe demonstrate the necessity of building a health policy that could contribute to the long-term sustainable development of the European Union (EU), as stated in the European Health Union (EHU) manifesto. The main desire to create an EHU is embodied in the launch of the European Health Data Space (EHDS). The EHDS seeks to foster a genuine single market for digital health services and products by, among other things, accelerating the uptake and implementation of harmonised and interoperable electronic health record (EHR) systems across the EU. In the context of primary and secondary use of EHR data, developments in Europe have thus far resulted in patchy and, in some places, non-interoperable solutions. Taking the gap between international ambitions and national realities as a starting point, this paper contends that both EU level and Member State level circumstances should be considered to make the EHDS a reality.

Global Constructive Work predicts left ventricular reverse remodeling one year after MitraClip implantation in patients with functional mitral regurgitation

Background

Percutaneous edge-to-edge mitral valve repair (PMVr) has recently been identified as an effective method for treating patients with functional mitral regurgitation. However, it is still unknown which patients will benefit by showing clinical improvement and left ventricular reverse remodeling.

Purpose

The purpose of this study is to analyze novel echocardiographic markers and identify markers of LV reverse remodeling after MitraClip implantation.

Methods

We retrospectively analyzed 58 high surgical risk (logistic EuroSCORE 23±15%) consecutive patients (aged 72±10yrs) with functional moderate-to-severe and severe mitral regurgitation (EROA 29±14mm2) and reduced LV contractility (EF 32±8%, GLS −8.6±3.7%). At baseline and 1-year after PMVr we assessed echocardiographic parameters such as MR severity, EF, Global Longitudinal Strain (GLS), Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW) and Global Work Efficiency (GWE).

Results

In patients with MitraClip implantation there was a significant reduction of MR (3.7±0.4 vs 1.7±0.8, p<0.001) one year after the intervention. The EF and GLS did not improve after the implantation (32±8 vs 33±10%, p=0.178 & −8.6±3.7 vs −8.6±3.7%, p=0.922 respectively) but Global Work Index (GWI) and Global Constructive Work (GCW) demonstrated significant improvement (607±282 vs 650±260mmHg%, p=0.04 & 854±288 vs 949±325mmHg%, p<0.001 respectively). The baseline EF, GLS, GWI, GCW and EROA were the factors that were significantly associated with more than 20% reduction of LVEDV one year after intervention (p<0.02 for all). To be more specific, left ventricles with better performance and contractility combined with worse mitral regurgitation were the ones that responded better. Further, baseline GCW was the only factor that was significantly associated with reduction of the LVESV. A ROC curve analysis identified a cut-off value of 846mmHg% (AUC 0.759, 95% CI: 0.588–0.930; p=0.007) to be associated with 10% reduction of LVESV, with a sensitivity and specificity of 79% and 74% respectively.

Conclusions

Transcatheter edge-to-edge repair is an effective method for treating patients with FMR and improves LV performance one year after intervention. A preserved baseline GCW seems to be a good predictor of LV reverse remodeling after MitraClip implantation.

Funding Acknowledgement

Type of funding source: None

P1757 Novel echocardiographic markers as predictors for left ventricular reverse remodeling one year after edge-to-edge mitral valve repair in patients with functional mitral regurgitation

Background

Percutaneous edge-to-edge mitral valve repair (PMVR) is a safe treatment option for high surgical risk patients with severe functional mitral regurgitation (FMR). Recent trials have proven this method’s efficiency but novel echocardiographic markers such as deformation imaging have never been analyzed in this subgroup of patients.

Purpose

The purpose of this study is to analyze novel echocardiographic parameters in patients treated for FMR and identify predictors of response in patients undergoing PMVR.

Methods

We retrospectively analyzed 79 consecutive high surgical risk patients (logistic EuroSCORE 21.8 ± 15.2%), with ischemic or dilated cardiomyopathy, reduced EF (31.0 ± 8.5%) and severe functional MR (FMR). Effective regurgitant orifice area (EROA) was measured at 28.8 ± 15.1mm2 and regurgitant volume (RV) at 41.7 ± 18.3ml. At baseline and 1-year after PMVR or optimal medical treatment (OMT) we assessed echocardiographic parameters such as LV global longitudinal strain (LVGLS) and peak left atrial longitudinal strain (PALS), LV end-systolic and end-diastolic volumes (LVESV, LVEDV), LA volume, MR severity along with BNP levels, NYHA class and 6 minute walking distance (6MWT).

Results

One year after PMVR there was a significant reduction of MR (3.7 ± 0.4 vs 1.7 ± 0.8) and BNP levels (980 ± 1027pg/ml vs 420 ± 338pg/ml, p = 0.005), improvement of NYHA class (3.20 ± 0.55 to 2.0 ± 0.6, P < 0.05) and increase of 6MWD (240 ± 137 to 298 ± 139m, P < 0.01). LA volume and LVEDV were reduced (141 ± 79ml to 114 ± 74ml and 221 ± 74 to 193 ± 62ml respectively) (P < 0.01 for all comparisons). On the other hand, patients treated with OMT didn’t have any change of their MR (3.4 ± 0.5 vs 3.4 ± 0.9), BNP levels (601 ± 652 vs 610 ± 748) or NYHA class status (2.6 ± 0.6 vs 2.4 ± 0.6). Additionally, LA and LV volumes were approximately the same (134 ± 69 vs 141 ± 61ml and 222 ± 64 vs 222 ± 56ml respectively) (p < 0.05 for all comparisons). Baseline LVGLS slightly increased post intervention (-8.5 ± 4.1% vs -9.1 ± 3.7%, r = 0.76, P < 0.01), and was associated with the absolute (r=-0.46, p = 0.01) and percentage difference in LVEDV (r= -0.61, P < 0.01). ROC curve analysis identified a cut-off value for GLS of -7.45% (AUC 0.815, 95% CI: 0.647-0.983; p = 0.007) associated with more than 15% LV reverse remodeling, with a sensitivity and specificity of 71% and 75% respectively.

Conclusions

Edge-to-edge repair is a safe and effective method for treating patients with functional MR and has a positive clinical impact in patients at one year follow up. A preserved LVGLS seems to be a good predictor of LV reverse modeling post intervention.

P1758 Global left ventricular myocardial work efficiency as a prognostic marker for clinical responders one year after edge-to-edge mitral valve repair in patients with functional mitral regurgitation

Background

Percutaneous edge-to-edge mitral valve repair (PMVR) has been proven to be effective for treating patients with functional MR (FMR). However it remains to be answered which patients will benefit more from this method. Novel echocardiographic markers like myocardial work efficiency can be quantified non-invasively and have never been analyzed in this subgroup of patients before.

Purpose

The purpose of this study is to analyze the myocardial work efficiency in patients treated with PMVR for FMR and identify predictors of clinical response.

Methods

We retrospectively analyzed 22 high surgical risk (logistic EuroSCORE 28.9 ± 18.2%) consecutive patients (aged 72 ± 8yrs) with functional moderate-to-severe and severe mitral regurgitation (EROA 28.6 ± 14.6mm2, RV 41.7 ± 15.8ml) and reduced LV contractility (EF 32.7 ± 7.5%, GLS -8.8 ± 3.4%). At baseline and 1-year after PMVR or optimal medical treatment (OMT) we assessed echocardiographic parameters such as MR severity, Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW) and Global Work Efficiency (GWE), along with BNP levels and NYHA class status.

Results

One year after PMVR there was a significant reduction of MR (3.6 ± 0.5 vs 1.8 ± 0.8, p = 0.009) and BNP levels (901 ± 610pg/ml vs 479 ± 385pg/ml, p < 0.001) and significant improvement of NYHA class status (3.0 ± 0.6 to 2.2 ± 0.4, p < 0.001). On the other hand, patients treated with OMT didn’t have any significant change of their MR (3.6 ± 0.5 vs 3.3 ± 1.0), BNP levels (296 ± 114 vs 241 ± 183pg/ml) or NYHA class status (2.6 ± 0.5 vs 2.4 ± 0.5). In device group, there was a preservation of GWI (572 ± 290 vs 609 ± 299mmHg%) and GCW (757 ± 310 vs 789 ± 316mmHg%) and non significant change of GWW and GWE (140 ± 70 vs 150 ± 73mmHg% and 79 ± 9 vs 79 ± 10% respectively, p < 0.05 for all comparisons). On the other hand in medical treatment group there was a significant impairment of GWI (635 ± 263 vs 564 ± 267mmHg%, p = 0.08) and GWE (83 ± 9 vs 76 ± 11%, p = 0.03) and significant increase of GWW (123 ± 90 vs 162 ± 74mmHg%, p < 0.001). Further, baseline GCW was reversely associated with the difference in BNP (r=-0.559, p = 0.038), NYHA class (r=-0.501, p = 0.06) and 6MWT (r=-0.577, p = 0.08) after PMVR, meaning that patients with worse energetics will respond better.

Conclusions

PMVR is an effective method for treating patients with FMR and preserves myocardial work index after one year of FU in contrast to medically treated patients in whom deterioration is observed.

P1560 Acute changes of mitral annular dimensions after transcatheter egde-to-edge repair: an indirect annuloplasty method?

Background

Percutaneous edge-to-edge mitral valve repair (PMVR) is a safe and alternative method for treating high-risk patients with severe mitral regurgitation (DMR or FMR). This transcatheter treatment aims at reducing the MR with a so-called "Alfieri stitch" method. However the impact on mitral annular dimensions after the device implantation is not well defined. The purpose of this study is to recognize the acute changes of mitral annular dimensions after transcatheter edge-to-edge repair.

Methods

We retrospectively analyzed 20 consecutive patients (aged 74 ± 10yrs) with degenerative or functional moderate-to-severe and severe mitral regurgitation (EROA 40.8 ± 20.5mm2, RV 52.6 ± 17.5ml) and reduced ejection fraction (EF 36.9 ± 15.4%). These patients were at high surgical risk or even inoperable in certain cases (logistic EuroSCORE 28.9 ± 18.2%) and evaluated by a heart team as candidates for transcatheter repair. All intraoperative transoesophageal echo studies were post processed with EchoPac v.203 or QLAB 9.0. 3D views of the mitral valve before and after the implantation of the device were analyzed with 4D AutoMVQ (GE) or MVQ (Phillips) software.

Results

PMVR was effective in treating the MR at the end of the operation (from 3.8 ± 0.4 to 1.3 ± 0.5 after the implantation, p < 0.05) in all patients. There was a significant reduction of the annulus area (from 12.25 ± 3.0cm2 to 10.18 ± 2.88cm2, p < 0.001) and circumference (from 13.23 ± 1.4cm to 12.18 ± 1.57cm, p < 0.001), in both DMR and FMR cases. The percentage reduction of annulus area and circumference after PMVR was 17.3 ± 0.8% and 8 ± 5% respectively and the number of the clips used for that purpose were 1.55 ± 0.6. Additionally, edge-to-edge repair significantly reduced the anterior-posterior diameter (from 3.49 ± 0.56cm to 3.02 ± 0.55cm, r = 0.86, p < 0.001) and the posteromedial-anterolateral diameter (from 4.15 ± 0.58cm to 3.88 ± 0.60cm, r = 0.9, p < 0.001). The number of the clips used did not play an important role in the percentage difference of the annulus dimensions (20% reduction with one clip vs 14.3 ± 7.6% with two or more, p < 0.05) and one possible explanation could be that patients receiving one clip had smaller annulus area comparing to the patients receiving two or more (11.2 ± 2.9mm2 vs 13.3 ± 2.7mm2 respectively, p < 0.05).

Conclusions

Transcatheter edge-to-edge repair is effective in treating MR in patients with DMR and FMR and has a direct impact on mitral annular dimensions acutely after the implantation.

P301Preserved global longitudinal strain predicts left ventricular reverse remodeling one year after edge-to-edge mitral valve repair in functional mitral regurgitation

Background

Percutaneous edge-to-edge mitral valve repair (PMVR) has emerged as an effective treatment modality for high surgical risk patients with severe functional mitral regurgitation (FMR). Novel echocardiographic parameters, such as deformation imaging and their predictive significance have not been analyzed in this group of patients.

Purpose

The purpose of this study is to identify echocardiographic predictors of response in patients with FMR undergoing PMVR.

Methods

We retrospectively analyzed 44 consecutive patients with ischemic or dilated cardiomyopathy, reduced ejection fraction and severe functional MR (FMR), aged 71±9 years, 71% males, LVEF 30.9±8.7%, mitral valve effective regurgitant orifice area (EROA)>20mm2, regurgitant volume (RV) >30ml and logistic EuroSCORE 22±14.7%. At baseline and 1-year after PMVR we assessed echocardiographic parameters such as LV longitudinal strain (LVGLS) and peak left atrial longitudinal strain (PALS) using speckle tracking echocardiography, LV end-systolic and end-diastolic volumes (LVESV, LVEDV), LA volume, MR severity by Doppler echocardiography along with BNP levels, NYHA class and 6 minute walking distance.

Results

One year after edge-to-edge repair there was a significant reduction of MR (74.2% had mild to moderate MR, 22.6% moderate-to-severe MR and 3.2% severe MR) and BNP levels (933±943pg/ml to 669±824pg/ml), improvement of NYHA class (3.11±0.55 to 2.0±0.6, P<0.05) and increase of the 6 minute walking distance (251±141 to 296±148m, P<0.05). LA volume was reduced (132.5±62.1ml to 115.2±57.7ml) and PALS was improved (6.89±3.47 to 7.94±5.27) (P<0.05 for all comparisons). Baseline LVGLS did not change significantly post intervention (−8.8±4.1 vs. −8.8±3.9, P=0.7) but the baseline value predicted the percentage difference in LVEDV (r=−0.61, P<0.01), LVESV (r=−0.47, P=0.03), BNP (r=0.45, P=0.04) and NYHA class (r=0.63, P<0.01). The best reverse LV remodeling was found in patients with GLS better than −10% and the trend was that the better the GLS the greater the LVEDV and LVESV reduction post-intervention. Additionally, patients with GLS between −10% and −5% had the largest improvement in BNP (P<0.05) and NYHA class (P=0.005).

Conclusions

Edge-to-edge repair is effective in reducing MR in patients with severe functional MR and has a positive impact in patients' clinical status at one year follow up. A preserved LVGLS seems to be a good predictor of reverse modeling and clinical improvement post intervention.

Ferrite based antennae for launching Alfvén waves

Whistler and Alfvén waves are known to scatter mirror-trapped electrons and protons into the loss cone of the earth's dipole magnetic field. An array of satellites with properly phased antennas can be used to artificially reduce the flux of energetic particles from regions where their flux has been naturally or artificially pumped. In any space based system, the power required to drive antennas is at a premium. We present here experimental evidence that the efficiency of an antenna can be greatly enhanced with the use of ferrite cores with high relative magnetic permeability μ. Ferrite-based antennas were constructed to launch Alfvén waves in a magnetized plasma. The wave magnetic field of shear Alfvén waves launched with a ferrite core was by the magnetization factor μ larger than that of a similar antenna without a ferrite. Combining multiple ferrite antennas allowed control of the injected perpendicular wavelength. This novel technique can be used to efficiently launch low frequency waves with amplitude above the threshold required for nonlinear triggering.

The Predictive Value of the Syntax Score in Patients With Chronic Coronary Artery Disease Undergoing Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting: A Pilot Study

Objectives:

To evaluate the usefulness of the SYNTAX score (SS) in predicting 1-year clinical outcomes in a population of patients with chronic coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).

Background:

Despite the proven prognostic value of the SS in patients with multivessel and/or left main (LM) CAD, its usefulness in other patient subsets remains uncertain.

Methods:

This was a prospective single centre cohort study conducted from September 2012 to November 2014 at the Nicosia General Hospital, Cyprus. Patients (n=140; 94% men and 6% women) with chronic CAD undergoing revascularization with either PCI or CABG were evaluated.

Results:

At 1-year, angina occurred in 20 patients (14.3%), myocardial infarction (MI) in 3 patients (2.1%), repeat revascularization procedures in 9 patients (6.4%) and death in 12 patients (8.6%). The SS independently predicted angina (p=0.024) but was not predictive of MI (p=0.964), death (p=0.292) or repeat revascularization (p=0.069).

Conclusion:

In this patient population, the SS predicted angina in the year following revascularization but was not predictive of MI, death or repeat revascularization.

Abstract P3-03-01: Intracranial PDX models of breast cancer metastasis

Background: Overexpression of the human epidermal growth factor receptor 2 (HER2) in breast cancer is an independent factor for development of brain metastases. Up to 37% of patients with HER2 positive disease relapse intracranially despite control of extra-cranial metastatic disease. Inability of anti-cancer agents to cross an intact blood-brain barrier (BBB) is a possible explanation for the increased incidence of brain metastases.

Subcutaneous (SQ) patient-derived xenograft (PDX) models are increasingly used for efficacy studies in drug development. However, orthotopic PDX models may confer a translational advantage as the patient tumor microenvironment is more closely mimicked. Especially when targeting brain tumors, the major impact of the BBB on drug bioavailability must be taken into consideration. The aim of this study was therefore to develop a panel of intracranial PDX models of breast cancer brain metastases for pre-clinical efficacy studies of new anticancer drugs.

Methods: SQ tumors from three different HER2 positive PDX breast cancer models designated ST340, ST1339 and ST1616B were enzymatically digested and used for intracranial stereotactic injection in nude mice. Contrast-enhanced T1- and T2-weighted Magnetic Resonance Imaging (MRI) were used to determine tumor take. Intracranial tumor growth was monitored using MRI and positron emission tomography (PET) in conjunction with the amino acid radio tracer 18F-FET.

Results: MRI confirmed tumor take in one model as early as 2 weeks after intracranial implantation. Increased 18F-FET uptake was detected in all models. MRI could be effectively used to monitor tumor growth and the corresponding 18F-FET PET images demonstrated increased 18F-FET uptake over time.

Conclusion: Three different HER2 positive intracranial PDX breast metastases models were established from low passage SQ PDX models. We suggest, that using these intracranial PDX models of brain metastases, new drugs for advanced breast cancer can be evaluated in preclinical models that more closely mimic the microenvironment and the BBB in patients. In addition, translational imaging techniques can be evaluated during preclinical testing and the potential of tracers like 18F-FET as imaging biomarkers of therapeutic response can be assessed. Together, the established SQ and orthotopic PDX models of breast cancer and brain metastases can be used as a relevant translational platform for testing of new drugs.

Citation Format: Nielsen CH, Nedergaard MK, Wick MJ, Papadopoulos K, Tolcher AW, Kjaer A. Intracranial PDX models of breast cancer metastasis. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-03-01.

Soybean oil: a potentially new intravascular perfusate

BACKGROUND

Given that micelles of lipids are colloids, the hypothesis was generated that the rapid administration of large volumes of soybean oil micelles would be an effective perfusion fluid. We also hypothesized that oxygen loading would be enhanced due to the greater solubility of oxygen in lipids compared to water.

METHODS

A 100% lethal mouse model of blood loss was used to compare the ability of soybean oil micelles to that of Ringer's lactate, blood and other fluids, with respect to raising and maintaining the blood pressure for one hour. Oxygen on- and off-loading of various concentrations of soybean oil micelles was determined using mass spectroscopy. Nitric oxide uptake by micelles was also determined in a similar fashion.

RESULTS

A 20% soybean oil emulsion was superior to Ringer's lactate in raising and maintaining blood pressure. A 20% soybean oil emulsion with 5% albumin added was superior to shed blood as well as solutions comprised of 5% albumin added to either normal saline or Ringer's lactate. There was a linear relationship between oxygen content and micelle concentration between 10% and 30%. Off-loading of oxygen from the micelles was nearly as fast as off-loading from water. Nitric oxide also loaded preferentially onto soybean oil micelles.

CONCLUSIONS

(1) Soybean oil emulsions were superior to other fluids in restoring and maintaining the blood pressure; (2) oxygen-carrying ability of soybean oil micelles exceeds that of water and follows Henry's law between 10% and 30% w/v oil content; (3) nitric oxide was carried by the micelles; (4) animals receiving soybean oil micelles did not exhibit fat embolization; (5) colloids comprised of soybean oil-containing micelles may be used to replace blood loss and may be used to deliver oxygen and other potentially therapeutic gases such as nitric oxide to tissues.