The Effects of the Paleo Diet on Autoimmune Thyroid Disease: A Mixed Methods Review

The aim of this systematic review was to examine the characteristics of Paleolithic diet (PD) interventions designed for adult patients with autoimmune thyroid disease (AITD) in order to determine if diet elements have the potential to successfully reduce thyroid antibodies (Ab) such as thyroglobulin (Tg), thyroid peroxidase (TPO), and thyroid stimulating hormone receptor (TSHR), and improve thyroid hormones (thyroxine (T4), triiodothyronine (T3) and thyroid stimulating hormone (TSH)) or resolve AITD pathogenesis. Randomized controlled trials (RCTs) with an adult population of 18 years and older, diagnosed with Hashimoto's thyroiditis (HT) or Graves' disease (GD) (Basedow's), who were placed on a diet of Paleolithic or ancestral nature, and achieved reduction of AITD Abs, improvement of thyroid hormones, and, or resolution of AITD were searched. Various electronic databases were used. Bias was assessed using critical appraisal tools from the Scottish Intercollegiate Guidelines Network (SIGN) and Joanna Briggs Institute (JBI). Studies were excluded according to exclusion criteria and results analyzed. One randomized controlled trial (RCT), a pilot study, and six case studies were found. In total, eight AITD studies focusing on Paleolithic or ancestral interventions were located. In highlight, females were the predominant gender. Case studies solely focused on AITD with protocols ranging from 8-60 weeks. All studies showed clinical improvements, one had significant improvement, two showed AITD resolution. After structured evaluation of nutritional interventions utilizing the PD on the effects of AITD, it was concluded foods of ancestral nature along with the addition of specific supplements, food components, exercise and mindfulness meditation, and exclusion of modern day foods have a considerable impact on thyroid Ab and hormones. The relevant studies suggest while this dietary protocol can be useful in clinical practice, larger-scale studies need to be conducted. Key teaching pointsThere are currently no dietary interventions recommended for the treatment of autoimmune thyroid disease. The Paleo diet has been documented to improve AITD antibodies and thyroid hormones in both Hashimoto's thyroiditis and Graves' disease.The Paleo diet can provide a natural source of nutrients similar to supplemental nutrients that have shown positive results on AITD.The paleo diet provides specific macronutrient percentages that may be beneficial in reducing AITD antibodies, while improving thyroid hormones.Methylation supplementation may be useful in AITD cases.

The community engagement course and action network: strengthening community and academic research partnerships to advance health equity

Background

Historically Black Colleges and Universities and Minority Serving Institutions are uniquely positioned to implement community-campus research partnerships based on a history of service, the pursuit of community trustworthiness and student demographics often similar to surrounding marginalized communities. The Morehouse School of Medicine Prevention Research Center collaborates with members of Historically Black Colleges and Universities, Minority Serving Institutes, and community organizations on the Community Engaged Course and Action Network. This network is the first of its kind and aims to strengthen members' ability to implement Community-Based Participatory Research (CBPR) principles and partnerships. Projects address public health priorities including mental health among communities of color, zoonotic disease prevention, and urban food deserts.

Materials and methods

To assess the effectiveness of the network, a Participatory Evaluation framework was implemented to conduct process evaluation which included review of partnership structures, operations, project implementation processes, and preliminary outcomes of the research collaborations. A focus group of Community Engagement Course and Action Network members (community and academic) was also conducted to identify benefits and challenges of the network with emphasis on key areas for improvement to further enhance the relationships between partners and to facilitate their subsequent community-campus research.

Results

Network improvements were tied to themes strengthening community-academic partnerships including sharing and fellowship, coalition building and collaboration, and greater connections and awareness of community needs through their current community-academic partnerships. The need to conduct ongoing evaluation during and after implementation, for determining the early adoption of CBPR approaches was also identified.

Conclusion

Evaluation of the network's processes, infrastructure, and operation provides early lessons learned to strengthen the network. Ongoing assessment is also essential for ensuring continuous quality improvement across partnerships such as determining CBPR fidelity, assessing partnership synergy, and dynamics, and for quality improvement of research protocol. The implications and potential for advancing implementation science through this and similar networks are great towards advancing leadership in modeling how foundations in community service can advance to CBPR partnership formation and ultimately, health equity approaches, that are local defined and assessed.

Asynchrony in coral community structure contributes to reef-scale community stability

Many aspects of global ecosystem degradation are well known, but the ecological implications of variation in these effects over scales of kilometers and years have not been widely considered. On tropical coral reefs, kilometer-scale variation in environmental conditions promotes a spatial mosaic of coral communities in which spatial insurance effects could enhance community stability. To evaluate whether these effects are important on coral reefs, we explored variation over 2006-2019 in coral community structure and environmental conditions in Moorea, French Polynesia. We studied coral community structure at a single site with fringing, back reef, and fore reef habitats, and used this system to explore associations among community asynchrony, asynchrony of environmental conditions, and community stability. Coral community structure varied asynchronously among habitats, and variation among habitats in the daily range in seawater temperature suggested it could be a factor contributing to the variation in coral community structure. Wave forced seawater flow connected the habitats and facilitated larval exchange among them, but this effect differed in strength among years, and accentuated periodic connectivity among habitats at 1-7 year intervals. At this site, connected habitats harboring taxonomically similar coral assemblages and exhibiting asynchronous population dynamics can provide insurance against extirpation, and may promote community stability. If these effects apply at larger spatial scale, then among-habitat community asynchrony is likely to play an important role in determining reef-wide coral community resilience.

Rib fracture-related morbidity and mortality for older persons in the era of fascial plane blocks: A cohort study

Introduction

Analgesia is key to successful conservative, nonsurgical management of patients admitted to the hospital with multiple rib fractures. Recently, new fascial plane regional anesthesia techniques have become widely available. We hypothesized that since the introduction of these new regional analgesia techniques, for patients over the age of 65 years, the effect of increasing numbers of rib fractures has been mitigated.

Methods

A retrospective study of patients admitted for the management of rib fractures between 2017 and 2020 was performed. Patients not admitted to the hospital, under the age of 65 years, or with chest trauma other than rib fractures were not eligible for inclusion. The primary outcome of interest was mortality. The secondary outcomes were the incidence of pneumonia and intensive care unit admission. Results were reported as the odds ratio and its 95% confidence interval and associated p-value. Statistical significance was set at [Formula: see text] < 0.05.

Results

Overall, 252 patients were included and 142 patients received a regional anesthesia. The mortality rate was 4% (n = 10) with no association between mortality and number of rib fractures ( p = 0.215). Twenty-four patients (9.5%) developed pneumonia during their hospital stay, again with no association with an increasing number of rib fractures. The intensive care unit admission rate was 13.1% (n = 33) and correlated with an increasing number of fractures (odds ratio = 1.15; 95% confidence interval = 1.01 to 1.31; p = 0.038).

Conclusion

Management including liberal utilization of regional anesthesia for at-risk patients appears to mitigate the effect of increasing numbers of rib fractures on the incidence of mortality and pneumonia.

Mixed reality surgical mentoring of combat casualty care related procedures in a perfused cadaver model: Initial results of a randomized feasibility study

BACKGROUND

Most telemedicine modalities have limited ability to enhance procedural and operative care. We developed a novel system to provide synchronous bidirectional expert mixed reality-enabled virtual procedural mentoring. In this feasibility study, we evaluated mixed reality mentoring of combat casualty care related procedures in a re-perfused cadaver model.

METHODS

Novices received real-time holographic mentoring from experts using augmented reality via Hololens (Microsoft Inc, Redmond, WA). The experts maintained real-time awareness of the novice's operative environment using virtual reality via HTC-Vive (HTC Corp, Xindian District, Taiwan). Additional cameras (both environments) and novel software created the immersive, shared, 3-dimensional mixed reality environment in which the novice and expert collaborated. The novices were prospectively randomized to either mixed reality or audio-only mentoring. Blinded experts independently evaluated novice procedural videos using a 5-point Likert scale-based questionnaire. Nonparametric variables were evaluated using the Wilcoxon rank-sum test and comparisons using the χ² analysis; significance was defined at P < .05.

RESULTS

Surgeon and nonsurgeon novices (14) performed 69 combat casualty care-related procedures (38 mixed reality, 31 audio), including various vascular exposures, 4-compartment lower leg fasciotomy, and emergency neurosurgical procedures; 85% were performed correctly with no difference in either group. Upon video review, mixed reality-mentored novices showed no difference in procedural flow and forward planning (3.67 vs 3.28, P = .21) or the likelihood of performing individual procedural steps correctly (4.12 vs 3.59, P = .06).

CONCLUSION

In this initial feasibility study, our novel mixed reality-based mentoring system successfully facilitated the performance of a wide variety of combat casualty care relevant procedures using a high fidelity re-perfused cadaver model. The small sample size and limited variety of novice types likely impacted the ability of holographically mentored novices to demonstrate improvement over the audio-only control group. Despite this, using virtual, augmented, and mixed reality technologies for procedural mentoring demonstrated promise, and further study is needed.

Cereal grain mineral micronutrient and soil chemistry data from GeoNutrition surveys in Ethiopia and Malawi

The dataset comprises primary data for the concentration of 29 mineral micronutrients in cereal grains and up to 84 soil chemistry properties from GeoNutrition project surveys in Ethiopia and Malawi. The work provided insights on geospatial variation in the micronutrient concentration in staple crops, and the potential influencing soil factors. In Ethiopia, sampling was conducted in Amhara, Oromia, and Tigray regions, during the late-2017 and late-2018 harvest seasons. In Malawi, national-scale sampling was conducted during the April–June 2018 harvest season. The concentrations of micronutrients in grain were measured using inductively coupled plasma mass spectrometry (ICP-MS). Soil chemistry properties reported include soil pH; total soil nitrogen; total soil carbon (C); soil organic C; effective cation exchange capacity and exchangeable cations; a three-step sequential extraction scheme for the fractionation of sulfur and selenium; available phosphate; diethylenetriaminepentaacetic acid (DTPA)-extractable trace elements; extractable trace elements using 0.01 M Ca(NO₃)₂ and 0.01 M CaCl₂; and isotopically exchangeable Zn. These data are reported here according to FAIR data principles to enable users to further explore agriculture-nutrition linkages.

Measurement(s)	Trace Element • soil chemical properties
Technology Type(s)	Inductively-Coupled Plasma Mass Spectrometry
Factor Type(s)	Geography • Staple cereal crop
Sample Characteristic - Organism	Staple cereal food crops
Sample Characteristic - Environment	Smallholder farming
Sample Characteristic - Location	Ethiopia • Malawi

996 EFFECT OF COVID-19 ON HIP FRACTURE CARE IN WALES - AN ANALYSIS OF HOW ORGANISATION OF SERVICES AFFECTED HOSPITAL LENGTH OF STAY

Introduction

The National Hip Fracture Database (NHFD) report that length of stay (LOS) fell (from 19.7 to 16.9 days) in the first year of the COVID-19 pandemic, as patients, families, cares, and staff in health and social care responded to this challenge. This analysis examines trends in Wales where LOS can be profiled very completely as it predominantly remains within a single health board.

Method

We used data from the NHFD www.nhfd.co.uk to define pre-pandemic LOS (in the year to 1st March 2020) and compare this with the following 18 months. We set figures for all 12 hospitals in Wales against the changes in service organisation which each reported to the NHFD's 2020 Facilities Survey, and against the local incidence of COVID-19 among their hip fracture patients.

Results

Monthly LOS fell markedly at the pandemic's onset; the national figure falling 8.3 days (from 31.2–22.9 days) between February and June 2020. Overall LOS in Wales fell by 1.6 days across the year as a whole, but this ranged from a fall of 6.3 days in one hospital to a rise of 4.5 days in another. Five hospitals reported a rise in LOS. These hospitals had either never had orthogeriatric support, or lost this to COVID-19 duties, they did not achieve the initial fall in LOS in response to the pandemic, and they reported pressures with ‘outliers’ after the first wave. Unlike other units in Wales they cited problems with workload, particularly in terms of physiotherapy.

Discussion

NHFD data provide a detailed picture of hospitals’ response to the COVID-19 pandemic, and allow us to examine service factors underpinning their resilience in the face of this challenge. More detailed work should be carried out for the 150 hospitals in England using the same sources of data.

Erector spinae plane block vs. peri-articular injection for pain control after arthroscopic shoulder surgery: a randomised controlled trial

Interscalene brachial plexus block is the standard regional analgesic technique for shoulder surgery. Given its adverse effects, alternative techniques have been explored. Reports suggest that the erector spinae plane block may potentially provide effective analgesia following shoulder surgery. However, its analgesic efficacy for shoulder surgery compared with placebo or local anaesthetic infiltration has never been established. We conducted a randomised controlled trial to compare the analgesic efficacy of pre-operative T2 erector spinae plane block with peri-articular infiltration at the end of surgery. Sixty-two patients undergoing arthroscopic shoulder repair were randomly assigned to receive active erector spinae plane block with saline peri-articular injection (n = 31) or active peri-articular injection with saline erector spinae plane block (n = 31) in a blinded double-dummy design. Primary outcome was resting pain score in recovery. Secondary outcomes included pain scores with movement; opioid use; patient satisfaction; adverse effects in hospital; and outcomes at 24 h and 1 month. There was no difference in pain scores in recovery, with a median difference (95%CI) of 0.6 (-1.9-3.1), p = 0.65. Median postoperative oral morphine equivalent utilisation was significantly higher in the erector spinae plane group (21 mg vs. 12 mg; p = 0.028). Itching was observed in 10% of patients who received erector spinae plane block and there was no difference in the incidence of significant nausea and vomiting. Patient satisfaction scores, and pain scores and opioid use at 24 h were similar. At 1 month, six (peri-articular injection) and eight (erector spinae plane block) patients reported persistent pain. Erector spinae plane block was not superior to peri-articular injection for arthroscopic shoulder surgery.

What can Europe learn from HCP knowledge and attitudes towards hepatitis A vaccination in the US?

Background

An estimated &gt;100 million new hepatitis A (hepA) infections occur annually worldwide. Centres for disease control and prevention reported 38795 hepA cases in the US since 2016, and 4475 outbreak-confirmed cases in Europe between 2016-2018. HepA outbreaks resulted mainly from person-to-person contact, especially among homeless, illegal drug users (IDU) and men who have sex with men (MSM). In 2020, we surveyed US health care providers (HCPs) to understand their knowledge and attitudes towards hepA vaccination in these populations at higher risk of infection and complications.

Methods

This was a cross-sectional, web-based survey of 400 HCPs (primary care providers, nurse practitioners, gastroenterologists, internal medicine and infectious disease specialists [IDs], emergency room physicians [ERs]) who had recommended and/or administered hepA vaccines to ≥ 19-year-olds.

Results

85% of 371 HCPs reported recommending hepA vaccine to homeless, 87% of 393 to IDU and 83% of 397 to MSM, although vaccination may not actually occur after recommendation. Results varied by specialty, 16% fewer ERs than IDs reported recommending the vaccine in these at-risk populations. Moreover, 64%, 75% and 71% of all (400) HCPs reported extremely important that homeless, IDU and MSM, respectively, get vaccinated for hepA, while 6%, 7% and 8% of all HCPs reported this as slightly, or not important. Reasons for not recommending hepA vaccine to homeless, IDU and MSM included uncertainty on guidelines (reported by 22/56, 24/50 and 29/66 HCPs, respectively) and low risk of infection (reported by 20/56, 30/50 and 27/66 HCPs, respectively).

Conclusions

Despite recent hepA outbreaks and strengthened recommendations for vaccination in at-risk populations, knowledge gaps persist among US HCPs. This survey may motivate European countries to reinforce national hepA vaccination recommendations and, in parallel, consider efforts to raise vaccination awareness.

Funding

GlaxoSmithKline Biologicals SA

Key messages

Education on hepatitis A vaccination recommendations in at-risk populations is needed. Health care providers’ vaccination knowledge plays a critical role to control the hepatitis A outbreak in the US and preventing hepatitis A in Europe.

Seeking Approval: International Higher Education Students' Experiences of Applying for Human Research Ethics Clearance in Australia

University human research ethics application procedures can be complicated and daunting, especially for international students unfamiliar with the process and the language. We conducted focus groups and interviews with four research higher degree and 21 Master’s coursework international students at an Australian university to gain their views on the human ethics application process. We found the most important influences on their experience were: the time it took to do an application; support from supervisors, peers and others; their own language skills; and their lack of familiarity with research ethics procedures. To improve the experience of international students undertaking research involving human research ethics applications, we recommend universities provide guidance on institutional ethics review processes, concepts and terminology, with translations in a range of languages, together with guidance on how to conduct research ethically within and outside the students’ own countries. We also recommend curricula be developed to further students’ understanding of the importance of ethical research practice, and that these curricula be embedded in undergraduate and postgraduate degree programs and reflected in course learning outcomes.

Reducing clinical review burden for insertable cardiac monitors

Funding Acknowledgements

Type of funding sources: None.

Background

The insertable cardiac monitor (ICM) is an essential tool for the ambulatory diagnosis of arrhythmias. However, definitive diagnoses still rely on time-consuming, manual adjudication of electrograms (EGMs) transmitted to the patient care network. This EGM review burden may be minimized by automatically selecting a subset of EGMs for fast review without delaying the diagnosis.

Purpose

Develop EGM selection strategies to reduce the EGM review burden without delaying diagnoses.

Methods

A retrospective analysis of 1,000 randomly selected Abbott Confirm Rx devices with 90+ days of remote transmission history was performed, regardless of transmission frequency, and all EGMs were adjudicated as either true or false positive (TP, FP). Up to 3 EGMs per day per arrhythmia type were prioritized for review based on ventricular rate and episode duration, with rules specific to each arrhythmia type: atrial fibrillation (AF), tachycardia, bradycardia, and pause. The resulting reduction in EGM review burden and TP days (patient-days with at least 1 TP EGM), as well as any diagnostic delay from the first transmitted TP, were calculated relative to reviewing all transmitted EGMs.

Results

In this population and transmission period, at least one AF, tachycardia, bradycardia, and pause EGM was transmitted by 424, 343, 190, and 325 unique devices, respectively, with a total of 35,723, 12,239, 19,752, and 28,002 EGMs, and a total of 6,163, 1,572, 1,438, and 646 TP days. For these patients with ≥1 EGM, the median [IQR] EGM transmission rate was 2.6 [0.7, 11.6], 1.1 [0.4, 4.7], 2.1 [0.6, 10.7], and 3.4 [0.6, 29.9] EGMs/patient/month, respectively. The optimal EGM selection strategy reduced this EGM review burden by 43%, 67%, 76%, and 50%, while only missing 3.4%, 2.2%, 0.3%, and 0.2% of TP days, respectively. Ultimately, 97%, 99%, 99%, and 99% of devices with a TP AF, tachycardia, bradycardia, or pause EGM exhibited no diagnostic delay vs. reviewing all transmitted EGMs.

Conclusion

EGM prioritization rules for selecting up to 3 episodes/day significantly reduced EGM burden across all patients, not just "frequent fliers," with no delay-to-diagnosis in &gt;97% of patients who exhibited a true arrhythmia. Implementing these rules on the patient care network may improve clinical workflow and ICM patient management. Abstract Figure.

225 Rheumatic heart disease in Timor Leste school students (RHD-TL) follow-up study: assessment of secondary prophylaxis and outcomes in Timor Leste

Background

The Rheumatic Heart disease in Timor Leste school students (RHD-TL) study identified Timor Leste as having some of the highest rates of definite rheumatic heart disease (RHD) in the world. The RHD-TL follow-up study aimed to assess the delivery and outcomes of the secondary prophylaxis program in known patients with echocardiographic screen detected definite and borderline RHD.

Methods

School-students in Timor Leste where reassessed over a 3-year period since the initial study in 2016. Prospective assessments included adherence to secondary prophylaxis, complications of prophylaxis, follow-up clinical assessment and serial echocardiography. Of the 48 patients, 25 Definite and 23 Borderline, 38 (79%) of all patients, and 92% of definite RHD cases have had one or more follow-up assessments including full datasets for adherence, recurrence rates and progression of disease. Follow-up is provided by the volunteer paediatric cardiology team and rheumatic heart disease team of two NGOs in collaboration with local clinics.

Results

The median duration of follow-up of the 38 patients was of 1.6 years. The median age was 13 years (range 8-22) and 75% were female. Adherence rates in patients with definite RHD was on average greater than 95% during the follow-up period. Of the 23 patients with mild or moderate RHD one case with documented acute rheumatic fever (ARF) recurrence progressed whilst 8 cases improved on benzathine-penicillin G (BPG) therapy. There was no progression of the 6 borderline cases who were not prescribed BPG. Out of the 9 borderline cases in whom BPG was prescribed, one, with 67% adherence, had a documented episode of ARF leading to echocardiographic progression and moderate definite RHD.

Conclusion

This was the first follow-up study to look at disease natural history, both in treated and untreated groups, in Timor-Leste and brought practical insights into the efficacy of the Timor Leste RHD monitoring and prophylaxis programs. Its ongoing project will enable advocacy and quality assessment for the program as it expands.

Abstract 225 Figure 1.

Can we rely on non-randomised studies? Findings from a meta-epidemiological review

Background

Increasingly, health technology assessment (HTA) agencies must decide whether new medicines should be used routinely in the absence of randomised controlled trial (RCT) data, relying solely on non-randomised studies (NRS), which are at high risk of bias due to confounding. Against the background of increased availability and improved methods to analyse non-randomised data (e.g., propensity score methods and instrumental variables), it is important for decision-makers to have guidance on the analysis and interpretation of NRS to inform health economic evaluation. We therefore aimed to systematically and empirically assess the performance of NRS using different analytical methods as compared to RCTs and develop recommendations on the basis of our findings.

Methods

We conducted a large-scale meta-epidemiological review to obtain estimates of the discrepancy in treatment effects in matched RCTs and NRS of pharmacologic interventions from published meta-analyses indexed in MEDLINE and the Cochrane Database of Systematic Reviews. We also consulted with HTA bodies, regulators and academics from five European countries to learn from their experience with using non-randomised evidence.

Results

We compiled the largest dataset of clinical topics with matching RCTs and NRS using various analytical methods to date, covering &gt;100 unique clinical questions. Incorporating information on direction of effect and effect size from &gt;700 unique studies, the dataset can be used to evaluate discrepancies in treatment effects between study designs across a wide range of therapeutic areas.

Conclusions

An empirically based understanding of the risk of bias in NRS is required in order to promote the adequate use of non-randomised evidence as input for health economic decision-making.

P3133Single parasternal long axis echocardiography by briefly trained health workers using handheld devices for detection of rheumatic heart disease: a prospective study of diagnostic accuracy

Introduction

Echocardiographic screening can detect rheumatic heart disease (RHD) in high-risk populations,but is limited by reliance on highly-trained experts and equipment. We sought to determine the diagnostic utility of an ultra-abbreviated single parasternal-long-axis-sweep of the heart (SPLASH) echocardiography protocol to detect RHD, performed by briefly-trained health workers.

Methods

In Timor-Leste and Northern Australia, individuals aged 5–20y were offered school-based echocardiographic screening. Health workers completed online modules followed by one-week of practical training, logging 50 echocardiograms prior to study. The index test was SPLASH, performed and reported by health workers using handheld GE V-scan devices. The index test was abnormal if any mitral or aortic regurgitation was detected. The reference test was a comprehensive echocardiogram, performed by an echocardiographers or cardiologist on a GE Vivid-Q, reported according to World Heart Federation criteria. The diagnostic accuracy of the index test was determined.

Results

2590 subjects underwent index and reference tests. Prevalence of definite RHD was 3.2% (83/2590). Sensitivity and specificity of index test were 0.75 (95% CI 0.64–0.83) and 0.77 (95% CI 0.75–0.78) respectively for detection of any definite RHD, and 0.91 (95% CI 0.74–0.98) and 0.76 (95% CI 0.74–0.78) respectively for detection of moderate or severe RHD.

Conclusion

Health workers using SPLASH detected the vast majority of moderate and severe RHD cases, but lacked sensitivity for detection of mild RHD. Further analysis is underway to evaluate the learning curve and other performance indicators of health workers performing and interpreting echocardiograms. This will allow refinement of SPLASH protocol and augmentation of health worker training to increase detection rates and accuracy for future population screening initiatives.

Acknowledgement/Funding

Heart Foundation Australia Vanguard Grant, Menzies HOT-NORTH pilot project grant, Snow Foundation, Rotary, Bawinanga Aboriginal Corporation, Mala'la

Critical Care in the Military Health System: A Survey-Based Summary of Critical Care Services

Introduction

Critical care is an important component of in-patient and combat casualty care, and it is a major contributor to U.S. healthcare costs. Regular exposure to critically ill and injured patients may directly contribute to wartime skills retention for military caregivers. Data describing critical care services in the Military Health System (MHS), however, is lacking. This study was undertaken to describe MHS critical care services, their resource utilization, and differences in care practices amongst military treatment facilities (MTFs).

Materials and Methods

Twenty-six MTFs representing 38 adult critical care services or intensive care units (ICUs) were surveyed. The survey collected information about organizational structure, resourcing, and unit characteristics at the time of a concurrent 24-h point-prevalence survey designed to describe patient characteristics and staffing in these facilities. The survey was anonymous and protected health information was not collected. We analyzed the data according to high capacity centers (HCCs) (≥200 beds) and low capacity centers (LCCs) (<200 beds). Differences between HCCs and LCCs were compared using Fisher's exact test.

Results

Seventeen MTFs (7 HCCs and 10 LCCs), representing 27 ICUs, responded to the survey. This was a 65% response rate for MTFs and a 71% response rate for services/ICUs. HCCs reported more closed vs. open ICUs; more dedicated critical care services (i.e., medical and surgical ICUs vs. mixed ICUs); fewer respiratory therapists available, but more with certification; more total nursing staff and more critical care certified nurses; the use of subjectively more effective protocols (10.5 vs. 6.7 protocols/unit or service); higher utilization of an ICU daily rounds checklist (65% vs. 0%); and less consistency of clinician type participation during multidisciplinary rounds. ICU leadership structure was similar among the institutions. The majority of respondents were unable to provide summary APACHE II scores, but HCCs were more likely to submit this information than LCCs. Most centers perform multidisciplinary rounds daily, but they are more likely to be run by a physician credentialed in critical care at HCCs (85% vs. 59%, p < 0.05). 67% of respondents reported mortality rates <5%. The two services that reported mortality rates greater than 10% were both LCCs.

Conclusion

This is the first comprehensive report about MHS critical care services. Despite notable variability in data reporting, an important finding itself, this study highlights notable differences in organizational structure and resourcing between HCCs and LCCs within the MHS. The clinical implication of these differences (i.e., impact on patient outcomes) of these differences require further study. Better understanding of MHS critical care services may improve enterprise decision-making about these services which could ultimately improve care of combat casualties.

Critical Care in the Military Health System: A 24-h Point Prevalence Study

Background

Healthcare expenditures are a significant economic cost with critical care services constituting one of its largest components. The Military Health System (MHS) is the largest, global healthcare system of its kind. In this project, we sought to describe critical care services and the patients who receive them in the MHS.

Methods

We surveyed 26 military treatment facilities (MTFs) representing 38 critical care services or intensive care units (ICUs). MTFs with multiple ICUs and critical care services responded to the survey as services (e.g., surgical or medical ICU service), whereas MTFs with only one ICU responded as a unit and gave information about all types of patients (i.e., medical and surgical). Our survey was divided into an administrative portion and a 24-h point prevalence survey of patients and patient care. The administrative portion is reported separately in this journal. The 24-h point prevalence survey collected information about all patients present in, admitted to, or discharged from participating services/units during the same 24-h period in December 2014. The survey was anonymous and protected health information was not collected.

Findings

Sixteen MTFs (69%) and 27 ICU services/units (71%) returned the point prevalence survey. MTFs with >200 beds (n = 3, 22%) were categorized as "high capacity centers" (HCCs) whereas those with ≤200 beds (n = 13, 78%) were characterized as low capacity centers (LCCs). Two MTFs (one HCC and one LCC) returned only administrative data. The remaining 16 MTFs reported data about 151 patients. In all, 100 (67%) of the patients were at three HCCs during this study period. One HCC accounted for 39% (59 patients) of all patient care during this study. Most patients were cared for in mixed medical/surgical ICUs (34.4%), followed by medical (21.2%), surgical (18.5%), trauma (11.9%), cardiac (7.9%), and burn (6.0%) ICUs. The most common medical indication for admission was cardiac followed by general medical. The most common surgical indications for admission were trauma, other, and cardiothoracic surgery. The average APACHE II score of all patients across both LCCs and HCCs was 11 ± 8.1 (8 ± 7.8 vs. 13 ± 7.7 p = 0.008). The lower acuity of patients in this study is reflected in a high turnover rate, low rate of arterial and central line placements (33%), and low rates of life support (all types, 30%; mechanical ventilation only, 21.2%; noninvasive mechanic ventilation only, 7.9%; and vasoactive medications, 6.6%). Thirty-five (23.2%) patients within the study were affected by a total of 57 complications. The three most common complications experienced were acute kidney injury, bleeding, and sepsis.

Discussion

This is the first detailed report about MHS critical care services and the patients receiving care. It describes a low acuity ICU patient population, concentrated at larger MTFs. This study highlights the need for the establishment of a system that allows for the continuous collection of high priority information about clinical care in the MHS in order to facilitate implementation of standardized protocols and process improvements.

Nutritional Support Using Enteral and Parenteral Methods

The purpose of this Clinical Practice Guideline is to provide an approach for optimal nutritional support in the postinjury period for those injured in combat. Indications and contraindications for enteral and parenteral nutrition are addressed. Timing of nutritional support, nutritional goals, energy requirements, and ideal formula selection for various types of traumatic injuries are addressed. Challenges encountered providing nutrional support for the traumatically injured in the deployed environment are also discussed.

Successful Implementation of Low-Cost Tele-Critical Care Solution by the U.S. Navy: Initial Experience and Recommendations

Intensivist physician involvement has been shown to improve outcomes for critically ill patients. Unfortunately, the number of Intensivists nationally is unable to meet the current demand. Similar to the civilian community, the Navy critical care workforce is limited by available resources. Tele-critical care (TCC) has recently been shown to improve outcomes for critically ill patients, and has been suggested as a suitable means of extending Intensivist expertise. Naval Hospital Camp Pendleton (NHCP) is a small community hospital located 41 miles north of Naval Medical Center San Diego (NMCSD). NHCP operates a relatively low-volume six-bed medical-surgical intensive care unit. The Intensivist staffing of NHCP has been variable, ranging from 3 Intensivists to periods of time with no on-site Intensivists. This intermittent staffing has led to (1) network disengagements, (2) unnecessary transfers to NMCSD, and (3) adverse outcomes for critically ill patients cared for at NHCP without Intensivist involvement. In early 2014, NMCSD established a TCC system to address this staffing challenge. Through the TCC program, the tele-Intensivist at NMCSD provides 24/7 coverage for patients located at NHCP using low-cost, off-the-shelf, synchronous high-definition video-teleconferencing equipment, and remote access to electronic medical record, imaging studies, and laboratory data. The tele-Intensivist also participates in multidisciplinary teaching rounds with the NHCP house staff. Several medical protocols have also been developed and implemented as part of the TCC program. When comparing the 12 months before implementation with the 19 months following implementation, we found (1) a trend toward increase volume of admissions per month (22.9 ± 7.5 vs. 27 ± 6.6, p = 0.11), (2) a decrease in total number of avoidable disengagements (12 ± 0.9 vs. 0, p = 0.0008), (3) increased maximum Acute Physiology and Chronic Health Evaluation II score per month (17.22 ± 2.2 vs. 21.8 ± 5.5, p = 0.018), and no adverse outcomes related to the TCC system. This reduction in disengagements correlated with a savings in out-of-network expenditures of $1.3 million over the 19 months of program operation. There was no change in either the patients' length of stay or the number of patients transferred to NMCSD. TCC improves readiness by increasing the volume and acuity of critical care patient encounters at the spoke hospital. TCC can also enhance Graduate Medical Education by providing Intensivist teaching, and supports the concept of "Regionalized Care" by improving the integration of care between hospitals. The quality of care is improved through the more rapid transfer of patients who require a higher level of care, standardization of care through protocols, and the Intensivist expertise that is applied to patients kept at the smaller facility. The value of care increased through both enhanced quality, and the cost savings associated with decreasing network disengagements. Leveraging new technology to provide remote care for our sickest beneficiaries has been proven a successful solution to the dilemma of limited Intensivist staffing. Leadership should consider TCC as a tool to extend Intensivist expertise to all of our small hospitals, and should explore the application of synchronous telehealth within the operational environment where similar staffing challenges exist.

Canine recommended breed weight ranges are not a good predictor of an ideal body condition score

Breed-specific ideal bodyweight range information is widely used by dog owners and breeders as a guideline to ensure animals are within a healthy weight range. Body Condition Scoring, a method used by veterinarians to assess an animal's overall shape with regard to weight is considered to be an excellent method to determine an animal's overall body condition; these values, however, do not always correspond to published weight ranges. Here, the weight, neuter status, age and a nine-point Body Condition Score of a population of 140 purebred dogs were recorded and subsequently analysed to determine whether bodyweight was an effective predictor for Body Condition Scores. This comparison indicated that published recommended, breed-specific body weight ranges are not a good predictor for an ideal BCS and as such, guidelines for owners and breeders need to be systematically reviewed.

Abstract P5-21-24: Retrospective assessment of treatment patterns and outcomes associated with palbociclib plus letrozole for postmenopausal women with HR+/HER2– advanced breast cancer enrolled in an early access program

Background: The objective of this study was to evaluate treatment patterns and clinical outcomes among patients who received palbociclib in combination with letrozole (P+L) for the treatment of HR+/HER2–advanced breast cancer (ABC) as part of an Expanded Access Program (EAP) in the United States.

Methods: Data were obtained by a retrospective chart review of patients previously enrolled in the EAP. Complete data from time of initial diagnosis of ABC until the date of chart abstraction (end of follow-up), including the post-EAP period, were obtained. Clinical outcomes assessed included clinical benefit rate (CBR), defined as complete response, partial response, or stable disease for ≥24 weeks from P + L initiation, progression free survival (PFS) and overall survival (OS). Survival outcomes were assessed using the Kaplan-Meier statistical analysis.

Results: Data from 126 patients were included in this analysis. Median age was 62.5 years at EAP enrollment, and a majority of patients were Caucasian (83%). Approximately 25% of patients had de novo metastatic disease. A majority of patients had a performance status of ECOG 0 (56%) or 1 (37%) at EAP enrollment. Visceral disease was present in 71% of patients and 16% had bone-only disease. The majority of patients in this cohort from the EAP were heavily pre-treated, having had up to 5 prior lines of therapy in the metastatic setting prior to initiating P + L therapy; nearly 59% received 3+ prior lines before initiating P + L. Only 11% of patients received P + L as their initial regimen for MBC. At the time of the last available record, 12 patients were still on P + L therapy, an average of 21 months after the start of the EAP program. Nearly 80% of patients had prior AI exposure and 69% had prior chemotherapy. CBR was 33% for the overall sample of patients treated with P + L and 22% in those with 3+ prior lines of treatment. Patients with prior AI exposure in the ABC setting (n=100) had a CBR of 27% while those without prior AI exposure had CBR of 58%. Patients with prior chemotherapy (n=87) had a CBR of 28% and those without prior chemotherapy had CBR of 46%. For the entire cohort, 6- and 12-month PFS rates were 40% and 25% respectively; 12- and 24-month OS rates were 66% and 44%, respectively. Patients receiving 3+ lines of prior therapy had 6- and 12-month PFS rates of 28% and 19%, respectively, and 12- and 24-month OS rates of 59% and 34% respectively.

Conclusions: Our results suggest that the majority of patients enrolled in the EAP program derived benefit from receiving treatment with P + L despite multiple prior lines of treatment and prior endocrine-based therapy, including prior AI. These findings further demonstrate the benefit of treatment with palbociclib combination therapy in HR+/HER2– MBC.

Citation Format: Brufsky A, Davis K, Mitra D, Nagar S, McRoy L, Cotter M, Stearns V. Retrospective assessment of treatment patterns and outcomes associated with palbociclib plus letrozole for postmenopausal women with HR+/HER2– advanced breast cancer enrolled in an early access program [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-21-24.

GBA mutations in Parkinson disease: earlier death but similar neuropathological features

BACKGROUND AND PURPOSE

Mutations in the glucocerebrosidase (GBA) gene are known to be a risk factor for Parkinson's disease (PD). Data on clinicopathological correlation are limited. The purpose of this study was to determine the clinicopathological findings that might distinguish PD cases with and without mutations in the GBA gene.

METHODS

Data from the Arizona Study of Aging and Neurodegenerative Disorders were used to identify autopsied PD cases that did or did not have a GBA gene mutation. Clinical and neuropathological data were compared.

RESULTS

Twelve PD cases had a GBA mutation and 102 did not. The GBA mutation cases died younger (76 vs. 81 years of age) but there was no difference in disease duration or clinical examination findings. No neuropathological differences were found in total or regional semi-quantitative scores for Lewy-type synucleinopathy, senile plaques, neurofibrillary tangles, white matter rarefaction or cerebral amyloid angiopathy scores.

CONCLUSIONS

In longitudinally assessed, autopsied PD cases, those with GBA mutations had a younger age at death but there was no evidence for clinical or neuropathological differences compared to cases without GBA mutations. Due to the small GBA group size, small differences cannot be excluded.

The role of women's leadership and gender equity in leadership and health system strengthening

Gender equity is imperative to the attainment of healthy lives and wellbeing of all, and promoting gender equity in leadership in the health sector is an important part of this endeavour. This empirical research examines gender and leadership in the health sector, pooling learning from three complementary data sources: literature review, quantitative analysis of gender and leadership positions in global health organisations and qualitative life histories with health workers in Cambodia, Kenya and Zimbabwe. The findings highlight gender biases in leadership in global health, with women underrepresented. Gender roles, relations, norms and expectations shape progression and leadership at multiple levels. Increasing women's leadership within global health is an opportunity to further health system resilience and system responsiveness. We conclude with an agenda and tangible next steps of action for promoting women's leadership in health as a means to promote the global goals of achieving gender equity.