The Impact of Digital Technology on Self-Management in Cancer: Systematic Review

BACKGROUND

Self-management (SM) plays an important role in supporting patients' adaptation to and management of the symptoms of chronic diseases. Cancer is a chronic disease that requires patients to have responsibility in management. Digital technology has the potential to enhance SM support, but there is little data on what SM skills are most commonly supported by digital technology.

OBJECTIVE

This review aimed to examine the SM core skills that were enabled and supported by digital interventions in people with cancer and identify any predictors of the effect of digital health intervention on SM core skills.

METHODS

Three electronic databases (MEDLINE, Scopus, and CINAHL) were searched for papers, published from January 2010 to February 2022, that reported randomized controlled trials (RCTs) involving patients with cancer or survivors of cancer where a digital technology intervention was evaluated and change in 1 or more SM core skills was a measured outcome.

RESULTS

This systematic review resulted in 12 studies that were eligible to identify which SM core skills were enabled and supported by digital intervention. The total number of participants in the 12 studies was 2627. The most common SM core skills targeted by interventions were decision-making, goal setting, and partnering with health professionals. A total of 8 (67%) out of 12 RCTs demonstrated statistically significant improvement in outcomes including self-efficacy, survivorship care knowledge and attitude, quality of life, increased knowledge of treatment, and emotional and social functioning. A total of 5 (62%) out of 8 positive RCTs used theoretical considerations in their study design; whereas in 1 (25%) out of 4 negative RCTs, theoretical considerations were used. In 3 studies, some factors were identified that were associated with the development of SM core skills, which included younger age (regression coefficient [RC]=-0.06, 95% CI -0.10 to -0.02; P=.002), computer literacy (RC=-0.20, 95% CI -0.37 to -0.03; P=.02), completing cancer treatment (Cohen d=0.31), male sex (SD 0.34 in social functioning; P=.009), higher education (SD 0.19 in social functioning; P=.04), and being a recipient of chemotherapy (SD 0.36 in depression; P=.008). In all 3 studies, there were no shared identical factors that supported the development of SM core skills, whereby each study had a unique set of factors that supported the development of SM core skills.

CONCLUSIONS

Digital technology for patients with cancer appears to improve SM core skills including decision-making, goal setting, and partnering with health care partners. This effect is greater in people who are younger, male, educated, highly computer literate, completing cancer treatment, or a recipient of chemotherapy. Future research should focus on targeting multiple SM core skills and identifying predictors of the effect of digital technology intervention.

TRIAL REGISTRATION

PROSPERO CRD42021221922; https://tinyurl.com/mrx3pfax.

Patients' experiences of a suppoRted self-manAGeMent pAThway In breast Cancer (PRAGMATIC): quality of life and service use results

PURPOSE

To describe trends and explore factors associated with quality of life (QoL) and psychological morbidity and assess breast cancer (BC) health service use over a 12-month period for patients joining the supported self-management (SSM)/patient-initiated follow-up (PIFU) pathway.

METHODS

Participants completed questionnaires at baseline, 3, 6, 9 and 12 months that measured QoL (FACT-B, EQ 5D-5L), self-efficacy (GSE), psychological morbidity (GHQ-12), roles and responsibilities (PRRS) and service use (cost diary).

RESULTS

99/110 patients completed all timepoints; 32% (35/110) had received chemotherapy. The chemotherapy group had poorer QoL; FACT-B total score mean differences were 8.53 (95% CI: 3.42 to 13.64), 5.38 (95% CI: 0.17 to 10.58) and 8.00 (95% CI: 2.76 to 13.24) at 6, 9 and 12 months, respectively. The odds of psychological morbidity (GHQ12 >4) were 5.5-fold greater for those treated with chemotherapy. Financial and caring burdens (PRRS) were worse for this group (mean difference in change at 9 months 3.25 (95% CI: 0.42 to 6.07)). GSE and GHQ-12 scores impacted FACT-B total scores, indicating QoL decline for those with high baseline psychological morbidity. Chemotherapy patients or those with high psychological morbidity or were unable to carry out normal activities had the highest service costs. Over the 12 months, 68.2% participants phoned/emailed breast care nurses, and 53.3% visited a hospital breast clinician.

CONCLUSION

The data suggest that chemotherapy patients and/or those with heightened psychological morbidity might benefit from closer monitoring and/or supportive interventions whilst on the SSM/PIFU pathway. Reduced access due to COVID-19 could have affected service use.

Functional Connectivity Analysis of Visually Evoked ERPs for Mild Cognitive Impairment: Pilot Study

Mild cognitive impairment (MCI) is considered the early stage of Alzheimer's disease, characterized as mild memory loss. A novel method of functional connectivity (FC) analysis can be used to detect MCI before memory is significantly impaired allowing for preventative measures to be taken. FC examines interactions between EEG channels to grant insight on underlying neural networks and analyze the effects of MCI. Applying FC method of weighted phase lag index (wPLI) to P300 ERPs provided insight on the link between the pathology of Alzheimer's disease and cognitive loss. wPLI was analyzed per frequency band (θ, α, μ, β) and by channel combination groups (intra-hemispheric short, intra-hemispheric long, inter-hemispheric short, inter-hemispheric long, transverse). MCI was found to have a statistically significant lower ΔwPLIP300 compared to normal controls in the μ intra-hemispheric short (p = 0.0286), μ intra-hemispheric long (p = 0.0477), μ inter-hemispheric short (p = 0.0018) and the α intra-hemispheric short (p = 0.0423). Results indicate a possible deficiency in the dorsal visual processing pathway among MCI subjects as well as an unbalanced coordination between the two hemispheres.

The Cost of a Nutritious Diet for Households Including People Living with HIV/AIDS in Nova Scotia: Findings and Lessons Learned by FoodNOW 2020 to 2022

Purpose: FoodNOW (Food to eNhance Our Wellness) engaged in assessment of simulated households that include a person living with HIV/AIDS (PLWHA) in Nova Scotia to determine if a basic nutritious diet is affordable.Methods: We used supermarket websites to cost food and beverage items listed in the National Nutritious Food Basket (NNFB) for simulated households, each with a PLWHA. Food costing methodologies were co-developed and adapted with community members in response to barriers presented by the COVID-19 pandemic.Results: We found that simulated households, each with one PLWHA, that had a potential deficit after monthly expenses were a household of four on Income Assistance (-$1,058.70), a lone mother with two children on Income Assistance (-$973.65), a lone man on Income Assistance (-$677.40), and a household of four with one minimum-wage earner (-$383.45).Conclusions: Nova Scotia households with a PLWHA living on Income Assistance or with a minimum-wage earner cannot reasonably afford a nutritious diet in addition to basic household expenses. Using these food costing data can allow dietitians to efficiently inform government action and policy change to improve the health and wellness of individuals and families.

Exploring Food and Nutrition Programming for People Living With HIV/AIDS: Interviews With Service Providers in Nova Scotia, Canada

There is a lack of nutritional programming and resources available for people living with HIV/AIDS (PLWHA) in Nova Scotia, Canada. This is problematic for several reasons, including that adequate food and nutrition knowledge is integrated to effective medical therapy and wellness for PLWHA. The aim of this research was to explore and describe the beliefs, values, and experiences of HIV-service providers involved programming for PLWHA in Nova Scotia. Using a post-structuralist lens, semi-structured interviews were conducted with nine service providers. Thematic analysis of interview transcripts identified four main themes: (1) recognizing the social determinants of health, (2) acknowledging and disrupting layered stigma, (3) understanding the commensality, and (4) navigating and utilizing networks of care. These findings suggest that those developing, delivering, and evaluating food and nutrition-related programming must engage in community-inclusive approaches that recognize the varied social determinants of health that shape the lived of PLWHA, leverage existing networks and resources, and actively disrupt layered stigma. Also, in agreement with existing evidence, participants stressed the value of communicating and supporting the practice of eating together (commensality) and cultivating networks of care.

The association between iron deficiency and outcomes: a secondary analysis of the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial

In the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial, the use of intravenous iron did not reduce the need for blood transfusion or reduce patient complications or length of hospital stay. As part of the trial protocol, serum was collected at randomisation and on the day of surgery. These samples were analysed in a central laboratory for markers of iron deficiency. We performed a secondary analysis to explore the potential interactions between pre-operative markers of iron deficiency and intervention status on the trial outcome measures. Absolute iron deficiency was defined as ferritin <30 μg.l^-1 ; functional iron deficiency as ferritin 30-100 μg.l^-1 or transferrin saturation < 20%; and the remainder as non-iron deficient. Interactions were estimated using generalised linear models that included different subgroup indicators of baseline iron status. Co-primary endpoints were blood transfusion or death and number of blood transfusions, from randomisation to 30 days postoperatively. Secondary endpoints included peri-operative change in haemoglobin, postoperative complications and length of hospital stay. Most patients had iron deficiency (369/452 [82%]) at randomisation; one-third had absolute iron deficiency (144/452 [32%]) and half had functional iron deficiency (225/452 [50%]). The change in pre-operative haemoglobin with intravenous iron compared with placebo was greatest in patients with absolute iron deficiency, mean difference 8.9 g.l^-1 , 95%CI 5.3-12.5; moderate in functional iron deficiency, mean difference 2.8 g.l^-1 , 95%CI -0.1 to 5.7; and with little change seen in those patients who were non-iron deficient. Subgroup analyses did not suggest that intravenous iron compared with placebo reduced the likelihood of death or blood transfusion at 30 days differentially across subgroups according to baseline ferritin (p = 0.33 for interaction), transferrin saturation (p = 0.13) or in combination (p = 0.45), or for the number of blood transfusions (p = 0.06, 0.29, and 0.39, respectively). There was no beneficial effect of the use of intravenous iron compared with placebo, regardless of the metrics to diagnose iron deficiency, on postoperative complications or length of hospital stay.

What Makes a Quality Health App-Developing a Global Research-Based Health App Quality Assessment Framework for CEN-ISO/TS 82304-2: Delphi Study

BACKGROUND

The lack of an international standard for assessing and communicating health app quality and the lack of consensus about what makes a high-quality health app negatively affect the uptake of such apps. At the request of the European Commission, the international Standard Development Organizations (SDOs), European Committee for Standardization, International Organization for Standardization, and International Electrotechnical Commission have joined forces to develop a technical specification (TS) for assessing the quality and reliability of health and wellness apps.

OBJECTIVE

This study aimed to create a useful, globally applicable, trustworthy, and usable framework to assess health app quality.

METHODS

A 2-round Delphi technique with 83 experts from 6 continents (predominantly Europe) participating in one (n=42, 51%) or both (n=41, 49%) rounds was used to achieve consensus on a framework for assessing health app quality. Aims included identifying the maximum 100 requirement questions for the uptake of apps that do or do not qualify as medical devices. The draft assessment framework was built on 26 existing frameworks, the principles of stringent legislation, and input from 20 core experts. A follow-up survey with 28 respondents informed a scoring mechanism for the questions. After subsequent alignment with related standards, the quality assessment framework was tested and fine-tuned with manufacturers of 11 COVID-19 symptom apps. National mirror committees from the 52 countries that participated in the SDO technical committees were invited to comment on 4 working drafts and subsequently vote on the TS.

RESULTS

The final quality assessment framework includes 81 questions, 67 (83%) of which impact the scores of 4 overarching quality aspects. After testing with people with low health literacy, these aspects were phrased as "Healthy and safe," "Easy to use," "Secure data," and "Robust build." The scoring mechanism enables communication of the quality assessment results in a health app quality score and label, alongside a detailed report. Unstructured interviews with stakeholders revealed that evidence and third-party assessment are needed for health app uptake. The manufacturers considered the time needed to complete the assessment and gather evidence (2-4 days) acceptable. Publication of CEN-ISO/TS 82304-2:2021 Health software - Part 2: Health and wellness apps - Quality and reliability was approved in May 2021 in a nearly unanimous vote by 34 national SDOs, including 6 of the 10 most populous countries worldwide.

CONCLUSIONS

A useful and usable international standard for health app quality assessment was developed. Its quality, approval rate, and early use provide proof of its potential to become the trusted, commonly used global framework. The framework will help manufacturers enhance and efficiently demonstrate the quality of health apps, consumers, and health care professionals to make informed decisions on health apps. It will also help insurers to make reimbursement decisions on health apps.

Exploring current nutritional programming and resources available to people living with HIV/AIDs in Canada: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to map the current literature and resources available on nutrition and food programming for people living with HIV/AIDS in Canada. This review is phase 1 of a 4-phase, provincially funded project called FoodNOW (Food to eNhance Our Wellness) focused on nutritional assessment of people living with HIV/AIDS in Nova Scotia, Canada.

INTRODUCTION

People living with HIV/AIDS may experience nutritional challenges, including food insecurity and nutrition-drug interactions. Nutritional programming is required for optimal care for people living with HIV/AIDS, however, there is a lack of information within the literature about current nutrition and food programming in Canada. This proposed review will investigate available programming and gaps.

INCLUSION CRITERIA

This review will consider literature focused on nutrition and food programming and resources in Canada for people living with HIV/AIDS. People living with HIV/AIDS of any age, sex, race, gender identity, or sexual orientation, including pregnant and lactating people living with HIV/AIDS, will be included as population of interest.

METHODS

The following databases will be searched: MEDLINE (EBSCO), CINAHL (EBSCO), Academic Search Premier (EBSCO), Social Services Abstracts (ProQuest), and Scopus. Types of gray literature eligible for review include reports from service providers and online public newspaper articles written by, with, or about people living with HIV/AIDS. Two independent reviewers will assess each study and any conflicts will be resolved through discussion. Data will be extracted by 2 independent reviewers. Results will be presented in tabular or diagrammatic format, with a narrative summary.

Increasing precision in the measurement of change in pediatric neurodegenerative disease

Due to the surge in new brain-directed treatments, metrics to detect the alteration in developmental trajectories in cognition and adaptive behavior have become increasingly important. We propose Growth Scale Values (GSVs) as a solution to monitoring children with severe neurologic/neurodegenerative conditions. This report stems from a panel of experts presenting at the Gorlin symposium (WORLD Symposium) and a subsequent open Webinar sponsored by the National MPS Society. Because norm-referenced scores (Standard Scores or Intelligence Quotient, i.e., IQ) do not yield information about gain, stability, or loss of skills, they are not suitable for natural history studies or clinical trials. Age-equivalent (AE) scores have been the standard metric used in natural history studies. While AEs are familiar and interpretable to clinicians and parents, they are imprecise due to lack of standard deviations, standard errors of measurement, and equal intervals between scores. Raw scores also have unequal intervals and are not comparable between ages or ability levels. The GSV, a nonlinear transformation of raw scores using item calibration to make an interval scale score, can be used for accurate measures of within-person change. GSVs have been identified as a useful metric for longitudinal measurement of other conditions involving neurodiversity. These growth scores circumvent inaccurate AEs in infants, are not limited by age and can be used for impaired patients who are chronologically above the normative age range. GSVs have interval properties (a given difference between GSV values represents the same difference in ability at all score levels) and each GSV value has a known standard error of measurement (SEM). GSVs are recommended to measure change in cognitive and adaptive behavior in natural history studies and in clinical trials for children with neurologic disease.

A comparison of ultrasound guided bilateral single injection shot Erector Spinae Plane blocks versus wound infiltration for post-operative analgesia in laparoscopic assisted colonic surgery- a prospective randomised study

Background

Both wound infiltration (WI) with local anaesthetic and Erector Spinae Plane block (ESPB) have been described for post-operative analgesia after abdominal surgery. This study compared the efficacy of WI versus ESPB for post-operative analgesia after laparoscopic assisted colonic surgery.

Methods

Seventy-two patients between 18 and 85 years of age undergoing elective surgery were randomised to receive either WI or ESPB. In the WI group a 40 ml bolus of 0.5% Ropivacaine, infiltrated at the ports and minimally invasive wound at subcutaneous and fascia layers. In the ESPB group at T8 level, under ultrasound guidance, a 22-gauge nerve block needle was passed through the Erector Spinae muscle to reach its fascia. A dose up to 40 ml of 0.5% Ropivacaine, divided into two equal volumes, was injected at each side. Both groups had a multimodal analgesic regime, including regular Paracetamol, dexamethasone and patient-controlled analgesia (PCA) with Fentanyl. The primary end point was a post-operative pain score utilising a verbal Numerical Rating Score (NRS, 0–10) on rest and coughing in the post anaesthetic care unit (PACU) and in the first 24 h. Secondary outcomes measured were: opioid usage, length of stay and any clinical adverse events.

Results

There was no significant treatment difference in PACU NRS at rest and coughing (p-values 0. 382 and 0.595respectively). Similarly, there were no significant differences in first 24 h NRS at rest and coughing (p-values 0.285 and 0.431 respectively). There was no significant difference in Fentanyl use in PACU or in the first 24 h (p- values 0.900 and 0.783 respectively). Neither was there a significant difference found in mean total Fentanyl use between ESPB and WI groups (p-value 0.787).

Conclusion

Our observations found both interventions had an overall similar efficacy.

Trial registration

The study was registered with the Australian New Zealand Clinical Trial Registry (ACTRN: 12619000113156).

Process evaluation of We Can Quit- stop-smoking programme for women in socio-disadvantage in Ireland

Background

Smoking tobacco poses a serious risk of early preventable death and disease for women living with socioeconomic disadvantage (SED). A smoking cessation programme ‘We Can Quit' (WCQ) tailored to women living in four SED areas developed in Ireland included group support delivered by trained lay local women and free nicotine replacement therapy (NRT). The intervention was pilot tested in a community-based, cluster randomised controlled trial, ‘We Can Quit 2'. Results of an embedded process evaluation to assess feasibility and acceptability of the programme and trial processes are presented.

Methods

The design was qualitative using the Medical Research Council's (MRC) process evaluation framework. Semi-structured interviews with trial participants (N = 18) and Community Facilitators (CFs) who delivered WCQ (N = 8) were conducted. An inductive approach was used and data were analysed using thematic coding.

Results

Peer-modelling, a non-judgemental environment, and CFs supportive role were viewed as facilitative elements of group support. Potential for broader message diffusion into the social networks of participating women was observed. Participants reported that free access to NRT was helpful for cessation. Some participants expressed concerns about NRT side effects. Community pharmacists provided important guidance relating to NRT and additional support between group sessions. Provision of a saliva samples proved challenging. Low literacy was a barrier to engagement with the programme and completion of trial-related materials. Hypothetical scenarios of direct or indirect observational fidelity assessment for a definitive trial (DT) were acceptable.

Conclusions

The MRC framework proved useful to capture the experience of women smokers in SED areas of engaging with a community-based smoking cessation trial. Programme and trial-related processes were feasible and acceptable. A future DT will need to address low literacy.

Key messages

A group-based stop-smoking programme including free NRT was acceptable and feasible to programme deliverers and women smokers living in disadvantaged communities. Women’s low literacy was a barrier to engagement with trial and completion of programme materials.

1161 Streamlining the Patient Journey for Operative Management During COVID 19

Aim

Leeds, UK is a high-volume acute surgery unit. Emergency operating was drastically affected by the pandemic and time from admission to definitive procedure significantly increased. This intervention aimed to streamline the patient journey from acute admission to the operating theatre.

Method

An audit considering delays to transfer, theatre access and recovery discharge, along with the criteria used for ‘Hot’ theatre was undertaken. Data was collected prospectively between 02/06/2020-06/07/2020 via a standardised proforma. Preliminary results suggested a geographically remote ‘hot’ theatre was associated with multi-factorial delays so was relocated to more familiar surroundings. This was re-audited between 06/07/2020-06/08/2020 aiming to characterise factors contributing to delay. A dedicated in-hours acute theatres porter was introduced for a trial period. Data was collected retrospectively between 24/08/2020-14/09/2020 and prospectively between 14/09-05/10/2020 via hospital electronic systems.

Results

Initially the average time from patient transfer to leaving theatre recovery was 4h6m55s (N = 52). Relocating theatres reduced this to 2h48m04s (N = 74)- an average reduction of 1h18m51s. The greatest reduction was seen in anaesthetic time between 1h17m54s to 41m29s. The introduction of a dedicated porter reduced the average transfer time to theatre from 36 minutes (N = 53) to 21 minutes (N = 68) (p &lt; 0.05).

Conclusions

Delay to theatre has a high cost financially and in its effect on patient outcomes. Delays are often multifactorial and robust systems are essential to minimise delays. Patients are best served by well-trained, dedicated ‘Acute’ team in familiar surroundings. Long-term implementation of dedicated portering service will save time, money and improve patient care.

Frailty is associated with long-term outcome in patients with sepsis who are over 80 years old: results from an observational study in 241 European ICUs

BACKGROUND

Sepsis is one of the most frequent reasons for acute intensive care unit (ICU) admission of very old patients and mortality rates are high. However, the impact of pre-existing physical and cognitive function on long-term outcome of ICU patients ≥ 80 years old (very old intensive care patients (VIPs)) with sepsis is unclear.

OBJECTIVE

To investigate both the short- and long-term mortality of VIPs admitted with sepsis and assess the relation of mortality with pre-existing physical and cognitive function.

DESIGN

Prospective cohort study.

SETTING

241 ICUs from 22 European countries in a six-month period between May 2018 and May 2019.

SUBJECTS

Acutely admitted ICU patients aged ≥80 years with sequential organ failure assessment (SOFA) score ≥ 2.

METHODS

Sepsis was defined according to the sepsis 3.0 criteria. Patients with sepsis as an admission diagnosis were compared with other acutely admitted patients. In addition to patients' characteristics, disease severity, information about comorbidity and polypharmacy and pre-existing physical and cognitive function were collected.

RESULTS

Out of 3,596 acutely admitted VIPs with SOFA score ≥ 2, a group of 532 patients with sepsis were compared to other admissions. Predictors for 6-month mortality were age (per 5 years): Hazard ratio (HR, 1.16 (95% confidence interval (CI), 1.09-1.25, P < 0.0001), SOFA (per one-point): HR, 1.16 (95% CI, 1.14-1.17, P < 0.0001) and frailty (CFS > 4): HR, 1.34 (95% CI, 1.18-1.51, P < 0.0001).

CONCLUSIONS

There is substantial long-term mortality in VIPs admitted with sepsis. Frailty, age and disease severity were identified as predictors of long-term mortality in VIPs admitted with sepsis.

616 Preventing Biofilms on BACTIGON® Coated Camstent Urinary Catheters in Patients Undergoing Elective Colorectal Surgery: A Single Centre Pilot Study

Introduction

Catheter associated urinary tract infections account for 40% of hospital acquired infections. They are associated with biofilms consisting of bacterial cells enmeshed in a self-generated extracellular matrix adhering to catheter surfaces. We have developed a novel polymer family that, coated onto urinary catheters, creates a “non-stick” surface preventing biofilm development.

Method

Prospective cohort of elective colorectal patients recruited pre-operatively, received a standard silicone (SS) or Camstent (BACTIGON®) coated urinary catheter. After removal, catheters were cut longitudinally into 3 segments. Biomass and biomineralisation were analysed using confocal fluorescence microscopy. Data were normalised by square rooting the catheter indwelling duration. Environmental scanning electron microscopy and energy dispersive x-ray spectroscopy was performed.

Results

Of 40 patients, 20 each received a SS or coated catheter. Between SS and coated catheters, average indwelling duration was similar and biofilm biomass was 32.068µg/cm2 (95%CI ±21.950) vs. 1.948µg/cm2 (95%CI ±2.595) (P = 0.0111). Confocal microscopy suggested a 93.93% reduction in biofilm biomass on coated catheters. Mineral compositions were different with biofilm and struvite/apatite on SS and calcium oxalate, endogenously derived, on coated catheters.

Conclusions

Inert BACTIGON® coated catheters appear superior at preventing biofilm formation than SS catheters. Clinical trials are needed to determine the clinical and health economic benefit of this intervention.

Astropharmacy: Exploring the Pharmacist’s Role in Space travel

Introduction

Significant alterations occur in human physiology and the way medications function in space (1). Understanding the efficacy and pitfalls of pharmacological intervention and developing space-related pharmacy services is therefore integral to ensuring a sustained presence for human spaceflight. In contemporary society, the pharmacist plays a significant role in a person’s health. However, pharmacist input towards the spaceflight participant’s health is minimal to nil.

Aim: T

o explore stakeholder perspectives towards the role of Astropharmacy in the space sector.

Methods

Pharmacists (n = 18) across the globe and space sector participants (n = 18) from governmental, commercial, and space tourism sectors participated, via 27 qualitative interviews and three focus groups. Participants were recruited via purposive and snowball sampling. A six-step thematic analysis was used and mapped into the Job Characteristics Model (JCM). JCM is a theory within work design, aiming to promote work experiences and personal outcomes. There are five job dimensions – skill variety, task identity, task significance, autonomy, and feedback which influence three psychological states required for a well-designed job. The three psychological states are meaningfulness, responsibility, and knowledge of work results, which lead to positive work and personal experiences (2).

Results

Three key themes were generated: medication management, medication research, and regulation/licensing. Medication management encompassed safeguarding the space traveller’s health, like space tourists, by conducting medication reviews (pre-and post-flight), medication advice (digital astro-telepharmacy information services during spaceflight) and developing personalised medication. Medication management also included ensuring shelf-life and continuous medication supply for deep space exploration. Medication research included novel drug development, innovative manufacturing, and understanding clinical applications of the pharmacokinetic and pharmacodynamic changes of medications in space. Innovative manufacturing like 3-D printing raises questions regarding the need for regulations/licensing of medications use and manufacturing in space. Based on the JCM our findings indicate that Astropharmacy possesses diverse duties eliciting meaningfulness, with clear responsibility and observable workplace results promoting task significance, and both the medication and patient focus promoting task identity. Autonomy was blurred within Astropharmacy as a degree of autonomy is needed due to the field’s novelty, but workforce regulations by governmental space agencies are expected. Lastly, workplace feedback can be achieved in Astropharmacy through performance reviews.

Conclusion

The Astropharmacy role is perceived to involve medication management, medication research and regulation/licensing of medications for space. The work design of astropharmacy is well-reflected in the JCM, implying that a novel and energising opportunity for the pharmacy profession is forthcoming. Although the data generated by qualitative research are not generalizable to other settings, these themes represent the first study to investigate the space sector qualitatively in the context of pharmacy, providing rich foundational data for future research. Consequently, the amalgamation of two previously distinct workplace domains may be a conceivable reality for the future of pharmacy practice.

References

1. Blue RS, Bayuse TM et al. Supplying a pharmacy for NASA exploration spaceflight: challenges and current understanding. Npj Microgravity. 2019;5(1):1–12.

2. Hackman RJ, Oldham G. Motivation through the design of work: Test of a theory. Organizational Behavior and Human Performance. 1976;16(2):250–279.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

System-mapping the child health system at a local level to reduce health inequalities

Background

Systems thinking has emerged as a promising approach to addressing complex public health issues. For children, the focus of the approach has been on single outcomes e.g. obesity, rather than addressing the broad range of inequalities in health outcomes. We report on an approach to developing a system-oriented perspective on the determinants of inequalities in child health and wellbeing in English local authorities.

Methods

Qualitative group concept mapping workshops (a 'soft' system science approach) were held in two contrasting English local authorities with a range of stakeholders: professionals (N = 35); children and young people (N = 33) and carers (N = 5). Initial area maps were refined using data from qualitative interviews with professionals (N = 16) and resulting maps reviewed and validated by expert stakeholders in each area (N = 9; N = 35). Commonalities between two area-specific system maps (and removal of locality-specific factors) were used to develop a map that could be applied in any English local area. Two rounds of online consultation (N = 21; N = 8) and qualitative interviews (N = 12) with experts in public health, local governance and systems science refined the final system map displaying the determinants of child health inequalities, and give insight into its potential utilisation.

Results

The process created a map of over 150 factors influencing inequalities in health outcomes for children aged 0-25 years at the local area level. The system map has six domains; physical environment, governance, economic, social, service, and personal.

Conclusions

To our knowledge this is the first study taking a systems approach to addressing inequalities across all aspects of child health. Group concept mapping can support systems thinking at the local level. The resulting system map illustrates the complexity of factors influencing child health inequalities and is a useful tool for strategy development, action prioritisation and systems evaluation planning.

Key messages

Group concept mapping can be successfully applied to facilitate a systems approach to child health inequalities at the local area level. Mapping the local child health system highlights complex relationships between physical, social, personal, service, governance and economic factors which influence inequalities and health outcomes.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Feed-derived iodine overrides environmental contribution to cow milk

Diets worldwide are deficient in iodine, leading to a range of undesirable health effects at the population level. Dairy products are a primary source of iodine in diets for those populations in which iodized salt is not systematically used or available. However, the flows of iodine through dairy agroecosystems are not well understood. The aim of this research was to investigate iodine flows though the dairy agroecosystem, including the influence of atmospheric depositional inputs, environmental variables, season, husbandry, and diet. Three farm-based sampling campaigns were carried out in this investigation, with milk, soil, silage, grass, and feed iodine determined by inductively coupled plasma mass spectroscopy, and nonparametric statistical analysis tests were conducted on data sets obtained. Natural iodine inputs into the environment are dominated by atmospheric deposition, which mainly from sea spray, and thus the location of farms relative to the coast and prevailing wind direction. Herbage and silage produced from grass-based systems strongly correlated with soil iodine, yet there was a strong disconnect between soil, forage, and feed and the milk that results. This was due to the levels of iodine in supplemental feeds being approximately 10-fold higher than those in forage-derived feeds. The practice of feed supplementation, accentuated by summer housing of cows, led to elevated milk iodine.

Safety and tolerability of injectable Rilpivirine LA in HPTN 076: A phase 2 HIV pre-exposure prophylaxis study in women

BACKGROUND

Daily oral TDF/FTC is protective against HIV infection when used for pre-exposure prophylaxis (PrEP). However, daily adherence to oral PrEP is difficult for many; therefore, finding alternative PrEP strategies remains a priority. HPTN 076 evaluated the long-acting injectable form of rilpivirine (RPV), known as RPV LA for safety, pharmacokinetics and acceptability.

METHODS

HPTN 076 (NTC 02165202) was a phase 2, double-blind, 2:1 randomized trial comparing the safety of 1200mg RPV LA (LA) to placebo (P). The study included a 28-day oral run-in phase of daily, self- administered oral RPV (25 mg), with directly observed oral dosing about six times. Of 136 enrolled sexually active, HIV-uninfected, low HIV-risk African (100) and US (36) adult women, injectable product was administered in two gluteal, intramuscular (IM) injections once every eight weeks to 122 participants following the oral run-in phase. A maximum of six injection time points occurred over a 48-week period. Acceptability, safety, tolerability and pharmacokinetic (PK) data were collected throughout the study. This paper includes primary endpoint data collected up to the week 52 post enrollment.

FINDINGS

The median age of the enrolled population was 31 years (IQR: 25,38), median weight 75 kg (IQR: 64, 89), median body mass index (BMI) 30 (IQR: 27, 35), 46% married, 94% Black and 60% unemployed. A total of 122 (80 LA, 42 P) women received at least one injection and 98 (64 LA, 34 P) received all six injections. During the injection phase, three women withdrew from the study (2 LA, 1 P) and 16 women discontinued study product (10 LA, 6 P). Fourteen women (11 LA and 3 P) discontinued oral study product and did not enter the injection phase. Study product discontinuations were not significantly different between the two arms throughout. Of the product discontinuations in the injection phase, 8% in LA and 5% in P arm were due to adverse events (AEs), including one randomized to the P arm with prolonged QTc interval on EKG. The proportion of women who experienced Grade 2 or higher AEs during the injection phase as the primary outcome was not significantly different between the two arms [73.8%, 95% CI: (63.2%, 82.1%) for LA and 73.8%, 95% CI: (58.9%, 84.7%), p>0.99]. Transient Grade ≥2 liver abnormalities occurred in 14% of women in the LA arm compared with 12% in P arm. Three LA women (4%) developed Grade 3 injection site reactions compared with none in P arm. In participants who received at least 1 injection, the geometric mean of overall RPV trough concentrations (Ctrough) was 62.2 ng/mL. In participants who received all six injections, the geometric mean of CTrough through the injection phase and after the last injection were 72.8 ng/mL and 100.9 ng/mL, respectively. At week 52 (eight weeks after last injection), the geometric mean of RPV Ctrough was 75.0 ng/mL. At the last injection visit (Week 44), 80 % of women who answered acceptability questions strongly agreed that they would think about using- and 68% that they would definitely use a PrEP injectable in the future.

INTERPRETATION

RPV LA IM injections every eight weeks in African and US women were safe and acceptable. Overall, despite more injection site reactions and pain in the participants receiving RPV LA the injections were well tolerated. Data from this study support the further development of injectable PrEP agents.

Outcomes Six Months after Delivering 100% or 70% of Enteral Calorie Requirements during Critical Illness (TARGET). A Randomized Controlled Trial

Rationale: The long-term effects of delivering approximately 100% of recommended calorie intake via the enteral route during critical illness compared with a lesser amount of calories are unknown.Objectives: Our hypotheses were that achieving approximately 100% of recommended calorie intake during critical illness would increase quality-of-life scores, return to work, and key life activities and reduce death and disability 6 months later.Methods: We conducted a multicenter, blinded, parallel group, randomized clinical trial, with 3,957 mechanically ventilated critically ill adults allocated to energy-dense (1.5 kcal/ml) or routine (1.0 kcal/ml) enteral nutrition.Measurements and Main Results: Participants assigned energy-dense nutrition received more calories (percent recommended energy intake, mean [SD]; energy-dense: 103% [28] vs. usual: 69% [18]). Mortality at Day 180 was similar (560/1,895 [29.6%] vs. 539/1,920 [28.1%]; relative risk 1.05 [95% confidence interval, 0.95-1.16]). At a median (interquartile range) of 185 (182-193) days after randomization, 2,492 survivors were surveyed and reported similar quality of life (EuroQol five dimensions five-level quality-of-life questionnaire visual analog scale, median [interquartile range]: 75 [60-85]; group difference: 0 [95% confidence interval, 0-0]). Similar numbers of participants returned to work with no difference in hours worked or effectiveness at work (n = 818). There was no observed difference in disability (n = 1,208) or participation in key life activities (n = 705).Conclusions: The delivery of approximately 100% compared with 70% of recommended calorie intake during critical illness does not improve quality of life or functional outcomes or increase the number of survivors 6 months later.

The Australasian Resuscitation In Sepsis Evaluation: Fluids or vasopressors in emergency department sepsis (ARISE FLUIDS), a multi-centre observational study describing current practice in Australia and New Zealand

OBJECTIVES

To describe haemodynamic resuscitation practices in ED patients with suspected sepsis and hypotension.

METHODS

This was a prospective, multicentre, observational study conducted in 70 hospitals in Australia and New Zealand between September 2018 and January 2019. Consecutive adults presenting to the ED during a 30-day period at each site, with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation, were eligible. Data included baseline demographics, clinical and laboratory variables and intravenous fluid volume administered, vasopressor administration at baseline and 6- and 24-h post-enrolment, time to antimicrobial administration, intensive care admission, organ support and in-hospital mortality.

RESULTS

A total of 4477 patients were screened and 591 were included with a mean (standard deviation) age of 62 (19) years, Acute Physiology and Chronic Health Evaluation II score 15.2 (6.6) and a median (interquartile range) systolic blood pressure of 94 mmHg (87-100). Median time to first intravenous antimicrobials was 77 min (42-148). A vasopressor infusion was commenced within 24 h in 177 (30.2%) patients, with noradrenaline the most frequently used (n = 138, 78%). A median of 2000 mL (1500-3000) of intravenous fluids was administered prior to commencing vasopressors. The total volume of fluid administered from pre-enrolment to 24 h was 4200 mL (3000-5661), with a range from 1000 to 12 200 mL. Two hundred and eighteen patients (37.1%) were admitted to an intensive care unit. Overall in-hospital mortality was 6.2% (95% confidence interval 4.4-8.5%).

CONCLUSION

Current resuscitation practice in patients with sepsis and hypotension varies widely and occupies the spectrum between a restricted volume/earlier vasopressor and liberal fluid/later vasopressor strategy.

Magnesium isotopes of the bulk solar wind from Genesis diamond-like carbon films

NASA's Genesis Mission returned solar wind (SW) to the Earth for analysis to derive the composition of the solar photosphere from solar material. SW analyses control the precision of the derived solar compositions, but their ultimate accuracy is limited by the theoretical or empirical models of fractionation due to SW formation. Mg isotopes are "ground truth" for these models since, except for CAIs, planetary materials have a uniform Mg isotopic composition (within ≤1‰) so any significant isotopic fractionation of SW Mg is primarily that of SW formation and subsequent acceleration through the corona. This study analyzed Mg isotopes in a bulk SW diamond-like carbon (DLC) film on silicon collector returned by the Genesis Mission. A novel data reduction technique was required to account for variable ion yield and instrumental mass fractionation (IMF) in the DLC. The resulting SW Mg fractionation relative to the DSM-3 laboratory standard was (-14.4‰, -30.2‰) ± (4.1‰, 5.5‰), where the uncertainty is 2ơ SE of the data combined with a 2.5‰ (total) error in the IMF determination. Two of the SW fractionation models considered generally agreed with our data. Their possible ramifications are discussed for O isotopes based on the CAI nebular composition of McKeegan et al. (2011).

Cigarettes and Straws: Late Positive Potential Modulation in Mental Illness and Nicotine Addiction

Tobacco use remains a major preventable cause of death worldwide, accumulating billions of dollars in healthcare spending annually in the U.S. alone. Evidence has found that among those addicted, individuals suffering with psychiatric illnesses are disproportionally abusing. To assess this disparity, our study observed event related potential (ERP) responses recorded with electroencephalogram (EEG) in chronic smokers with (MI; n=6) and without mental illness (NMI; n=6). We found that the MI group alone presented heightened late positive potential (LPP) responses while processing cigarette (addictive) stimuli compared to neutral images (t-value = 3.11 at Cz, 3.92 at Pz). Our study illustrates the significance of the LPP as a promising biomarker to assess tobacco addiction in individuals facing mental illness.

Determination of ß-Glucan in Barley and Oats by Streamlined Enzymatic Method: Summary of Collaborative Study

A collaborative study was conducted involving 8 laboratories (including the authors’ laboratories) to validate the streamlined enzymatic method for determination of ß-D-glucan in barley and oats. In the method, the flour sample is cooked to hydrate and gelatinize ß-glucan, which is subsequently hydrolyzed to soluble fragments with the lichenase enzyme. After volume and pH adjustments and filtration, the solution is treated with ß-glucosidase, which hydrolyzes ß-gluco-oligosaccharides to D-glucose. D-Glucose is measured with glucose oxidase-peroxidase reagent. Other portions of lichenase hydrolysate are treated directly with glucose oxidase-peroxidase reagent to measure free glucose in test sample. If levels of free glucose are high, the sample is extracted first with 80% ethanol. For all samples analyzed, the repeatability relative standard deviation (RSDr) values ranged from 3.1 to 12.3% and the reproducibility relative standard deviation (RSDR) values ranged from 6.6 to 12.3%. The streamlined enzymatic method for determination of ß-D-glucan in barley and oats has been adopted first action by AOAC INTERNATIONAL.

Facial Recognition Task for the Classification of Mild Cognitive Impairment with Ensemble Sparse Classifier

Conventional methods for detecting mild cognitive impairment (MCI) require cognitive exams and follow-up neuroimaging, which can be time-consuming and expensive. A great need exists for objective and cost-effective biomarkers for the early detection of MCI. This study uses a sequential imaging oddball paradigm to determine if familiar, unfamiliar, or inverted faces are effective visual stimuli for the early detection of MCI. Unlike the traditional approach where the amplitude and latency of certain deflection points of event-related potentials (ERPs) are selected as electrophysiological biomarkers (or features) of MCI, we used the entire ERPs as potential biomarkers and relied on an advanced machine-learning technique, i.e. an ensemble of sparse classifier (ESC), to choose the set of features to best discriminate MCI from healthy controls. Five MCI subjects and eight age-matched controls were given the MoCA exam before EEG recordings in a sensory-deprived room. Traditional time-domain comparisons of averaged ERPs between the two groups did not yield any statistical significance. However, ESC was able to discriminate MCI from controls with 95% classification accuracy based on the averaged ERPs elicited by familiar faces. By adopting advanced machine-learning techniques such as ESC, it may be possible to accurately diagnose MCI based on the ERPs that are specifically elicited by familiar faces.

Effect of diet and type of pregnancy on plasma metabolic response in sheep and its further effect on lamb performance

This trial evaluated the individual and interactional effects of diet and type of pregnancy (twin or single) on plasma metabolic response in ewes and their lambs from late pre-partum to late post-partum. Thus, a flock of 18 Ile de France breed sheep, consisting of 8 twin-bearing and 10 single-bearing ewes, were allocated to one of two groups according to their diet, either based on ad libitum naturalized pasture hay (NPH) or red clover hay (RCH), from d 45 pre-partum to d 60 post-partum. Plasma samples were collected at different times to determine albumin, cholesterol, total protein and urea, plus glucose and β-hydroxybutyrate (BHB) concentration in ewes. The data was processed using the lme4 package for R, and SPSS Statistics 23.0 for Windows. The results showed that both diet and type of pregnancy influenced the metabolic profile in ewes, showing an inverse relationship between single- and twin-bearing ewes regarding glucose and especially BHB proportions from pre-partum to birth. During post-partum, higher urea concentrations were observed in twin- and single-bearing ewes fed RCH in contrast to those fed NPH, as a result of the higher-quality forage offered to ewes. Regarding lambs, the diet and type of pregnancy influenced the total protein and urea levels, where an inverse relationship at birth and early post-partum between albumin and cholesterol vs. total protein and urea was detected, reflecting a trend (P value between 0.06 and 0.07) to a better performance by groups of single lambs, especially those from single-bearing ewes fed RCH. Finally, under the conditions of this study, the maternal diet and type of pregnancy influenced the plasma metabolic response in ewes and their lambs, affecting the lamb performance especially at birth.

Geriatric patients on antithrombotic therapy as a criterion for trauma team activation leads to over triage

BACKGROUND

Our institution amended its trauma activation criteria to require a Level II activation for patients ≥65 years old on antithrombotic medication presenting with suspected head trauma.

METHODS

Our institutional trauma registry was queried for geriatric patients on antithrombotic medication in the year before and after this criteria change. Demographics, presentation metrics, level of activation, and outcomes were compared between groups.

RESULTS

After policy change, a greater proportion of patients received a trauma activation (19.9 vs. 74.9%, P < 0.001) and a greater proportion of these patients were discharged directly home without injury (4.3 vs. 44%, P < 0.001). However, a smaller proportion of patients with a critical Emergency Department disposition or traumatic intracranial hemorrhage failed to receive a trauma activation (65.1 vs. 23.5%, P < 0.001; 70.7% vs. 27.3%, P < 0.001). There was no change in mortality (4.3 vs. 2.0%, P = 0.21).

CONCLUSIONS

Implementing new criteria increased overtriage, decreased undertriage, and had little effect on mortality.

Modern Neonatal Transport: Sound and Vibration Levels and Their Impact on Physiological Stability

OBJECTIVE

To measure sound and vibration in rotary wing air transport (RWAT) and ground ambulance transport (GAT), comparing them to current recommendations, and correlating them with physiological stability measures in transported neonates.

STUDY DESIGN

This is a prospective cohort observational study including infants ≤ 7 days of age transported over an 8-month period. Infants with neurologic conditions were excluded. Sound and vibration was continuously measured during transport. Transport Risk Index of Physiologic Stability (TRIPS) scores were calculated from vital signs as a proxy for physiological stability.

RESULTS

In total, 118 newborns were enrolled, of whom 109 were analyzed: 67 in RWAT and 42 in GAT. Peak sound levels ranged from 80.4 to 86.4 dBA in RWAT and from 70.3 to 71.6 dBA in GAT. Whole-body vibration ranged from 1.68 to 5.09 m/s² in RWAT and from 1.82 to 3.96 m/s² in GAT. Interval TRIPS scores for each infant were not significantly different despite excessive sound and vibration.

CONCLUSION

Noise levels during neonatal transport exceed published recommendations for both RWAT and GAT and are higher in RWAT. Transported infants are exposed to vibration levels exceeding acceptable adult standards. Despite excessive noise and vibration, levels of physiological stability remained stable after transport in both RWAT and GAT groups.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.