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.

Safety of intravenous lacosamide in hospitalized children and neonates

OBJECTIVE

Seizures are common in critically ill children and neonates, and these patients would benefit from intravenous (IV) antiseizure medications with few adverse effects. We aimed to assess the safety profile of IV lacosamide (LCM) among children and neonates.

METHODS

This retrospective multicenter cohort study examined the safety of IV LCM use in 686 children and 28 neonates who received care between January 2009 and February 2020.

RESULTS

Adverse events (AEs) were attributed to LCM in only 1.5% (10 of 686) of children, including rash (n = 3, .4%), somnolence (n = 2, .3%), and bradycardia, prolonged QT interval, pancreatitis, vomiting, and nystagmus (n = 1, .1% each). There were no AEs attributed to LCM in the neonates. Across all 714 pediatric patients, treatment-emergent AEs occurring in >1% of patients included rash, bradycardia, somnolence, tachycardia, vomiting, feeling agitated, cardiac arrest, tachyarrhythmia, low blood pressure, hypertension, decreased appetite, diarrhea, delirium, and gait disturbance. There were no reports of PR interval prolongation or severe cutaneous adverse reactions. When comparing children who received a recommended versus a higher than recommended initial dose of IV LCM, there was a twofold increase in the risk of rash in the higher dose cohort (adjusted incidence rate ratio = 2.11, 95% confidence interval = 1.02-4.38).

SIGNIFICANCE

This large observational study provides novel evidence demonstrating the tolerability of IV LCM in children and neonates.

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.

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 < 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.

A phase 2 randomized, double-blind, placebo-controlled, proof-of-concept study of oral seletalisib in primary Sjögren's syndrome

OBJECTIVES

This phase 2 proof-of-concept study (NCT02610543) assessed efficacy, safety and effects on salivary gland inflammation of seletalisib, a potent and selective PI3Kδ inhibitor, in patients with moderate-to-severe primary Sjögren's syndrome (PSS).

METHODS

Adults with PSS were randomized 1:1 to seletalisib 45 mg/day or placebo, in addition to current PSS therapy. Primary end points were safety and tolerability and change from baseline in EULAR Sjögren's Syndrome Disease Activity Index (ESSDAI) score at week 12. Secondary end points included change from baseline at week 12 in EULAR Sjögren's Syndrome Patient Reported Index (ESSPRI) score and histological features in salivary gland biopsies.

RESULTS

Twenty-seven patients were randomized (seletalisib n = 13, placebo n = 14); 20 completed the study. Enrolment challenges led to early study termination with loss of statistical power (36% vs 80% planned). Nonetheless, a trend for improvement in ESSDAI and ESSPRI [difference vs placebo: -2.59 (95% CI: -7.30, 2.11; P=0.266) and -1.55 (95% CI: -3.39, 0.28), respectively] was observed at week 12. No significant changes were seen in saliva and tear flow. Serious adverse events (AEs) were reported in 3/13 of patients receiving seletalisib vs 1/14 for placebo and 5/13 vs 1/14 discontinued due to AEs, respectively. Serum IgM and IgG concentrations decreased in the seletalisib group vs placebo. Seletalisib demonstrated efficacy in reducing size and organisation of salivary gland inflammatory foci and in target engagement, thus reducing PI3K-mTOR signalling compared with placebo.

CONCLUSION

Despite enrolment challenges, seletalisib demonstrated a trend towards clinical improvement in patients with PSS. Histological analyses demonstrated encouraging effects of seletalisib on salivary gland inflammation and organisation.

TRIAL REGISTRATION

https://clinicaltrials.gov, NCT02610543.

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.

Efficacy and safety of adjunctive lacosamide in the treatment of primary generalised tonic-clonic seizures: a double-blind, randomised, placebo-controlled trial

OBJECTIVE

To evaluate efficacy and safety of lacosamide (up to 12 mg/kg/day or 400 mg/day) as adjunctive treatment for uncontrolled primary generalised tonic-clonic seizures (PGTCS) in patients (≥4 years) with idiopathic generalised epilepsy (IGE).

METHODS

Phase 3, double-blind, randomised, placebo-controlled trial (SP0982; NCT02408523) in patients with IGE and PGTCS taking 1-3 concomitant antiepileptic drugs. Primary outcome was time to second PGTCS during 24-week treatment.

RESULTS

242 patients were randomised and received ≥1 dose of trial medication (lacosamide/placebo: n=121/n=121). Patients (mean age: 27.7 years; 58.7% female) had a history of generalised-onset seizures (tonic-clonic 99.6%; myoclonic 38.8%; absence 37.2%). Median treatment duration with lacosamide/placebo was 143/65 days. Risk of developing a second PGTCS during 24-week treatment was significantly lower with lacosamide than placebo (Kaplan-Meier survival estimates 55.27%/33.37%; HR 0.540, 95% CI 0.377 to 0.774; p<0.001; n=118/n=121). Median time to second PGTCS could not be estimated for lacosamide (>50% of patients did not experience a second PGTCS) and was 77.0 days for placebo. Kaplan-Meier estimated freedom from PGTCS at end of the 24-week treatment period (day 166) for lacosamide/placebo was 31.3%/17.2% (difference 14.1%; p=0.011). More patients on lacosamide than placebo had ≥50% (68.1%/46.3%) or ≥75% (57.1%/36.4%) reduction from baseline in PGTCS frequency/28 days, or observed freedom from PGTCS during treatment (27.5%/13.2%) (n=119/n=121). 96/121 (79.3%) patients on lacosamide had treatment-emergent adverse events (placebo 79/121 (65.3%)), most commonly dizziness (23.1%), somnolence (16.5%), headache (14.0%). No patients died during the trial.

CONCLUSIONS

Lacosamide was efficacious and generally safe as adjunctive treatment for uncontrolled PGTCS in patients with IGE.

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.

Randomized open-label trial of intravenous brivaracetam versus lorazepam for acute treatment of increased seizure activity

OBJECTIVE

The objective of the present trial was to assess efficacy and safety of intravenous (IV) brivaracetam (BRV) vs. lorazepam (LZP) in patients with epilepsy undergoing evaluation in an epilepsy monitoring unit (EMU) who experienced seizures requiring acute treatment.

METHODS

This was a phase 2, open-label, randomized, active-control, proof-of-concept trial (EP0087; NCT03021018). Patients (18-70 years) admitted to EMU were randomized 1:1:1 to single-dose bolus IV LZP (dose per investigator's practice), IV BRV 100 mg, or IV BRV 200 mg. Trial medication had to be administered within 30 min of qualifying seizure. Primary efficacy outcome was time to next seizure (clinical observation with electroencephalogram [EEG] confirmation) or to rescue medication use within 12 h of trial medication administration. Secondary outcomes included seizure freedom and rescue medication use within 12 h of trial medication administration. Safety and tolerability outcomes included treatment-emergent adverse events (TEAEs).

RESULTS

Overall, 46 patients were randomized, and 45 received trial medication for a qualifying seizure. Patients in the LZP arm had doses from 1 to 4 mg (median: 1 mg). Eleven of 45 patients had a seizure within 12 h of trial medication administration (LZP 5/15 [median time to next seizure: 5.55 h], BRV 100 mg 3/15 [5.97 h], BRV 200 mg 3/15 [3.60 h]). No patients received additional rescue medication to control their qualifying seizure. Most patients were seizure-free over 12 h (LZP 9/15 [60.0%], BRV 100 mg 12/15 [80.0%], BRV 200 mg 12/15 [80.0%]). Rescue medication use within 12 h was numerically higher for LZP (6/15 [40.0%]) vs. BRV 100 mg (1/15 [6.7%]) and vs. BRV 200 mg (2/15 [13.3%]). Treatment-emergent adverse events were reported by 5/16 (31.3%), 6/15 (40.0%), and 3/15 (20.0%) of LZP, BRV 100 mg, and BRV 200 mg patients; one LZP patient had a serious TEAE (seizure cluster). Most common TEAEs (≥10% of patients) were sedation and somnolence with LZP, and dizziness, headache, and nausea with BRV.

SIGNIFICANCE

Intravenous LZP, IV BRV 100 mg, and IV BRV 200 mg showed similar efficacy in controlling acute seizure activity in the EMU. Treatment-emergent adverse events were as expected for each medication. Although this trial should be interpreted with caution because of small patient numbers, it suggests a possible role of BRV in the acute treatment of increased seizure activity.

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.

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.

The early impact of initiatives to close attainment gaps at UCL

  This article provides an overview of core aspects of efforts to close the black, Asian and minority ethnic (BAME) attainment gap across University College London (UCL). Although the main ‘Catalyst Student Success’ project focuses on home undergraduate students, at UCL we are also using similar approaches to enhance inclusivity in postgraduate courses. The focus in this paper is nevertheless on undergraduates. The detailed use of student attainment data by the UCL Centre for Teaching and Learning Economics is outlined and discussed to underpin the introduction of the use of UCL’s ‘Inclusive Curriculum Health Check’ (ICHC) – UCL BAME Attainment Project 2018 – as a framework for the initiatives taken by departments. A table with the initial responses from the departments in one faculty is presented and selected points are discussed. The value and potential of the initiatives recommended through the ICHC are explored in a table which links systematic review evidence (Schneider and Preckel, 2017) to the ICHC. Staff actions in partnership with students are designed primarily to have a positive impact on the experience and outcomes of BAME students, but the research evidence suggests that favourable effects will accrue for all students.  

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.

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.

A systematic review of the use, quality and effects of pelvic examination in primary care for the detection of gynaecological cancer

AIM

This three part systematic review gathered all the current evidence on the use, quality and effects of pelvic examination (abdominal palpation, bimanual vaginal examination ± visualisation of the cervix) in primary care in diagnosing gynaecological cancer. Research questions • Do primary care practitioners perform pelvic examination during the assessment of symptoms, which are potentially indicative of gynaecological cancer? (RQ1) • What is the quality of pelvic examination performed in primary care, in terms of technical competence and interpretation of findings? (RQ2) • Is pelvic examination associated with the referral of patients with gynaecological cancer, and if so, in what way? (RQ3) Methods: PRISMA guidelines were followed. MEDLINE, EMBASE and Cochrane databases were searched using a combination of four terms, their MeSH terms and synonyms: pelvic examination; primary care; competency and gynaecological cancer. Inclusion and exclusion criteria were defined. Citation lists of all identified papers were searched. Two authors (PW and PM or CMB or CB) independently screened titles, abstracts and the full texts of publications. Data extraction was performed by PW and duplicated in all papers by a second reviewer (PM, CMB or CB). Paper quality was assessed using CASP methodology.

RESULTS

Nine hundred fifty four references were identified: 21 met the inclusion criteria: 5 RQ1; 6 RQ2; 10 RQ3. Examination rates prior to referral were generally low: one paper identified pre-referral PE in 52% of the patients; remaining papers demonstrated examination in less than half of the patients with suspicious symptoms. No papers explored GPs' competence at performing PE directly; but one paper identified 39% of 'clinically suspicious' cervices referred for colposcopy as having no abnormality. Pre-referral PE was associated with reduced diagnostic delay and early stage diagnosis.

CONCLUSIONS

Pre-referral pelvic examination in symptomatic women appears to be under-performed, despite urgent suspected cancer referral guideline recommendation to do so (Healthcare Improvement Scotland 2014 ; National Institute for Health and Care Excellence 2015 ). While no evidence was found to confirm GPs' competence for performing PE, there was an association with shorter diagnostic delay and better outcomes in those women where it was performed.

Newborn and infant physical examination standards in a dedicated clinic for developmental dysplasia of the hip

Introduction In 2014 our centre started a dedicated clinic for developmental dysplasia of the hip (DDH). The aim of the clinic was to streamline DDH referrals, enabling timely review, imaging and multidisciplinary treatment. Ongoing audit has been carried out based on the UK National Screening Committee newborn and infant physical examination (NIPE) guidelines, first published in 2008. Methods A three-year prospective audit was undertaken between 2014 and 2016 assessing compliance with NIPE standards (ST2b and ST2d) relating to timeliness of expert consultation following positive ultrasonography findings of DDH with positive examination or risk factors. Results A total of 257 babies born between January 2014 and December 2016 were seen in our dedicated DDH clinic, with 106 with abnormalities on ultrasonography and 54 requiring treatment. Compliance with 'expert consultation within 4 weeks of age for babies with an abnormality detected on clinical examination and positive ultrasonography' improved from 50% in 2014 to 53% in 2015 and 71% in 2016. Compliance with 'expert consultation within 8 weeks of age for babies with positive risk factors, negative examination and positive ultrasonography' improved from 65% in 2014 to 93% in 2015 and 100% in 2016. Conclusions This prospective audit assessing timeliness of expert consultation has demonstrated ongoing improvements between 2014 and 2016. A greater proportion of babies with ultrasonography evidence of DDH have been seen at the appropriate time. In the majority of cases, this has enabled timely non-invasive treatment with a Pavlik harness rather than surgery.

eHealth readiness of dietitians

BACKGROUND

The present study aimed to determine the eHealth readiness and changes over time of dietitians in Australia.

METHODS

Two cross-sectional analyses of Australian dietitians were conducted in 2013 and 2016, using a survey adapted from one conducted in 2011 by the US Academy of Nutrition and Dietetics. The survey encompassed 30 questions on eHealth readiness across five dimensions: access, standards, attitude, aptitude and advocacy. Descriptive statistics, independent t-tests, chi-squared tests and Z-tests were computed to compare responses from the 2013 and 2016 surveys.

RESULTS

The survey completion rate represented 14.5% (747) of the Dietitians Association of Australia members in 2013 and 8% (417) in 2016. The survey responses in relation to access and standards suggest that dietitians are well positioned for eHealth. For attitude and aptitude, there is a moderate level of preparedness, with minor improvements over time. Although showing significant improvement (P < 0.05), advocacy highlights the area requiring the most development because the majority of dietitians (61%) reported 'no role' in eHealth solutions.

CONCLUSIONS

Dietitians are progressing in relation to access, attitudinal and aptitudinal readiness for eHealth, although they rate poorly with respect to advocacy readiness. It was concluded that dietitians are not yet ready, and also that valuable opportunities to achieve the benefits that eHealth can deliver will be missed, if dietitians do not take the lead in guiding the development, selection and implementation of nutrition-related technologies. Strengthening the dimension of advocacy and ensuring collaboration across the profession, drawing on the varying expertise demonstrated across the practice areas and by the different generations, will be central to improving dietitian eHealth readiness.

Improving patient experiences of mental health inpatient care: a randomised controlled trial

BACKGROUND

Poorer patient views of mental health inpatient treatment predict both further admissions and, for those admitted involuntarily, longer admissions. As advocated in the UK Francis report, we investigated the hypothesis that improving staff training improves patients' views of ward care.

METHOD

Cluster randomised trial with stepped wedge design in 16 acute mental health wards randomised (using the ralloc procedure in Stata) by an independent statistician in three waves to staff training. A psychologist trained ward staff on evidence-based group interventions and then supported their introduction to each ward. The main outcome was blind self-report of perceptions of care (VOICE) before or up to 2 years after staff training between November 2008 and January 2013.

RESULTS

In total, 1108 inpatients took part (616 admitted involuntarily under the English Mental Health Act). On average 51.6 staff training sessions were provided per ward. Involuntary patient's perceptions of, and satisfaction with, mental health wards improved after staff training (N582, standardised effect -0·35, 95% CI -0·57 to -0·12, p = 0·002; interaction p value 0·006) but no benefit to those admitted voluntarily (N469, -0.01, 95% CI -0.23 to 0.22, p = 0.955) and no strong evidence of an overall effect (N1058, standardised effect -0.18 s.d., 95% CI -0.38 to 0.01, p = 0.062). The training costs around £10 per patient per week. Resource allocation changed towards patient perceived meaningful contacts by an average of £12 (95% CI -£76 to £98, p = 0.774).

CONCLUSION

Staff training improved the perceptions of the therapeutic environment in those least likely to want an inpatient admission, those formally detained. This change might enhance future engagement with all mental health services and prevent the more costly admissions.

The rapid and accurate categorisation of critically ill patients (RACE) to identify outcomes of interest for longitudinal studies: a feasibility study

The capacity to measure the impact of an intervention on long-term functional outcomes might be improved if research methodology reflected our clinical approach, which is to individualise goals of care to what is achievable for each patient. The objective of this multicentre inception cohort study was to evaluate the feasibility of rapidly and accurately categorising patients, who were eligible for simulated enrolment into a clinical trial, into unique categories based on premorbid function. Once a patient met eligibility criteria a rapid 'baseline assessment' was conducted to categorise patients into one of eight specified groups. A subsequent 'gold standard' assessment was made by an independent blinded assessor once patients had recovered sufficiently to allow such an assessment to occur. Accuracy was predefined as agreement in >80% of assessments. One hundred and twenty-two patients received a baseline assessment and 104 (85%) were categorised to a unique category. One hundred and six patients survived to have a gold standard assessment performed, with 100 (94%) assigned to a unique category. Ninety-two patients had both a baseline and gold standard assessment, and these agreed in 65 (71%) patients. It was not feasible to rapidly and accurately categorise patients according to premorbid function.