A qualitative feasibility and acceptability study of an acceptance and commitment-based bibliotherapy intervention for people with cancer

Self-directed bibliotherapy interventions can be effective means of psychological support for individuals with cancer, yet mixed findings as to the efficacy of these interventions indicate the need for further research. We investigated the experience of individuals with cancer after using a new self-help book, based on Acceptance and Commitment Therapy (ACT). Ten participants with cancer (nine females and one male, 40-89 years old) were given access to a bibliotherapy self-help ACT-based book and participated in post-intervention semi-structured interviews. Five themes were generated from reflexive thematic analysis: (1) The value of bibliotherapy (2) Timing is important (3) Resonating with cancer experiences (4) Tools of the book (5) ACT in action. The book was found to be acceptable (self-directed, accessible, understandable content, good responsiveness to exercises) and feasible (easy to use, ACT-consistent). Although not explicitly evaluated, participants' reports indicated defusion, present moment awareness, and consideration of values, as the ACT processes that contributed to adjustment, via helping them to regain control over their lives and become more present within the moment. Findings also indicate that the intervention may be best accessed following completion of initial medical treatment.

Inflammatory biomarker signatures in post-surgical drain fluid may detect anastomotic leaks within 48 hours of colorectal resection

BACKGROUND

The optimal treatment of colorectal cancer is surgical resection and primary anastomosis. Anastomotic leak can affect up to 20% of patients and creates significant morbidity and mortality. Current diagnosis of a leak is based on clinical suspicion and subsequent radiology. Peritoneal biomarkers have shown diagnostic utility in other conditions and could be useful in providing earlier diagnosis. This pilot study was designed to assess the practical utility of peritoneal biomarkers after abdominal surgery utilising an automated immunoassay system in routine use for quantifying cytokines.

METHODS

Patients undergoing an anterior resection for a rectal cancer diagnosis were recruited at University Hospital of Wales, Cardiff between June 2019 and June 2021. A peritoneal drain was placed in the proximity of the anastomosis during surgery, and peritoneal fluid was collected at days 1 to 3 post-operatively, and analysed using the Siemens IMMULITE platform for interleukin (IL)-1β, IL-6, IL-10, CXCL8, tumour necrosis factor alpha (TNFα) and C-reactive protein (CRP).

RESULTS

A total of 42 patients were recruited (22M:20F, median age 65). Anastomotic leak was detected in four patients and a further five patients had other intra-abdominal complications. The IMMULITE platform was able to provide robust and reliable results from the analysis of the peritoneal fluid. A metric based on the combination of peritoneal IL-6 and CRP levels was able to accurately diagnose three anastomotic leaks, whilst correctly classifying all negative control patients including those with other complications.

CONCLUSIONS

This pilot study demonstrates that a simple immune signature in surgical drain fluid could accurately diagnose an anastomotic leak at 48 h postoperatively using instrumentation that is already widely available in hospital clinical laboratories.

Cognition and freezing of gait in Parkinson's disease: A systematic review and meta-analysis

Freezing of gait (FOG) is a common and disabling symptom in people with Parkinson's Disease (PwPD). Although cognition is thought to be worse in PwPD who freeze, a comprehensive analysis of this relationship will inform future research and clinical care. This systematic review and meta-analysis compared cognition between PwPD who do and do not exhibit FOG across a range of cognitive domains and assessed the impact of disease severity and medication status on this relationship. 145 papers (n = 9010 participants) were included in the analysis, with 144 and 138 articles meeting the criteria to assess moderating effects of disease severity and medication status, respectively. PwPD who freeze exhibited worse cognition than PwPD without FOG across global cognition, executive function/attention, language, memory, and visuospatial domains. Greater disease severity and "ON" levodopa medication status moderated the FOG status-cognition relationship in global cognitive performance but not in other cognitive domains. This meta-analysis confirmed that cognition is worse in PwPD with FOG and highlights the importance of disease severity and medication status in this relationship.

412 Knowledge and Practices for the Prevention of the Diabetic Foot in North Wales

Aim

Diabetes mellitus can result in a wide range of foot complications such as ulceration, infection, and amputation. The National Institute for Health and Care Excellence (NICE) recommend that all diabetic patients should receive verbal and written information relating to their foot care. Here we assess our compliance with the national guidelines and the levels of patient knowledge amongst the diabetic population in the North West of Wales.

Method

A questionnaire was provided to all adult diabetic patients attending the outpatient podiatry service over the course of three weeks at Ysbyty Gwynedd, North Wales. The survey included compliance and knowledge-based questions regarding foot care.

Results

A total of 65 patients were recruited and completed questionnaires. The majority of the patients were males (male:female ratio 2:1) and over 70 years and had type II diabetes.

98% of patients admitted to receiving verbal diabetic advice while only 57% received written information. Compliance with daily foot checks was 82%. Regarding patient knowledge, over 90% of patients selected the correct answer to 11 out of the 15 knowledge-based questions. Despite 95% recognising that poor footwear can contribute to diabetic foot complications, only 86% recognised that walking barefoot carries similar risks.

Conclusions

Diabetic foot knowledge is high within our studied population. Use of patient information leaflets can be further improved to help educate patients in avoiding barefoot walking and to prevent diabetic foot complications and limb loss.

206 Longevity of Deep Brain Stimulation Batteries at a Tertiary Neurosurgical Centre

Introduction

Deep brain stimulation (DBS) is a surgery used in the treatment of movement disorders. It involves surgical placement of electrodes in the brain that are connected to a battery-powered stimulator to regulate brain activity. DBS has been used successfully in the management of Parkinson's disease (PD). It has improved patients' movement and quality of life. However, one inconvenience is the limited battery life and the need for battery change to prevent deterioration in function. In this audit, we measured the longevity of DBS batteries in PD at a tertiary neurosurgical centre.

Method

A retrospective audit on the longevity of DBS batteries in 86 Patients with PD. We collected data on; date and position of device implant, type of battery used (rechargeable vs non-rechargeable), and the two most recent battery changes. We excluded battery changes that were due to infection.

Results

86 patients had DBS batteries. 21 patients had rechargeable batteries (Abbot Brio, Medtronic Activa RC and Boston Gevia), and 65 had non-rechargeable batteries (Abbot Infinity, Abbot Libra XP, Medtronic Activa PC). 53 patients have undergone a battery change, 49 of those were non-rechargeable batteries. Average battery life of non-rechargeable batteries was 3.06 ± .55 years in Infinity (n = 16), 4.0 ± 1.7 years in Libra XP(n = 22), and 4.6± .9 years in Activa PC (n = 11).

Conclusions

All three types of non-rechargeable batteries are lasting less than five years. Activa PC batteries had the lengthiest battery life of 4.6± .9 years, while infinity had the shortest battery life of 3.06± .55 years.

217 Covid-19 And Femoral Neck Fracture: A Retrospective Review

Aim

Covid-19 has dominated healthcare over the past year. It most severely affects the elderly, a population whom also commonly present following falls, sustaining femoral neck fractures. Our aim was to retrospectively evaluate the effects of concomitant covid-19 infection in patients presenting acutely with femoral neck fractures.

Method

We conducted a retrospective review of all patients with femoral neck fractures during the ‘first wave’ of the coronavirus pandemic in Ysbyty Gwynedd (Bangor, UK), between April 2020 to June 2020. We noted each patient’s covid-19 status within 14 days of presentation with their acute femoral neck fracture and compared length of stay, discharge destination and mortality rate between covid and non-covid groups.

Results

There was a total of 75 femoral neck fractures in the 3-month period studied. 4 patients had incomplete data and were excluded from analysis. Of the remaining 71 patients, 15 (21%) were covid-positive within 14 days of admission, 47 patients (66%) were confirmed covid-negative and 9 patients (13%) received no coronavirus testing. The average age of patients was 88 in the covid-positive group and 84 in the covid-negative group. Those who developed covid-19 infection had an increased length of hospital stay (33 days covid-positive versus 14 days covid-negative; p = 0.25) and significantly increased in-hospital mortality rate (47% covid-positive versus 6% covid-negative; p = 0.001).

Conclusions

These results show that concomitant infection with covid-19 shortly after femoral neck fracture is associated with a significant increase in hospital mortality. They highlight the importance of trying to prevent covid-19 infection in this patient group.

216 Fix or Replace: Is Internal Fixation Still A Viable Option in The Elderly with Un-Displaced Intracapsular Femoral Neck Fractures?

Aim

The treatment of impacted or un-displaced femoral neck fractures in the elderly osteoporotic patient is still largely debated, with arthroplasty versus internal fixation two surgical options1. Our aim was to retrospectively review patients over the age of 80 with un-displaced intracapsular hip fractures who had undergone internal fixation and assess their rate of mortality and revision surgery.

Method

We conducted a retrospective review of all patients with femoral neck fractures over a 4-year period between January 2015 to December 2018. We refined this to only patients over the age of 80 with un-displaced intracapsular femoral neck fractures fixed with cannulated screws. We noted their mental and mobility status, their follow-up attendance over 3 years, their mortality and rate of revision surgery.

Results

There were a total of 1232 femoral neck fractures in a 4-year period. Of these, 37 were >80 with un-displaced intracapsular femoral neck fractures, with 23 fixed with cannulated screws and 14 with a Dynamic Hip Screw. Mean age – 85, M:F (1:4.75). All patients were either Garden Classification Type I or II. 4% had cognitive impairment. All patients were independently mobile. 83% were followed up for 3 years, with 1 patient (4%) undergoing revision surgery 3 years following cannulated screw fixation. The 30-day mortality rate was 5%.

Conclusions

The treatment choice for un-displaced intracapsular femoral neck fractures in the elderly remains debateable. Our retrospective review shows that the rate of re-operation is low in patients who have undergone fixation with cannulated screws and so this remains a viable option.

104 Assessing for Delirium in A District General Emergency Department—Why are We Failing and How can We Improve?

Introduction

Delirium is among the most common of medical emergencies with a prevalence of 20% in adult acute general medical patients. Despite this delirium is underdiagnosed and treatment is variable. Assessment of delirium is missed or carried out unreliably in EDs.

Methodology

Using the Model for Improvement, we developed a driver diagram to plan our project. Assessing whether patients over 65 years old were assessed for delirium during their visit to the ED using a validated tool over a 6-month period. Evaluating the impact of our interventions using annotated run charts. Exclusion criteria—GCS under 13, NEWS2 greater than 5.

Aim

Identify current performance of delirium assessment in over 65 s in Weston General Hospital ED and improve to 100% of over 65 s screened. Assess whether this has been communicated in the discharge summary.

Results

Baseline data showed 22.2% (4/18) of patients meeting inclusion criteria were screened for delirium. We implemented multiple interventions over a 2-month period—discussing at ED handover, hospital wide email, presentation at grand round and displaying a poster in the ED. In the 6 weeks after the interventions were implemented there was increase to 45.4% (15/33) of patients over 65 screened. Delirium/cognitive impairment identified in 42.5% (48/113) of patients screened. This is higher than the national average of hospital admissions therefore it is likely people screen those who display signs of delirium. Cognitive impairment communicated in discharge letter in only 29.4% (33/113) of all patients.

Conclusion

There has been a great improvement in delirium screening. However, we did not meet our target of 100% of patients being screened. Interventions currently being implemented—addition of SQID tool to minors clerking document, addition of compulsory tick box delirium question on all discharge summaries. Further data will be collected to assess effectiveness of these interventions.

Variable pitch hydrodynamic electro-optic gratings utilising bent liquid crystal dimers

Electrohydrodynamic instabilities (EHDI) in liquid crystals form uniform and continuously variable diffractive structures when subject to certain material and geometry determined conditions. A one-dimensional grating is one such diffractive structure, where the refractive index changes periodically in a direction parallel to the initial liquid crystal director. The period of this structure has been shown previously to vary continuously between the values of the cell gap and half-cell gap approximately, allowing continuous angular modulation of optical beams but with a limited angular range. In this work, the lower pitch limit is shown to also be governed in part by the ratio of the splay and bend elastic constants (k₁₁/k₃₃) of the liquid crystal. A host nematic liquid crystal with standard elastic constant ratios (k₁₁/k₃₃ < 1) is doped with odd-alkyl-spaced dimeric liquid crystal CB7CB, to create a liquid crystal mixture with a far higher elastic constant ratio (k₁₁/k₃₃ > 5) than for those previously used in literature EHDI studies. The EHDI gratings formed in this new mixture exhibit pitch lengths significantly below half-cell gap, allowing up to 50% wider angle continuous steering of light. This improves the potential for application in beamsteering and diffractive optical devices.

Participant experiences of the DWELL programme: focus group findings on motivation, experiences, facilitators and barriers

Initiatives to increase effective, low-cost self-management are essential to the sustainability of care for type 2 diabetes (T2D), however research shows that there is currently no standard approach. The DWELL programme seeks to motivate and empower people with T2D to better self-manage their condition through focussed content underpinned by motivational interviewing. As part of the DWELL evaluation study, end-of-programme focus groups were conducted to elicit participant experiences. 33 focus groups with 153 participants (including a small number of partners) took place in the two UK DWELL delivery sites. The focus group data was subjected to thematic content analysis to elicit key themes. Findings indicate that DWELL participants are motivated through a desire for better knowledge and management of their diabetes. Facilitating factors of the programme include: facilitator and peer support; the holistic and autonomous approach which provides participants with the opportunity to better understand the condition and its impact on their whole lives; and a tailored individual approach. Barriers and suggested improvements include content and operational changes, which are fed back to DWELL facilitators as part of the process evaluation in order that they can continually update the programme. Participants report positive outcomes in terms of wellbeing, social and mental health, enhanced knowledge and positive lifestyle changes. These themes align with quantitative outcome measures for participants, including weight loss, reduced BMI and glycated haemoglobin (HbA1c), enhanced empowerment and improved eating behaviours and illness perceptions and control. Interim findings suggest that DWELL outcomes include improved health literacy, participant empowerment and self-management. These findings underscore the need to incorporate a holistic, tailored approach to structured patient education for T2D.

The Diabetes and WELLbeing programme: protocol of a multi-site European complex intervention study

A quasi-experimental design evaluation study examines long-term impact of the 12-week DWELL programme, a self-management intervention for people with type 2 diabetes (T2D), based on adult learning and person-centred approaches, delivered in 5 community and hospital sites in 4 European countries. Overall target is 780 people with T2D. Staff are trained in motivational interviewing, group facilitation, diabetes education, and programme approach which consists of core and 'pick and mix' sessions on diabetes education, physical activity, healthy eating and wellbeing. Pre-post measures are taken at baseline (T0), end-of-programme (T1), at 6 months (T2) and 12 months (T3). There is a non-equivalent control group of 190 at T2/T3. Biomedical data are collected by staff and psychosocial data are collected via self-completed validated scales. Metabolic measures include: HbA1c, BMI and waist circumference. Demographics capture: age, gender, ethnicity, household composition, education, employment, income. Psychosocial data are collected on illness perception, patient empowerment, eating behaviours, physical activity, physical/mental health status, health-related quality of life (EQ-5D), use of diabetes-related health services and self-care activities. Participant experiences are recorded via motivational interviews at T0 and T1 and focus groups at T1. Process evaluation data are collected via interviews with staff and patient ambassadors. The DWELL programme started in 2018 and results will be available in 2021.

The study will produce rich data on long-term impact of intervention to allow replication and further development. It will permit cross-border conclusions on sustainability and embeddedness of model in varied service settings, and empowerment-based public health approach to T2D self-management.

Patient empowerment, eating behaviours and illness control: pre-post outcomes from DWELL delivery in UK and France

Diabetes self-management programmes can improve clinical and healthy lifestyle outcomes. Research has demonstrated that improved engagement with type 2 diabetes (T2D) care is associated with greater empowerment beliefs and a perceived internal control over their illness. As part of the DWELL evaluation study, an interim subset of 139 participants in the UK and 53 participants in France were assessed pre- and post-intervention on measures of weight, BMI, waist circumference and glycated haemoglobin (HbA1c), as well as self-efficacy beliefs (DES-SF), healthy eating behaviours (DEBQ) and perceptions of illness (IPQ-R). Pre-post comparisons in both countries demonstrated statistically significant decreases in weight (UK: Z = 6.71, p&lt;.001, FR: Z = 3.33, p&lt;.05), BMI (UK: Z = 6.70, p&lt;.001, FR: Z = 3.21, p&lt;.05), waist circumference (UK: Z = 6.71, p&lt;.001, FR: Z = 3.24, p&lt;.05),and HbA1c (UK: Z = 6.29, p&lt;.001, FR: Z = 4.18, p &lt;.001). Importantly, participation in the DWELL programme was associated with increased self-efficacy beliefs (UK: Z = 5.63, p&lt;.001, FR: Z = 5.54, p&lt;.001), greater perceived personal control over their diabetes (UK: Z = 3.17, p&lt;.05, FR: Z = 2.20, p&lt;.05), reduced negative feelings about their illness (UK: Z = 3.01, p &lt;.05, FR: Z = 2.19, p&lt;.05) and decreased eating in response to external food cues (UK: Z = 3.79, p&lt;.001, FR: Z = 2.34, p&lt;.05). In the UK, participants also reported an increased optimism for treatment control of their diabetes (Z = 3.06, p &lt;.05) and for their long-term prognosis (Z = 1.99, p&lt;.05).These preliminary findings support the efficacy of the DWELL programme in improving diabetes-related biomedical outcomes, as well as improvements in patient empowerment, healthy eating habits and increased perceived illness control. Further analysis, available at a later date, will include a larger sample of participants, including longitudinal data with follow-ups six- and 12- months post participation in the DWELL programme.

PRL3 enhances T-cell acute lymphoblastic leukemia growth through suppressing T-cell signaling pathways and apoptosis

T cell acute lymphoblastic leukemia (T-ALL) is an aggressive malignancy of thymocytes and is largely driven by the NOTCH/MYC pathway. Yet, additional oncogenic drivers are required for transformation. Here, we identify protein tyrosine phosphatase type 4 A3 (PRL3) as a collaborating oncogenic driver in T-ALL. PRL3 is expressed in a large fraction of primary human T-ALLs and is commonly co-amplified with MYC. PRL3 also synergized with MYC to initiate early-onset ALL in transgenic zebrafish and was required for human T-ALL growth and maintenance. Mass spectrometry phosphoproteomic analysis and mechanistic studies uncovered that PRL3 suppresses downstream T cell phosphorylation signaling pathways, including those modulated by VAV1, and subsequently suppresses apoptosis in leukemia cells. Taken together, our studies have identified new roles for PRL3 as a collaborating oncogenic driver in human T-ALL and suggest that therapeutic targeting of the PRL3 phosphatase will likely be a useful treatment strategy for T-ALL.

OP0338 MASS SPECTROMETRY IDENTIFIES NOVEL BIOMARKERS IN GIANT CELL ARTERITIS, USEFUL IN PATIENTS ON INTERLEUKIN-6 RECEPTOR BLOCKADE

Background:

Acute phase reactants (erythrosedimentation rate [ESR], C-reactive protein [CRP]) have limited utility in GCA, even in patients treated with prednisone alone. Furthermore, the lack of reliable biomarkers in patients receiving interleukin (IL)-6 blockade therapy is a major unmet need.

Objectives:

To identify biomarkers of disease activity in GCA patients treated with prednisone monotherapy and with prednisone in combination with tocilizumab (TCZ).

Methods:

We mapped the serum proteome of GCA patients with active and inactive disease in an unbiased manner using high-throughput multiplexed mass spectrometry. Proteomic analyses were performed in 5 µl serum samples with 11-plexed tandem mass tag (TMT) technology using an Orbitrap Lumos mass spectrometer. A SEQUEST-based database search engine was employed for peptide identification. Quantification was based on TMT reporter ion intensities. All patients were sampled during their participation in the GiACTA trial,1in which they received TCZ plus 26 weeks of prednisone (TCZ group) or placebo plus 26 or 52 weeks of prednisone (PRED group). Active disease was defined as the presence of cranial or PMR symptoms requiring treatment intensification regardless of ESR and CRP levels. Samples were selected if patients were in clear states of active or inactive disease at GiACTA systematic sample collection timepoints (baseline and weeks 4, 12, 24, 48). An exhaustive leave-2-out strategy was used to identify classification markers. All possible pairs of samples were isolated as test samples and the remaining training samples were used to identify the protein markers. Proteins with an absolute log2 fold concentration difference ≥0.5 between active and inactive samples and a P-value <0.1 were retained and sorted based on the metric -log10(P-value)*absolute(log2 fold change). Top markers within each training set were selected to generate normalized ranks {0,1} across all samples. A mean rank was calculated for every sample. The set of normalized ranks for the test samples across all sets of top markers were bootstrapped for each test sample 100 times with replacement. The bootstrapped rankings were evaluated by determining areas under the curves (AUC) of receiver operator characteristic (ROC) curves.

Results:

The PRED group included 21 patients (active, n = 16; inactive, n = 5) and the TCZ group included 21 patients (active, n = 14; inactive, n = 7). Using high-throughput sample preparation methods without applying any depletion of known highly abundant serum proteins, we quantified 760 proteins across all samples and 344 proteins in at least half the samples. Compared to inactive PRED-treated patients, active PRED-treated patients showed significant overexpression of several acute phase reactants including serum amyloid A1 and 2 (SAA1, SAA2) and complement factor H (CFH) (Fig. 1a). The magnitude of concentration change and the level of statistical significance observed for SSA1, SSA2 and CFH in PRED-treated patients were higher than those of CRP (Fig. 1a). Compared to inactive TCZ-treated patients, active TCZ-treated patients demonstrated significant overexpression of multiple biomarkers including haptoglobin, haptoglobin precursor, SSA2 and complement factor 4A, and underexpression of peptidase inhibitor 16 (Fig. 1b), a protein involved in vascular and regulatory T cell biology. Sets of 10 biomarkers resulted in a classification of active versus inactive disease with ROC AUCs of 0.89 (95% CI 0.79-0.96) in the PRED group (Fig. 2a) and 0.97 (95% CI 0.95-0.97) in the TCZ group (Fig. 2b).

Conclusion:

We identified several differentially expressed serum proteins in GCA patients with active and inactive disease receiving prednisone monotherapy or TCZ-based treatment regimens. In both treatment groups, a signature of biomarkers classified disease activity status with high accuracy. Haptoglobin, a readily available laboratory test, may be useful in monitoring disease activity in GCA patients receiving IL-6 blockade therapy.

References:

[1]Stoneet al.NEJM2017

Disclosure of Interests:

Sebastian Unizony Grant/research support from: Genentech, Inc., Robert Morris: None declared, Johannes Kreuzer: None declared, Wilhelm Haas: None declared, John H. Stone Grant/research support from: Roche, Consultant of: Roche

Falls and Cancer

Falls among older people are common and are associated with substantial morbidity, mortality and healthcare costs. Increasingly cancer is becoming a disease of older people and fall rates are higher in elders living with cancer. Cancer and its treatments potentiate important risk factors for falls, including muscle weakness, poor balance, proprioception, cognitive impairment and functional disability. Sarcopenia refers to the progressive deterioration in muscle strength, mass and quality with ageing. Chronic conditions and cancer amplify this decline and are associated with a greater negative effect on function. Age-related impairments of lower limb neurological function are commonly exacerbated by neurotoxic chemotherapy, resulting in gait and balance deficits. Postural instability and falls erode confidence and result in a negative cycle of diminishing activity levels, further deconditioning and a higher risk of further falls. Cancer-related fatigue, sleep and mood disturbances compound this progressive frailty, further worsening treatment tolerance and outcomes. Cognitive impairment is a potent risk factor for falling and is frequently associated with gait abnormalities. The well-recognised effects of cancer treatment on working memory, attention, processing speed and executive function are often apparent (when their presence is sought) before treatment and may be as much the result of the cancer itself as they are 'chemo brain'. Structured exercise programmes focusing on progressively challenging strength and balance training are of proven benefit in falls prevention. Regular aerobic exercise accrues additional benefits in improved cardiorespiratory resilience and concomitant positive effects on treatment tolerance. Increased activity levels positively influence cognition, mood and foster an improved sense of well-being. Simple, practicable clinic-based tests of physical functioning, cognition and neurological function can help to identify those at high risk of falls and functional decline. The use of such instruments can aid judicious treatment planning and identify those most likely to benefit from more detailed specialist comprehensive geriatric assessment.

A changed reality: Experience of an acceptance and commitment therapy (ACT) group after stroke

Copious research on the utility of Acceptance and Commitment Therapy (ACT) in long-term conditions has demonstrated promising results. However, little research has been conducted on ACT within stroke, particularly studies that are qualitative in nature. The aim of this paper was to gain insight into stroke survivors' experiences of ACT and to explore what processes help facilitate adjustment in living with residual disability. Interviews with thirteen stroke survivors following their attendance at a stroke-adapted ACT group were analysed using a grounded theory approach. Stroke survivors varied in age, severity of stroke, limitations and duration since stroke. Interviews revealed a main difficulty of "accepting a changed reality" following stroke. Survivors' narratives regarding their experiences of ACT revealed insight into which processes helped facilitate movement towards accepting symptoms and a changed reality and into helpful and less helpful aspects of the intervention. Stroke survivors find ACT helpful in adjusting to stroke limitations. ACT appears to have potential as a psychological intervention for stroke survivors experiencing psychological distress. Amendments to the format of the intervention to enhance the impact of ACT impact are identified.

Urban blue: A global analysis of the factors shaping people's perceptions of the marine environment and ecological engineering in harbours

Marine harbours are the focus of a diverse range of activities and subject to multiple anthropogenically induced pressures. Support for environmental management options aimed at improving degraded harbours depends on understanding the factors which influence people's perceptions of harbour environments. We used an online survey, across 12 harbours, to assess sources of variation people's perceptions of harbour health and ecological engineering. We tested the hypotheses: 1) people living near impacted harbours would consider their environment to be more unhealthy and degraded, be more concerned about the environment and supportive of and willing to pay for ecological engineering relative to those living by less impacted harbours, and 2) people with greater connectedness to the harbour would be more concerned about and have greater perceived knowledge of the environment, and be more supportive of, knowledgeable about and willing to pay for ecological engineering, than those with less connectedness. Across twelve locations, the levels of degradation and modification by artificial structures were lower and the concern and knowledge about the environment and ecological engineering were greater in the six Australasian and American than the six European and Asian harbours surveyed. We found that people's perception of harbours as healthy or degraded, but not their concern for the environment, reflected the degree to which harbours were impacted. There was a positive relationship between the percentage of shoreline modified and the extent of support for and people's willingness to pay indirect costs for ecological engineering. At the individual level, measures of connectedness to the harbour environment were good predictors of concern for and perceived knowledge about the environment but not support for and perceived knowledge about ecological engineering. To make informed decisions, it is important that people are empowered with sufficient knowledge of the environmental issues facing their harbour and ecological engineering options.

The CORE-10 in screening for current mental health problems and severe mental illness in prisoners

BACKGROUND

Few mental health screening tools are validated for prisoners. Existing tools do not guide referral between primary and secondary care pathways.

AIMS

This study aimed to assess performance of the CORE-10 in screening any current mental health problem and current severe mental illness (SMI) in prisoners.

METHOD

CORE-10 ratings were compared with mini international neuropsychiatric interview (MINI) version 6.0 ratings and current practice outcomes for 150 male prisoners. Receiver operating curve (ROC) analyses were used to estimate the likelihood with which CORE-10 ratings matched MINI ratings, yielding "area under the curve" statistics.

RESULTS

ROC analyses suggested a strong relationship between CORE-10 screen scores and the more detailed assessment both in identifying any problem (AUC 0.85) and severe mental illness (AUC 0.76). Sensitivity was 0.88 and 0.83, and specificity was 0.64 and 0.61, respectively. Retest reliability was moderate (ICC = 0.83). The CORE-10 identified many cases of "any problem" and of severe illness also identified by the MINI who had not been referred to clinical services in routine practice.

CONCLUSIONS

This study provides evidence for the potential of the CORE-10 for improving appropriate referrals for prisoners to mental health services.

Measuring outcomes following tibial fracture

AIM

The aim of this study was to determine how outcome is measured following adult tibial fracture in the modern era of functional outcome measurement and patient reported outcomes.

METHODS

A systematic review of publications since 2009 was performed, looking specifically at acute, adult tibial shaft fractures. Ovid Medline, Embase, PubMed and PsycINFO databases were searched for relevant titles which were then screened by two authors with adjudication where necessary by a third. Relevant articles were reviewed in full and data was extracted concerning the study participants, study design and any measures that were used to quantify the results following fracture. The results were collated and patient reported outcome measures were assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) standards.

RESULTS

A total of 943 titles and articles were reviewed, with 117 included for full analysis. A wide range of clinical and radiological "outcomes" were described, along with named clinician- and patient-reported outcome measures. There was considerable heterogeneity and lack of detail in the description of the simplest outcomes, such as union, infection or reoperation. Reported clinician and patient reported outcome measures are variably used. None of the identified patient reported outcome measures have been validated for use following tibial fracture.

CONCLUSION

We recommend definition of a core outcome set for use following tibial fracture. This will standardise outcome reporting following these injuries. Furthermore, there is need for a validated patient reported outcome measure to better assess patient important outcomes in this patient group.

Adhesive Arachnoiditis following Inadvertent Epidural Injection of 2% Chlorhexidine in 70% Alcohol—Partial Recovery over the Ensuing Eight Years

We report a case of serious neurologic injury due to inadvertent epidural injection of 8 ml of the antiseptic 2% chlorhexidine in 70% alcohol during a procedure aimed to relieve the pain of labour. This resulted in immediate severe back pain, progressive tetraparesis and sphincter dysfunction caused by damage to the spinal cord and nerve roots. Subacute hydrocephalus necessitated drainage, but cranial nerve and cognitive function were spared. Magnetic resonance imaging documented marked abnormality of the spinal cord and surrounding leptomeninges. In the ensuing eight years, there has been clinical and electrophysiological evidence of partial recovery, but neurologic deficit remains severe.

Keeping active: maintenance of physical activity after exercise programmes for older adults

OBJECTIVES

To explore factors associated with maintenance of moderate-to-vigorous physical activity (MVPA) in community-dwelling adults aged ≥65 years after completing a 24-week exercise programme.

STUDY DESIGN

This is a cohort study nested within a randomised controlled trial evaluating group- and home-based exercise programmes for older people in England.

METHODS

MVPA levels and factors potentially associated with physical activity (PA) were self-reported at recruitment, 6, 12, 18 and 24 months after exercise programme. Multilevel logistic regression estimated odds ratios (ORs) for achieving target MVPA level (150 min/week) 6-24 months after exercise programmes ended.

RESULTS

Older people (OR per year increase: 0.89, 95% confidence interval [CI] 0.86, 0.93) and women (OR 0.47, 95% CI 0.33, 0.67) were less likely to achieve target MVPA. Those physically active at recruitment (OR 11.28, 95% CI 7.95, 16.01), with wider social networks (OR per unit increase in Lubben Social Network Scale: 1.06, 95% CI 1.03, 1.10) and performing more sit-to-stands in 30 s (OR for quartile 3 compared with quartile 1: 1.87, 95% CI 1.12, 3.10), were more likely to achieve target MVPA. Negative exercise expectations increased the odds of achieving target MVPA but only among the less active at recruitment (OR per unit increase in Outcome and Expectation for Exercise negative subscale: 1.90, 95% CI 1.39, 2.60). Associations did not differ significantly across the follow-up period.

CONCLUSION

A range of factors are associated with maintenance of PA 6-24 months after exercise programmes. Factors are not more strongly associated with shorter vs longer term PA maintenance. Commissioners and providers should consider targeting maintenance interventions to those least likely to maintain PA.

Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies

BACKGROUND

Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men.

METHODS

In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes.

RESULTS

Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97-2·24) and tripled risk among women (3·00, 2·71-3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35-59 years: 2·60, 2·30-2·94) than in older individuals (aged 70-89 years: 2·01, 1·85-2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35-59 years had the highest death RR across all age and sex groups (5·55, 4·15-7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35-59 years, the excess absolute risk was 0·05% (95% CI 0·03-0·07) per year in women compared with 0·08% (0·05-0·10) per year in men; the corresponding excess at ages 70-89 years was 1·08% (0·84-1·32) per year in women and 0·91% (0·77-1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes.

INTERPRETATION

Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).

Patient-derived xenografts effectively capture responses to oncology therapy in a heterogeneous cohort of patients with solid tumors

Background

While patient-derived xenografts (PDXs) offer a powerful modality for translational cancer research, a precise evaluation of how accurately patient responses correlate with matching PDXs in a large, heterogeneous population is needed for assessing the utility of this platform for preclinical drug-testing and personalized patient cancer treatment.

Patients and methods

Tumors obtained from surgical or biopsy procedures from 237 cancer patients with a variety of solid tumors were implanted into immunodeficient mice and whole-exome sequencing was carried out. For 92 patients, responses to anticancer therapies were compared with that of their corresponding PDX models.

Results

We compared whole-exome sequencing of 237 PDX models with equivalent information in The Cancer Genome Atlas database, demonstrating that tumorgrafts faithfully conserve genetic patterns of the primary tumors. We next screened PDXs established for 92 patients with various solid cancers against the same 129 treatments that were administered clinically and correlated patient outcomes with the responses in corresponding models. Our analysis demonstrates that PDXs accurately replicate patients' clinical outcomes, even as patients undergo several additional cycles of therapy over time, indicating the capacity of these models to correctly guide an oncologist to treatments that are most likely to be of clinical benefit.

Conclusions

Integration of PDX models as a preclinical platform for assessment of drug efficacy may allow a higher success-rate in critical end points of clinical benefit.

Improvement of Siderotic ERG

For fear of endophthalmitis and siderosis, ferrous intraocular foreign bodies are usually removed as soon as they are discovered; markedly reduced, siderotic ERG changes are considered permanent. We report a patient who presented with a chronically retained intravitreal foreign body and significant clinical as well as electrophysiologic signs of siderosis. Only 3 months after surgery, the ERG showed almost complete recovery. If siderosis is not present, adequate and regular follow-up examinations may in certain cases substitute for immediate removal of chronically retained intraocular foreign bodies.

Intraocular Foreign Bodies: Myths and Truths

Over the centuries, the management of eyes with intraocular foreign bodies (IOFB) has posed a special challenge to the physician, and the anxiety created by such injuries has never abated. During the past few decades, several new diagnostic tests, IOFB removal techniques, and methods to treat the complications of the injury have been introduced. Nevertheless, old habits die hard: many of the management options that used to be standard are not appropriate any more but have proved difficult to change. This article reviews over forty of these die-hard myths and confronts them with factual statements published in the peer-review international literature.

Consultants' and Patients' Views about Patient Access to their General Practice Records

Semi-structured interviews were conducted with 24 hospital consultants and 47 general practice patients, asking for their opinions about a proposed policy of partial access to records in one general practice. Eleven consultants were opposed to the policy, 10 were in favour and three were classified as ambivalent. Arguments against access were couched largely in terms of consultants' own interests whereas arguments in favour of access were couched in terms of patients' interests. Although 81% of patients interviewed said that they should in principle be allowed to see their own records, only 51% wanted access to their own records. Fears expressed by consultants on patients' behalf are not necessarily well founded.

Predictors of post-traumatic growth in stroke survivors

PURPOSE

The development of post-traumatic growth was studied longitudinally within 14 months poststroke. The predictions of two models of post-traumatic growth were examined.

METHOD

Forty-three stroke survivors were investigated at two time points (i.e., time 1 and time 2), six months apart. Each completed the Post-traumatic Growth Inventory, Rumination Scale, Impact of Events Scale, Multidimensional Scale of Social Support, the Barthel Index and the COPE scale.

RESULTS

Post-traumatic growth was evident four to five months after stroke, increasing significantly over the next six months at which point levels resembled those reported in cross-sectional stroke studies. Active and denial coping and rumination at time 1 were positively associated, and age was negatively associated, with post-traumatic growth at time 2, but acceptance coping was not associated. Neither active coping nor rumination mediated the effect of social support on post-traumatic growth as predicted. As predicted, rumination mediated the relationship between post-traumatic stress and post-traumatic growth. Exploratory stepwise regression demonstrated rumination and active coping at time 1 accounted for 45% of variance in post-traumatic growth at time 2.

CONCLUSIONS

Post-traumatic growth can develop soon after stroke. Deliberate rumination is a key factor in post-traumatic growth. Both active coping and denial coping were associated with post-traumatic growth demonstrating the psychological complexity of poststroke adjustment. Implications for rehabilitation Therapists can expect stroke survivors to show post-traumatic growth in the first months after stroke. Therapists should look to promote post-traumatic growth and positive adjustment through working with survivors to increase active coping (attempts to deal effectively with the impact of stroke) and rumination (cognitive processing of the impact of the stroke). Since denial coping was also associated with posttraumatic growth, stroke survivors who maintain overly optimistic views about the severity and impact of their stroke are likely to benefit from therapists continually facilitating capacity for growth and well-being.

Induced membrane technique for treating tibial defects gives mixed results

Aims

This study describes the use of the Masquelet technique to treat segmental tibial bone loss in 12 patients.

Patients and Methods

This retrospective case series reviewed 12 patients treated between 2010 and 2015 to determine their clinical outcome. Patients were mostly male with a mean age of 36 years (16 to 62). The outcomes recorded included union, infection and amputation. The mean follow-up was 675 days (403 to 952).

Results

The mean tibial defect measured 5.8 cm (2 to 15) in length. Of the 12 patients, 11 had an open fracture. Eight underwent fixation with an intramedullary nail, three with plates and one with a Taylor Spatial Frame. The mean interval between stages was 57 days (35 to 89). Bony union was achieved in only five patients. Five patients experienced infective complications during treatment, with two requiring amputation because of severe infection.

Conclusion

The Masquelet technique was relatively ineffective in achieving union in this series, and was associated with a high rate of infection. Cite this article: Bone Joint J 2017;99-B:680–5.

The relationship between stroke survivors' perceived identity and mood, self-esteem and quality of life

OBJECTIVES

To examine change in identity after stroke and to elucidate its relationship with mood and quality of life. To test Higgins' theory of the impact of identity (self-discrepancy) on anxiety and depression. To examine the role of self-esteem in mediating the relationship between identity and outcomes.

METHOD

Sixty-five community-living first-time stroke survivors, mean age 61.58 and time since stroke 5.60 years, were recruited from stroke charities. A cross-sectional study used the Head Injury Semantic Differential Scale, the Hospital Anxiety and Depression Scale, the Rosenberg Self-Esteem Scale, the Stroke-Specific Quality of Life Questionnaire (adapted) and the Barthel Index.

RESULTS

Identity was rated more negatively after stroke than before (t(64) = 6.46, p < .00). Greater discrepancy in identity was associated with anxiety (r = .38, p < .00), depression (r = .59, p < .00), self-esteem (r = -.48, p < .00) and quality of life (r = -.54, p < .00). Overall positivity of identity after stroke predicted outcomes even better than discrepancy. The association between discrepancy and mood and quality of life was mediated by self-esteem (β = .30, p < .01; β = -.24, p < .01, respectively). Specific types of discrepancy defined by Higgins did not show differential relationships with anxiety and depression as predicted.

CONCLUSIONS

Identity changes after stroke and identity and self-esteem are associated with important outcomes for stroke survivors.

Feeding management, production and performance of 13 pasture-based dairy farms in a Mediterranean environment

Physical performance data from 13 dairy farms in Western Australia, six feeding all concentrate in the milking parlour and seven feeding a portion of concentrate in a partial mixed ration (PMR) with forage, were collected between March 2012 and June 2013. Each farm was visited 13 times at intervals of 4–6 weeks, and feed intake and milk production was recorded on each visit. Four farms had access to fresh pasture all year round via irrigation. Milk yield (MY) and composition data was calculated daily from milk processor records. Pasture dry matter intake (DMI) was estimated based on metabolisable energy supply and requirements according to published feeding standards. All milk and feed-related measures were significantly affected by visit date (P < 0.01). Mean annual concentrate intake and MY was 2082 ± 344 kg/cow and 7679 ± 684 kg/cow, respectively. Daily concentrate DMI was greatest in May 2012 (8.9 ± 2.2 kg/cow), near the end of the non-grazing season, and lowest in August 2012 (5.1 ± 1.5 kg/cow). On an average annual basis, PMR farms provided 22 ± 15% of total concentrate fed as part of a PMR, and 28 ± 11% of total concentrates and by-products fed as part of a PMR. Daily grazed pasture DMI was highest on all farms in September 2012 (12.9 ± 2.4 kg/cow), and averaged 6.6 kg/cow on the four irrigated farms between January and May. Daily yield of energy-corrected milk was highest in September 2012 (26.9 kg/cow) and lowest in January 2013 (21.9 kg/cow). Milk fat content was highest in summer and lowest in winter; the reverse was true of milk protein. Feed conversion efficiency was significantly affected by visit date, but mean feed conversion efficiency was the same (1.37) for in-parlour and PMR farms. Overall there was some evidence that PMR feeding systems on Western Australian dairy farms are not optimised to their full potential, but a high degree of variability in performance between all farms was also apparent.

Beyond the front end: Investigating a thigh worn accelerometer device for step count and bout detection in Parkinson's disease

Free-living ambulation with accelerometer-based devices is an attractive methodology to assess habitual behaviour within Parkinson's disease (PD). However, slowness of movement can contribute to difficulty in quantifying ambulatory/walking outcomes within this group by these devices. This study investigates the use of a commercial accelerometer device (activPAL^™) in those with moderate PD to understand its proprietary software (inbuilt algorithm) limitations. The values provided by the proprietary software are evaluated in comparison to novel algorithms on the same raw data to examine limitations for use within this cohort. The bespoke algorithms help to alter sensitivity in outcomes stemming from the same accelerometer data while also highlighting how slight changes in algorithms can drastically inflate/deflate values. In general, results show that the proprietary software generally quantifies lower values of outcomes (step and bout count), which is similar to previous findings. Variations in algorithm functionality highlight large heterogeneity in bout and step counts resulting from a lack of how they are defined within the literature. The novel alternative ambulatory algorithms presented here should be considered for use on raw data from the activPAL^™ in those with moderate/severe PD.

Neonatal lumbar puncture: are clinical landmarks accurate?

BACKGROUND

The intercristal line (ICL), defined by the superior aspect of the iliac crest, is used to clinically identify the entry point for lumbar puncture (LP) in neonates. Accepted practice is to insert the needle at the L3/4 or L4/5 intervertebral space.

AIM

To investigate the vertebral level crossed by the ICL as determined by manual palpation and the ability of manual palpation to reliably identify a specified intervertebral space.

METHOD

A total of 30 term neonates were recruited. Paediatricians identified and marked the ICL and the intervertebral space above, with babies in left lateral position. The anatomical positions of both points and the end of the conus medullaris were confirmed using ultrasonography.

RESULTS

The ICL was marked from L2/3 to L5/S1. In 25 babies (83%), the ICL was identified at the desired vertebral level between L3/4 and L4/5. The intervertebral space above this line was marked between L1/2 to L4/5. The potential site for LP was identified higher than intended in 11 cases (36%). The end of the conus medullaris ranged from L1 to L3 terminating at L2 or lower in 11 cases (36%).

CONCLUSIONS

There are wide variations in the positions of the ICL and potential LP site. Using the ICL to guide LP does not appear to be accurate, raising the possibility of potential spinal cord damage.