Economic impact analysis of a minimally invasive temperature-controlled radiofrequency device versus nasal surgery for the treatment of nasal airway obstruction in the United States

OBJECTIVE

To determine the economic impact of a minimally invasive temperature-controlled radiofrequency (TCRF) device for treating nasal airway obstruction (NAO).

METHODS

A budget impact model was developed for two scenarios: a reference scenario of functional rhinoplasty surgery with concomitant septoplasty and inferior turbinate reduction (ITR) performed in the hospital outpatient department where TCRF is not an available treatment option and a new scenario consisting of in-office TCRF treatment of the nasal valve and ITR. A payor perspective was adopted with a hypothetical population plan size of one million members. Costs were estimated over a time horizon of 4 years. The eligible population included patients with severe/extreme NAO and nasal valve collapse (NVC) as the primary cause or significant contributor. Data inputs were sourced from targeted literature reviews. Uncertainty within the model structure and input parameters was assessed using one-way sensitivity analysis.

RESULTS

The introduction of a TCRF device resulted in population-level cost savings of $20,015,123 and per-responder average cost savings of $3531 through a 4-year time horizon due to lower procedure costs and complication rates of the device relative to the surgical comparator. Results were robust when varying parameter values in sensitivity analyses, with cost savings being most sensitive to the prevalence of NAO and estimated response rates to functional rhinoplasty and TCRF.

CONCLUSIONS

In patients with severe/extreme NAO, with NVC as the primary or major contributor, introducing TCRF with ITR as a treatment option demonstrates the potential for significant cost savings over functional rhinoplasty with septoplasty and ITR.

Acceptability of Online Yoga Among Individuals With Chronic Conditions and Their Caregivers: Qualitative Study

BACKGROUND

The online delivery of yoga interventions rapidly expanded during the COVID-19 pandemic, and preliminary studies indicate that online yoga is feasible across multiple chronic conditions. However, few yoga studies provide synchronous online yoga sessions and rarely target the caregiving dyad. Online chronic disease management interventions have been evaluated across conditions, life spans, and diverse samples. However, the perceived acceptability of online yoga, including self-reported satisfaction and online delivery preferences, is underexplored among individuals with chronic conditions and their caregivers. Understanding user preferences is essential for successful and safe online yoga implementation.

OBJECTIVE

We aimed to qualitatively examine the perceived acceptability of online yoga among individuals with chronic conditions and their caregivers who participated in an online dyadic intervention that merged yoga and self-management education to develop skills (MY-Skills) to manage persistent pain.

METHODS

We conducted a qualitative study among 9 dyads (>18 years of age; individuals experiencing persistent moderate pain) who participated in MY-Skills online during the COVID-19 pandemic. The intervention consisted of 16 online, synchronous yoga sessions over 8 weeks for both dyad members. After the completion of the intervention, participants (N=18) participated in semistructured telephone interviews for around 20 minutes, discussing their preferences, challenges, and recommendations for improved online delivery. Interviews were analyzed by using a rapid analytic approach.

RESULTS

MY-Skills participants were, on average, aged 62.7 (SD 19) years; were primarily women; were primarily White; and had a mean of 5.5 (SD 3) chronic conditions. Both participants and caregivers reported moderate pain severity scores (mean 6.02, SD 1.3) on the Brief Pain Inventory. The following three themes were identified related to online delivery: (1) participants indicated a preference for the intervention to be in person rather than online because they were distracted in the home setting, because they felt that in-person yoga would be more engaging, because the yoga therapist could physically correct positions, and because of safety concerns (eg, fear of falling); (2) participants indicated good acceptability of online MY-Skills delivery due to convenience, access, and comfort with being in their home; and (3) recommendations for improving online delivery highlighted a need for additional and accessible technical support.

CONCLUSIONS

Both individuals with chronic conditions and their caregivers find online yoga to be an acceptable intervention. Participants who preferred in-person yoga did so due to distractions in the home and group dynamics. Some participants preferred in-person corrections to ensure correct positioning, while others felt safe with verbal modifications in their homes. Convenience and access were the primary reasons for preferring online delivery. To improve online delivery, future yoga studies should include specific activities for fostering group engagement, enhancing safety protocols, and increasing technical support.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03440320; https://clinicaltrials.gov/ct2/show/NCT03440320.

Disutility of injectable therapies in obesity and type 2 diabetes mellitus: general population preferences in the UK, Canada, and China

INTRODUCTION

Once-daily and once-weekly injectable glucagon-like peptide-1 receptor agonist therapies (GLP-1 RAs) are established in obesity and type 2 diabetes mellitus (T2DM). In T2DM, both once-daily and once-weekly insulin are expected to be available. This study elicited utilities associated with these treatment regimens from members of the general public in the UK, Canada, and China, to quantify administration-related disutility of more-frequent injectable treatment, and allow economic modelling.

METHODS

Two anchor states (no pharmacological treatment), and seven treatment states (daily oral tablet and generic injectable regimens of variable frequency), with identical outcomes were tested A broadly representative sample of the general public in each country participated (excluding individuals with diabetes or pharmacologically treated obesity). An adapted Measurement and Valuation of Health protocol was administered 1:1 in web-enabled interviews by trained moderators: visual analogue scale (VAS) as a "warm-up", and time trade-off (TTO) using a 20-year time horizon for utility elicitation.

RESULTS

A total of 310 individuals participated. The average disutility of once-daily versus once-weekly GLP-1 RA was - 0.048 in obesity and - 0.033 in T2DM; the corresponding average disutility for insulin was - 0.064. Disutilities were substantially greater in China, relative to UK and Canada.

DISCUSSION

Within obesity and T2DM, more-frequent treatment health states had lower utility. Scores by VAS also followed a logical order. The generated utility values are suitable for use in modelling injectable therapy regimens in obesity and T2DM, due to the use of generic descriptions and assumption of equal efficacy. Future research could examine the reasons for greater administration-related disutility in China.

EXPERIENCING PAIN TOGETHER: CARE PARTNERS REFLECT ON A DYADIC INTERVENTION FOR PAIN SELF-MANAGEMENT

When caregivers and care receivers (caregiving dyad) both experience persistent pain, there is increased risk for shared adverse health outcomes, including social isolation and decreased relationship satisfaction. Yet, there are few non-pharmacological pain interventions for the caregiving dyad. The purpose of this study was to understand changes in the caregiving dyad after participating in a dyadic, multi-modal intervention for pain self-management. Fifteen caregiving dyads with pain (N=30) participated in the Merging Yoga and self-management to develop Skills (MY-Skills) intervention. Open-ended questions were included in the post-intervention evaluation tool to discuss changes in the dyadic relationship. Qualitative methods were used to analyze data, develop a coding scheme, and identify themes. Findings suggest the intervention strengthened relationships by improving communication, enhancing emotional connection, and increasing physical activity. This study demonstrates the importance of dyadic approaches to interventions for care partners with pain.

EXPLORING THE ASSOCIATION BETWEEN FAMILY DYNAMICS AND PREPAREDNESS FOR FAMILY CAREGIVING AT THE END OF LIFE

The transition to providing end-of-life (EOL) care to a family member can be challenging for family caregivers as they face difficult decisions regarding medical course of treatment, increasing caregiving responsibilities, and anticipatory grief. Low preparedness for EOL caregiving is associated with higher levels of caregiver strain, increased levels of depression and anxiety, and complicated and prolonged grief after the death of the family member. Despite the breadth of caregiving research, little is known about how family relationships and interactions relate to caregiver preparedness for EOL caregiving. Thus, the purpose of this study was to explore the association between family caregivers’ family dynamics and their perceived preparedness for the transition to EOL caregiving. A sample of 173 family caregivers were recruited to complete an online, self-report survey. A structural equation model was used to analyze the association between family dynamics and caregiving preparedness. Most caregivers reported balanced family cohesion (75.1%) and family flexibility (75.7%), but low family communication and low family satisfaction. In addition, 20.2% of caregivers reported being not at all prepared for the transition to EOL caregiving. Although there was a lack of meaningful association between family dynamics and preparedness for EOL caregiving, it may be that family relationships and interactions grow more complex as families age and individuals take on new and different roles (such as family caregiving) within the family system. This study demonstrates the need for future research to develop new measures to explore how aging family dynamics relate to family caregiver experiences and outcomes.

INDIVIDUALS AND THEIR CAREGIVERS WITH PERSISTENT PAIN: A FEASIBILITY AND ACCEPTABILITY STUDY

Persistent pain interventions targeting the caregiving dyad (i.e., caregivers and care receivers) are scarce. Thus, the purpose of this pilot study was to assess the feasibility and acceptability of the Merging Yoga and self-management to develop Skills (MY-Skills) intervention for caregiving dyads experiencing persistent pain. MY-Skills is a group intervention and was delivered in-person or online (due to COVID-19) twice a week for eight weeks, with each two-hour session including self-management education followed by yoga. Benchmarks for feasibility were set a prioi and included: recruitment, attrition, attendance, safety, acceptability/satisfaction, and study completion. Thirteen participants (caregivers n=7, care-receivers n=6) completed the in-person intervention and 18 individuals (9 dyads) completed the online version. Feasibility benchmarks were met, except for recruitment, where >1000 individuals were screened for eligibility. Interventions may lead to improved wellbeing, yet further research is needed to establish efficacy of health-related outcomes for the caregiving dyad experiencing persistent pain.

Soil microbial community structures are shaped by agricultural systems revealing little temporal variation

Many studies in soil microbial ecology are undertaken with a single sampling event, with the influence of temporal progression rarely being considered. Under field conditions, soil samples were taken from different agricultural systems; a sown grassland to maize rotation (MC), an intensively managed permanent grassland (INT), as well as extensively managed permanent grasslands with high (EXT_HP), low to sufficient (EXT_LP) and deficient available P (EXT_DP), six times throughout the 2017 growing season. Thus, this study aimed to determine if any differences in soil microbiome structures between both sharply contrasting (MC - INT - EXT), slightly differing (EXT_HP - EXT_DP) and quite similar (EXT_HP - EXT_LP and EXT_LP - EXT_DP) agricultural systems persist through changing growth conditions within the growing season. For both fungal and bacterial community structure, the influence of agricultural system (CV = 0.256, P < 0.001 and CV = 0.145, P < 0.01, respectively) was much greater than that of temporal progression (√CV = 0.065 and 0.042, respectively, both P < 0.001). Importantly, nearly all agricultural systems persistently harbored significantly distinct fungal community structures across each of the six sampling events (all at least P < 0.05). There were not as many pairwise differences in bacterial community structure between the agricultural systems, but some did persist (MC and EXT_HP ∼ EXT_DP, all P < 0.001). Additionally, persistent indicator fungal OTUs (IndVal >0.7, P ≤ 0.05) associated to each agricultural system (except EXT_LP) were found in each of the six sampling events. These results highlight the temporal stability of pairwise differences in soil microbiome structures between established agricultural systems through changing plant growth conditions, even between those with a comparable management regime. This is a highly relevant finding in informing the sampling strategy of studies in soil microbial ecology as well as for designing efficient soil biodiversity monitoring systems.

Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Left ventricular unloading with Impella versus IABP in patients on VA-ECMO for cardiogenic shock

Background

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) use for circulatory support in shock is limited by increased left ventricular afterload. Impella and intra-aortic balloon pump (IABP) can be used in conjunction with VA-ECMO to help unload the left ventricle. Data comparing the two strategies are limited.

Purpose

We performed a systematic review and meta-analysis of published data to compare outcomes of patients with shock supported by VA-ECMO in conjunction with Impella versus IABP.

Methods

We conducted a search of Medline, Embase, and Cochrane databases to identify studies comparing the use of Impella versus IABP in patients on VA-ECMO. The primary outcome of interest was all-cause mortality (in-hospital or 30-day). Secondary outcomes included transition to destination therapy with left ventricular assist device (LVAD) or transplant, stroke, need for continuous renal replacement therapy (CRRT), bleeding, and hemolysis. Risk ratios (RR) with 95% confidence interval and the heterogeneity statistic I2 were reported for each outcome.

Results

Six observational studies with a total of 629 patients were included in the analysis. Of these, 205 (33%) and 424 (67%) patients were supported by Impella and IABP respectively, in addition to VA-ECMO. All six studies reported the primary outcome. No difference was observed in all-cause mortality between VA-ECMO with Impella and VA-ECMO with IABP (RR 1.02 [0.74–1.40], I2=74%). Similar rates were observed for transition to LVAD or transplant (RR 0.75 [0.45–1.27], I2=0%), stroke (RR 1.50 [0.80–2.83], I2=0%), and need for CRRT (RR 1.04 [0.82–1.32], I2=0%). However, use of VA-ECMO with Impella was associated with a higher risk of bleeding (RR 1.91 [1.28–2.86], I2=68%) and hemolysis (RR 4.61 [1.24–17.17], I2=66%) as compared with use of VA-ECMO with IABP.

Conclusion

In patients with shock requiring VA-ECMO, concurrent use of Impella and IABP had similar risk of mortality, transition to LVAD/transplant, stroke, and need for CRRT. However, Impella use was associated with higher risk of bleeding and hemolysis. Randomized trials are needed to identify the optimal strategy for left ventricular unloading in patients with cardiogenic shock on VA-ECMO.

Funding Acknowledgement

Type of funding sources: None.

Development of a Multi-Modal, Dyadic Intervention for Persistent Pain: A Qualitative Study

People who experience persistent pain often require help from a family member, partner, or friend. These caregivers frequently have pain, but are often not included in interventions. Caregivers and care-receivers who both experience pain are more likely to be socially isolated, experience communication conflict, and have decreased quality of life. Interventions should target caregiving dyads to help them manage their pain together. Feasibility studies that include manual development, intervention evaluation, and refinement of intervention manuals support randomized controlled trials and help move interventions from research to practice. Thus, the purpose of this qualitative study was to explore (a) the needs of caregiving dyads, (b) input from medical and allied health experts, and (c) feedback from intervention facilitators and evaluators, informing the development and refinement of an intervention manual for people with persistent pain. A total of 16 caregiving dyads and one individual (caregiver couldn’t participate) experiencing pain participated in focus groups. Eight experts then participated in a focus group or one-on-one interview. Lastly, after the intervention ended, 15 intervention facilitators and fidelity evaluators participated in one focus group. Data were uploaded into NVivo software and analyzed using constant comparison. Findings identified the importance of interventions to focus on pain interference, novel and modifiable approaches to managing pain as a dyad, and addressing the emotional and psychological effects of experiencing pain. Using qualitative approaches to develop, test, and refine an intervention manual enhances the relevancy, acceptability, and translation of our intervention to meet the needs of caregiving dyads experiencing pain.

Family Caregivers' Feelings of Preparedness for the Transition to End-Of-Life Caregiving

The high levels of stress experienced by family caregivers may affect their physical and psychological health, including their sleep quality. However, there are few population-based studies comparing sleep between family caregivers and carefully-matched controls. We evaluated differences in sleep and identified predictors of poorer sleep among the caregivers, in a comparison of 251 incident caregivers and carefully matched non-caregiving controls, recruited from the national REasons for Geographic and Racial Differences in Stroke (REGARDS) Study. Incident caregivers and controls were matched on up to seven demographic and health factors (age, sex, race, education level, marital status, self-rated health, and self-reported serious cardiovascular disease history). Sleep characteristics were self-reported and included total sleep time, sleep onset latency, wake after sleep onset, time in bed, and sleep efficiency. Family caregivers reported significantly longer sleep onset latency, before and after adjusting for potential confounders, compared to non-caregiving controls (ps < 0.05). Depressive symptoms in caregivers predicted longer sleep onset latency, greater wake after sleep onset, and lower sleep efficiency. Longer total sleep time in caregivers was predicted by employment status, living with the care recipient, and number of caregiver hours. Employed caregivers and caregivers who did not live with the care recipient had shorter total sleep time and spent less time in bed than non-employed caregivers. Additional research is needed to evaluate whether sleep disturbances contributes to health problems among caregivers.

Small-scale agricultural grassland management can affect soil fungal community structure as much as continental scale geographic patterns

A European transect was established, ranging from Sweden to the Azores, to determine the relative influence of geographic factors and agricultural small-scale management on the grassland soil microbiome. Within each of five countries (factor ‘Country’), which maximized a range of geographic factors, two differing growth condition regions (factor ‘GCR’) were selected: a favorable region with conditions allowing for high plant biomass production and a contrasting less favorable region with a markedly lower potential. Within each region, grasslands of contrasting management intensities (factor ‘MI’) were defined: intensive and extensive, from which soil samples were collected. Across the transect, ‘MI’ was a strong differentiator of fungal community structure, having a comparable effect to continental scale geographic factors (‘Country’). ‘MI’ was also a highly significant driver of bacterial community structure, but ‘Country’ was clearly the stronger driver. For both, ‘GCR’ was the weakest driver. Also at the regional level, strong effects of MI occurred on various measures of the soil microbiome (i.e. OTU richness, management-associated indicator OTUs), though the effects were largely regional-specific. Our results illustrate the decisive influence of grassland MI on soil microbial community structure, over both regional and continental scales, and, thus, highlight the importance of preserving rare extensive grasslands.

Program Evaluation of Population- and System-Level Policies: Evidence for Decision Making

BACKGROUND

Policy evaluations often focus on ex post estimation of causal effects on short-term surrogate outcomes. The value of such information is limited for decision making, as the failure to reflect policy-relevant outcomes and disregard for opportunity costs prohibits the assessment of value for money. Further, these evaluations do not always consider all relevant evidence, other courses of action, or decision uncertainty.

METHODS

In this article, we explore how policy evaluation could better meet the needs of decision making. We begin by defining the evidence required to inform decision making. We then conduct a literature review of challenges in evaluating policies. Finally, we highlight potential methods available to help address these challenges.

RESULTS

The evidence required to inform decision making includes the impacts on the policy-relevant outcomes, the costs and associated opportunity costs, and the consequences of uncertainty. Challenges in evaluating health policies are described using 8 categories: 1) valuation space; 2) comparators; 3) time of evaluation; 4) mechanisms of action; 5) effects; 6) resources, constraints, and opportunity costs; 7) fidelity, adaptation, and level of implementation; and 8) generalizability and external validity. Methods from a broad set of disciplines are available to improve policy evaluation, relating to causal inference, decision-analytic modeling, theory of change, realist evaluation, and structured expert elicitation.

LIMITATIONS

The targeted review may not identify all possible challenges, and the methods covered are not exhaustive.

CONCLUSIONS

Evaluations should provide appropriate evidence to inform decision making. There are challenges in evaluating policies, but methods from multiple disciplines are available to address these challenges.

IMPLICATIONS

Evaluators need to carefully consider the decision being informed, the necessary evidence to inform it, and the appropriate methods.[Box: see text].

COVID-19 testing in outbreak-free care homes: what are the public health benefits?

BACKGROUND

COVID-19 care home outbreaks represent a significant proportion of COVID-19 morbidity and mortality in the UK. National testing initially focused on symptomatic care home residents, before extending to asymptomatic cohorts.

AIM

The aim was to describe the epidemiology and transmission of COVID-19 in outbreak free care homes.

METHODS

A two-point prevalence survey of COVID-19, in 34 Liverpool care homes, was performed in April and May 2020. Changes in prevalence were analysed. Associations between care home characteristics, reported infection, prevention and control interventions, and COVID-19 status were described and analysed.

FINDINGS

No resident developed COVID-19 symptoms during the study. There was no significant difference between: the number of care homes containing at least one test positive resident between the first (17.6%, 95% confidence interval (CI) 6.8-34.5) and second round (14.7%, 95% CI 5.0-31.1) of testing (p>0.99); and the number of residents testing positive between the first (2.1%, 95% CI 1.2-3.4) and second round (1.0%, 95% CI 0.5-2.1) of testing (P=0.11). Care homes providing nursing care (risk ratio (RR) 7.99, 95% CI 1.1-57.3) and employing agency staff (RR 8.4, 95% CI 1.2-60.8) were more likely to contain test positive residents. Closing residents shared space was not associated with residents testing positive (RR 2.63, 95% CI 0.4-18.5).

CONCLUSIONS

Asymptomatic COVID-19 care homes showed no evidence of disease transmission or development of outbreaks; suggesting that current infection prevention and control measures are effective in preventing transmission. Repeat testing at two to three weeks had limited or no public health benefits over regular daily monitoring of staff and residents for symptoms. These results should inform policies calling for regular testing of asymptomatic residents.

Grandparent Resilience: Improving Self-Efficacy in Grandparents Raising Grandchildren

Grandparents often protect against childhood trauma and promote resilience through their nurturance, love, and support when raising grandchildren. Despite the beneficial role grandparents have on their grandchildren, grandparents may experience challenges of their own, including physical, mental, and emotional health issues, lack of resources, and social isolation. Few interventions exist to help grandparents successfully adapt to the challenges they face as primary parenting figures. The purpose of this study was to test preliminary efficacy of a strengths-based intervention for grandparents raising grandchildren aimed at increasing self-care behaviors, managing emotions, and connecting to community resources. Grandparents (N = 137) providing primary care to grandchildren were recruited to participate in a single-group, pre- and post-test design, 6-week intervention. Self-efficacy was assessed at baseline, post-intervention, and at a 6-month follow-up. To evaluate who the intervention might be most beneficial for, grandparents’ service knowledge, perceived support from others, and length of care provided, measured at baseline, were analyzed for moderating effects. Results of paired-samples t-tests reveal significant increases in self-efficacy (p = .013) from baseline to post-test, which were maintained at the 6-month follow-up (p = .010). Hierarchical multiple regression showed interaction effects of the hypothesized moderators were not significant, indicating improvements in self-efficacy regardless of individual variability at baseline. As demonstrated, interventions can be effective at increasing self-efficacy in grandparents raising grandchildren and strengths-based approaches have the potential to provide universal benefits to grandparents, thus improving functioning in grandfamilies and promoting the health and well-being of grandparents and their grandchildren.

Moderation of Physical Health on Emotional Health Among Grandparents Raising Grandchildren

An estimated 69.5 million older adults in the United States report being grandparents. It is also evident that the number of grandparents raising grandchildren among them is increasing. Although caring for their grandchildren often provides grandparents a sense of purpose and increased life satisfaction, unexpected responsibilities of parenting worsen the already challenging experience of aging (e.g., potential for poor physical and mental health). Thus, it is essential to study the well-being of grandparents raising grandchildren. Links between depressive symptoms and emotional health have been widely studied in previous research. However, limited research has focused on physical health as a potential moderator, despite indirect evidence shown that more depressive symptoms may be observed among those with worse physical health conditions. To address this, we used Optum® SF-36v2® Health Survey to collect physical- and mental-health data and Center for Epidemiological Studies Depression Scale (CES-D-10) to collect information on depressive symptoms in 137 grandparents raising grandchildren (age 40-83) before, immediately after, and six months after a six-week intervention focused on self-care practices. The presence of more depressive symptoms indicated worse emotional health. Physical health moderated these associations at all three time points, such that depressive symptoms were less strongly related to emotional health if grandparents self-reported better physical-health scores. These findings have important implications for future intervention studies. The importance of good physical health practices for grandparents raising grandchildren is evident, including increased physical engagement and better pain management.

Polypharmacy and potential drug-drug interactions for people with HIV in the UK from the Climate-HIV database

Objectives

People with HIV (PWHIV) are likely to need therapies for comorbidities as they age. We assessed risk of drug–drug interactions (DDIs) in PWHIV.

Methods

The Climate‐HIV electronic recording system was used to cross‐sectionally analyse records from PWHIV aged ≥ 18 years attending four UK HIV units with a current antiretroviral (ARV) prescription in February 2018. Antiretroviral and non‐ARV medications were categorized by clinical significance of DDIs (University of Liverpool DDI tool). Potential DDIs were predicted using treatment guidelines for commonly recorded comorbidities.

Results

Among 4630 PWHIV (44% female), 41% were ≥ 50 years old. The average number of non‐ARV comedications increased from < 1 for patients aged ≤ 24 years to > 5 for patients aged ≥ 75 years; 65% were taking one or more non‐ARV comedications. The median (interquartile range) number of non‐ARVs was 1 (0–2) and 2 (1–5) for those aged < 50 and ≥ 50 years, respectively. Common comorbidities/concurrent health conditions occurred more frequently in patients aged ≥ 50 years vs. < 50 (53% vs. 34%). Boosted protease inhibitors were associated with the highest proportion of contraindicated comedications; dolutegravir and raltegravir had the fewest. For non‐ARVs, sildenafil and quetiapine were most likely to result in DDIs. Guideline‐recommended treatments for hepatitis C, hepatitis B, and tuberculosis had the highest proportions of contraindications when combined with ARV regimens, while treatments for hepatitis C, malignancy, and mental health conditions had the highest proportion of combinations potentially causing DDIs requiring dose monitoring or adjustment.

Conclusions

Non‐ARV use by PWHIV is high and increases with age. Treatment decisions for ageing PWHIV should consider guideline recommendations for comorbidities.

OPTN/SRTR 2018 Annual Data Report: Pancreas

The overall number of pancreas transplants continued to increase to 1027 in 2018, after a nadir of 947 in 2015. New additions to waiting list remained stable, with 1485 candidates added in 2018. Proportions of patients with type II diabetes waiting for transplant (14.6%) and undergoing transplant (14.8%) have steadily increased since 2016. Waiting times for simultaneous pancreas/kidney transplant have decreased; median months to transplant was 13.5 for simultaneous pancreas/kidney transplant and 19.7 for pancreas transplant alone in 2018. Outcomes, including patient and kidney survival, as well as rejection rates, have improved consistently over the past several years. Pancreas graft survival data are being collected by the Organ Procurement and Transplantation Network and will be included in a future report once there are sufficient cohorts for analysis.

IMPROVING HEALTH AND WELL-BEING OF GRANDPARENTS RAISING GRANDCHILDREN: A STRENGTHS-BASED INTERVENTION

Many grandparents raising grandchildren experience depression. Few interventions take a strengths-based approach to improve their mental health. To address this gap, this study utilized an adapted version of Powerful Tools for Caregivers (PTC) for grandparents (PTC-G) to improve their self-care, communication, and self-efficacy. Grandparents completed self-assessments including the CES-D short form prior to the intervention, immediately after the 6-week program, and at 6-months. Focus groups were also conducted during the 6-month follow-up to further explore positive behavior change. Data from all sources were analyzed to show that the PTC-G program significantly lowered depressive symptoms of grandparents raising grandchildren. Qualitative data shows that grandparents report increased awareness and use of self-care practices and community services. By improving the health and well-being of grandparents raising grandchildren, the PTC-G intervention shows promise in reducing depression and improving long-term mental health outcomes in vulnerable grandfamilies.

OPTN/SRTR 2017 Annual Data Report: Pancreas

In 2017, 1492 patients were added to the pancreas transplant waiting list, 964 listed as active, a slight increase from 2016. This is significant because for the first time in the past decade, the steady downward trend in additions to the waiting list has been reversed. Proportions of pancreas donors with cerebrovascular accident as cause of death decreased, with a concomitant increase in proportions with anoxia and head trauma. This is partly a result of the national opioid crisis, and it reflects increasing use of younger donors for pancreas transplant. The 2017 outcome report remains compromised by previous variation in reporting graft failure. Although the OPTN Pancreas Transplantation Committee has approved more precise definitions of pancreas graft failure, implementation of these definitions took place recently, and the data are not reflected in this report.

Bioethics education in Democratic Republic of Congo: Experiences and challenges

In regions marked by socio-economic turmoil, the task of teaching bioethics to health professionals and researchers can be more challenging than elsewhere. To demonstrate this, in this article we describe some of our teaching experiences in the Democratic Republic of Congo over the past decade. A first difficulty is linguistic. Anglo-Saxon language and culture largely dominates the field of bioethics, complicating teaching and education for those who do not master the language. A second obstacle is conceptual. Bioethics is often misunderstood as reflection on technological developments in medicine, which distorts its objectives and narrows its scope, particularly in resource-constrained settings. A third difficulty is cultural and political. Ethics in this setting is difficult to distinguish from common morality and the work of moralists, who comment on problems in medicine from a religious standpoint. Moreover, when interacting with communities and institutions that are strongly hierarchical, the critical stance of bioethics can give rise to resistance and rejection. These are among the array of difficulties that undoubtedly have given rise to sharp critiques of bioethics training initiatives in developing countries, where the introduction of bioethics has been depicted as a form of Western imperialism. While taking these criticisms seriously, our experiences in the field show how these seemingly insurmountable difficulties can be transformed into (more or less) manageable challenges.

An assessment of the microbiological quality and safety of raw drinking milk on retail sale in England

AIMS

This study aimed to review the microbiological results for raw drinking milk (RDM) samples submitted to Public Health England laboratories between 2014 and 2016 in order to produce up-to-date data on the microbiological safety of RDM and inform future risk assessments on its sale.

METHODS AND RESULTS

A total of 902 samples of RDM were collected from retail sale in England for microbiological examination. Overall, 454 of 770 samples (59·0%) taken for routine monitoring were of a satisfactory quality, whilst eight (1·0%) were 'unsatisfactory and potentially injurious to health' due to the presence of Shiga toxin-producing Escherichia coli, Campylobacter or elevated levels of Listeria monocytogenes or coagulase-positive staphylococci. In contrast, 16 of 114 (14·0%) of samples taken in follow-up to a previous unsatisfactory result and 5 of 18 (27·8%) of samples related to illness were potentially injurious. A total of 229 of 902 samples (25·4%) gave unsatisfactory results due to elevated aerobic colony counts and/or coliforms, whilst 139 of 902 samples (15·4%) were of borderline quality due to coagulase-positive staphylococci. Listeria monocytogenes was detected at levels of <100 CFU per ml in 66 of 902 samples (7·3%) and other Listeria species in 44 of 902 samples (4·9%).

CONCLUSIONS

Pathogens and/or indicators of poor hygiene were present in almost half of samples examined. Cows' milk samples gave a significantly greater proportion of unsatisfactory results compared to milk from other species (i.e. goat, sheep, buffalo, camel).

SIGNIFICANCE AND IMPACT OF THE STUDY

These results demonstrate the importance of maintaining strict controls on the production and sale of this product.

No country for old livers? Examining and optimizing the utilization of elderly liver grafts

Of the 1.6 million patients >70 years of age who died of stroke since 2002, donor livers were retrieved from only 2402 (0.15% yield rate). Despite reports of successful liver transplantation (LT) with elderly grafts (EG), advanced donor age is considered a risk for poor outcomes. Centers for Medicare and Medicaid Services definitions of an "eligible death" for donation excludes patients >70 years of age, creating disincentives to donation. We investigated utilization and outcomes of recipients of donors >70 through analysis of a United Network for Organ Sharing Standard Transplant Analysis and Research-file of adult LTs from 2002 to 2014. Survival analysis was conducted using Kaplan-Meier curves, and Cox regression was used to identify factors influencing outcomes of EG recipients. Three thousand one hundred four livers from donors >70, ≈40% of which were used in 2 regions: 2 (520/3104) and 9 (666/3104). Unadjusted survival was significantly worse among recipients of EG compared to recipients of younger grafts (P < .0001). Eight independent negative predictors of survival in recipients of EG were identified on multivariable analysis. Survival of low-risk recipients who received EG was significantly better than survival of recipients of younger grafts (P = .04). Outcomes of recipients of EG can therefore be optimized to equal outcomes of younger grafts. Given the large number of stroke deaths in patients >70 years of age, the yield rate of EGs can be maximized and disincentives removed to help resolve the organ shortage crisis.

OPTN/SRTR 2016 Annual Data Report: Pancreas

The number of pancreas transplants performed in the United States increased by 7.0% in 2016 over the previous year, the first such increase in more than a decade, largely attributable to an increase in simultaneous kidney pancreas transplants. Transplant rates increased in 2016, and mortality on the waiting list decreased. The declining enthusiasm for pancreas after kidney (PAK) transplants persisted. The uniform definition of graft failure was approved by the OPTN Board of Directors in 2015 and will be implemented in early 2018. Meanwhile, SRTR continues to refrain from reporting pancreas graft failure data. The OPTN/UNOS Pancreas Transplantation Committee is seeking to broaden allocation of pancreata across compatible ABO blood types in a proposal out for public comment July 31 to October 2, 2017. A new initiative to provide guidance on the benefits of PAK transplants is also out for public comment.

The effect of local hydrodynamics on the spatial extent and morphology of cold-water coral habitats at Tisler Reef, Norway

This study demonstrates how cold-water coral morphology and habitat distribution are shaped by local hydrodynamics, using high-definition video from Tisler Reef, an inshore reef in Norway. A total of 334 video frames collected on the north-west (NW) and south-east (SE) side of the reef were investigated for Lophelia pertusa coral cover and morphology and for the cover of the associated sponges Mycale lingua and Geodia sp. Our results showed that the SE side was a better habitat for L. pertusa (including live and dead colonies). Low cover of Geodia sp. was found on both sides of Tisler Reef. In contrast, Mycale lingua had higher percentage cover, especially on the NW side of the reef. Bush-shaped colonies of L. pertusa with elongated branches were the most abundant coral morphology on Tisler Reef. The highest abundance and density of this morphology were found on the SE side of the reef, while a higher proportion of cauliflower-shaped corals with short branches were found on the NW side. The proportion of very small L. pertusa colonies was also significantly higher on the SE side of the reef. The patterns in coral spatial distribution and morphology were related to local hydrodynamics-there were more frequent periods of downwelling currents on the SE side-and to the availability of suitable settling substrates. These factors make the SE region of Tisler Reef more suitable for coral growth. Understanding the impact of local hydrodynamics on the spatial extent and morphology of coral, and their relation to associated organisms such as sponges, is key to understanding the past and future development of the reef.

Venous flaps for coverage of traumatic soft tissue defects of the hand: a systematic review

A PRISMA-guided systematic review was performed of all published cases that detail the use of venous flaps for soft tissue reconstruction of the hand following trauma. Outcome measures examined included flap survival rates, venous congestion, and return to theatre. Database searches were performed on Medline, Embase, AHMED, CINAHL. A total of 381 articles were identified. Data were extracted from 45 articles that met inclusion criteria. A total of 756 flaps were described and their data analysed. A total of 75% of flaps were arterialized and 25% were pure venous flaps. There was no difference in survival rate for arterialized or pure venous flaps. Unplanned return to theatre occurred in 5.3% due to flap compromise or necrosis. Early venous congestion was present in 60% of cases. Total early failure requiring re-operation occurred in 19 flaps (2.5%) of cases. Venous flaps offer a versatile and well-tolerated reconstructive option. Early venous congestion is common, but can be managed non-operatively.

LEVEL OF EVIDENCE

II.

Observations of marine wildlife tourism effects on a non-focal species

A radio-acoustic positioning system was used to assess the effects of shark cage-diving operators (SCDO) on the fine-scale movements of a non-focal species, the smooth stingray Bathytoshia brevicaudata. The results revealed that the time spent in the array was individually variable, but generally increased when SCDO were present and that the presence of SCDO may have the capacity to elicit changes in the space use of B. brevicaudata. These results indicate that the effects of marine wildlife tourism may extend beyond the focal species of interest.