Knowledge interface co-design of a diabetes and metabolic syndrome initiative with and for Aboriginal people living on Ngarrindjeri country

Objectives

This research program involves two phases to identify enablers and barriers to diabetes care for Aboriginal people on Ngarrindjeri country; and co-design a strength-based metabolic syndrome and Type 2 Diabetes (T2D) remission program with the Ngarrindjeri community.

Study design

A study protocol on qualitative research.

Methods

The study will recruit Aboriginal people living on Ngarrindjeri country above 18 years of age with a diagnosis of metabolic syndrome or T2D. Recruitment for phases one and two will occur through the Aboriginal Health Team at the Riverland Mallee Coorong Local Health Network. The lived experiences of T2D will be explored with 10-15 Aboriginal participants, through an Aboriginal conversational technique called 'yarning' (60-90 min) in phase 1. Elders and senior community representatives (n = 20-30) will participate in four co-design workshops (2-4 h) in phase 2. Qualitative data will be transcribed and thematically analysed (NVivo version 12). The analysis will focus on protective factors for the Cultural Determinants of Health. Ethics approval was obtained from Aboriginal Health Research Ethics Committee in South Australia (04-22-1009), and Flinders University Human Research Ethics Committee (5847).

Results

This work will be used to pilot the co-designed diabetes remission trial. Outcomes will be published in peer-reviewed journals, presented at conferences, focusing on following best practice guidelines from the Australian Institute of Aboriginal and Torres Strait Islander Studies and National Health and Medical Research Council. Research translation will occur through digital posters, manuals, and infographics.

Conclusions

The findings will be summarised to all Aboriginal organisations involved in this study, along with peak bodies, stakeholders, Aboriginal Services, and interested participants.

Findings from three methods to identify falls in hospitals: Results from the Ambient Intelligent Geriatric Management system fall prevention trial

OBJECTIVE

To (a) compare characteristics of patients who fall with those of patients who did not fall; and (b) characterise falls (time, injury severity and location) through three fall reporting methods (incident system reports, medical notes and clinician reports).

METHODS

A substudy design within a stepped-wedge clinical trial was used: 3239 trial participants were recruited from two inpatient Geriatric Evaluation and Management Units and one general medicine ward in two Australian states. To compare the characteristics of patients who had fallen with those who had not, descriptive tests were used. To characterise falls through three reporting methods, bivariate logistic regressions were used.

RESULTS

Patients who had fallen were more likely than patients who had not fallen to be cognitively impaired (51% vs. 29%, p < 0.01), admitted with falls (38% vs. 28%, p = 0.01) and have poor health outcomes such as prolonged length of stay (24 [16-34] vs. 12 [8-19] days [IQR], p < 0.01) and less likely to be discharged directly to the community (62% vs. 47%, p < 0.01). Most falls were captured from medical notes (93%), with clinician (71%) and incident reports (68%) missing 21%-25% of falls. The proportion of injurious falls identified through incident reports was higher than medical records or clinician reports (40% vs. 34% vs. 37%).

CONCLUSIONS

This study reaffirms the need to improve reporting falls in incident systems and at clinical handover to the team leader. Research should continue to use more than one method of identifying falls, but include data from medical records. Many falls cause injury, resulting in poor health outcomes.

From pelvic radiation to social isolation: a qualitative study of survivors' experiences of chronic bowel symptoms after pelvic radiotherapy

PURPOSE

We explored survivors' experiences of chronic bowel symptoms following pelvic radiotherapy, strategies employed in living with these symptoms, effects on daily activities, and roles at home and in the workplace.

METHODS

Semi-structured interviews were conducted with 28 individuals (10 gynaecological, 14 prostate, four anal/rectal cancer survivors) who had completed pelvic radiotherapy at least six months prior to data collection and who had experience of bowel symptoms during this post-treatment period. Reflexive thematic analysis was undertaken.

RESULTS

We propose four themes describing a process leading from experience of symptoms to withdrawal from activities and roles. These are (1) losing control (the experience of unintended anal leakage or discharge); (2) experiencing embarrassment and fear (the experience of embarrassment or fear of embarrassment as a result of discharge becoming public); (3) managing and reacting (acting to reduce the likelihood of discharge or to prevent this becoming public); and (4) restriction and withdrawal (avoiding specific activities or situations so as to reduce or remove the risk of embarrassment). Returning to the workplace presented additional challenges across these themes.

CONCLUSIONS

Impacts of chronic bowel symptoms can be severe. Survivors employ a variety of methods and strategies in living with their symptoms. Some of these support continued role fulfilment but some constitute a withdrawal from pre-treatment roles. Current healthcare provision and statutory protections fail to fully meet needs following pelvic radiotherapy.

IMPLICATIONS FOR CANCER SURVIVORS

There is a need to develop and implement evidence-based services and supported self-management programmes for survivors experiencing chronic bowel problems post-radiotherapy.

Analysis of fibrinolytic shutdown in trauma patients with traumatic brain injury

BACKGROUND

Coagulation profiles following major trauma vary depending on injury pattern and degree of shock. The physiologic mechanisms involved in coagulation function at any given time are varied and remain poorly understood. Thromboelastography (TEG) has been used evaluate coagulation profiles in the trauma population with some reports demonstrating a spectrum of fibrinolysis to fibrinolytic shutdown on initial presentation. The objective of this study was to evaluate the fibrinolytic profile of patients with TBI using thromboelastography (TEG). We hypothesized that patients with TBI would demonstrate low fibrinolytic activity.

METHODS

All trauma activations at an ACS-verified level 1 trauma center received a TEG analysis upon arrival from December 2019 to June 2021. A retrospective review of the results and outcomes was conducted, and TBI patients were compared to patients without TBI. Linear regression was used to evaluate the effect of patient and injury factors on fibrinolysis. Hyperfibrinolysis was defined as LY30 ​> ​7.7%, physiologic fibrinolysis as LY30 0.6-7.7%, and fibrinolytic shutdown as LY30 ​< ​0.6%.

RESULTS

A total of 1369 patients received an admission TEG analysis. Patients with TBI had a significantly higher median ISS (16 vs. 8, p ​< ​0.001), lower median admission Glasgow Coma Scale (14 vs. 15, p ​< ​0.001), longer intensive care unit length of stay (3 vs. 2 days, p ​< ​0.0001), increased ventilator days (216 vs. 183, p ​< ​0.001), higher mortality (14.6% vs. 5.1%, p ​< ​0.001), but lower shock index (0.6 vs. 0.7, p ​< ​0.0001) compared to those without TBI. Median LY30 was found to be decreased in the TBI group (0.1 vs. 0.2, p ​= ​0.0006). Patients with TBI were found to have a higher rate of fibrinolytic shutdown compared those without TBI (68.7% vs. 63.5%, p ​= ​0.054). ISS, sex, and shock index were found to be predictive of LY30 on linear regression, but TBI was not (Β: 0.09, SE: 0.277, p ​= ​0.745). The rate of DVT/PE did not appear to be elevated in patients with TBI (0.8%) and without TBI (1.2%).

CONCLUSIONS

Trauma patients with and without TBI were found to have high rates of fibrinolytic shutdown. Although there was a high incidence of fibrinolytic shutdown, it did not appear to have an impact on the rate of thrombotic complications. The clinical significance of these results is unclear and differs significantly from recent reports which demonstrated that TBI is associated with a 25% rate of fibrinolytic shutdown. Further investigation is needed to better define the fibrinolytic pathway in patients with trauma and TBI to develop optimal treatment algorithms.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

The state of integrated disease surveillance in seven countries: a synthesis report

OBJECTIVES

Integrated disease surveillance (IDS) offers the potential for better use of surveillance data to guide responses to public health threats. However, the extent of IDS implementation worldwide is unknown. This study sought to understand how IDS is operationalized, identify implementation challenges and barriers, and identify opportunities for development.

STUDY DESIGN

Synthesis of qualitative studies undertaken in seven countries.

METHODS

Thirty-four focus group discussions and 48 key informant interviews were undertaken in Pakistan, Mozambique, Malawi, Uganda, Sweden, Canada, and England, with data collection led by the respective national public health institutes. Data were thematically analysed using a conceptual framework that covered governance, system and structure, core functions, finance and resourcing requirements. Emerging themes were then synthesised across countries for comparisons.

RESULTS

None of the countries studied had fully integrated surveillance systems. Surveillance was often fragmented, and the conceptualization of integration varied. Barriers and facilitators identified included: 1) the need for clarity of purpose to guide integration activities; 2) challenges arising from unclear or shared ownership; 3) incompatibility of existing IT systems and surveillance infrastructure; 4) workforce and skills requirements; 5) legal environment to facilitate data sharing between agencies; and 6) resourcing to drive integration. In countries dependent on external funding, the focus on single diseases limited integration and created parallel systems.

CONCLUSIONS

A plurality of surveillance systems exists globally with varying levels of maturity. While development of an international framework and standards are urgently needed to guide integration efforts, these must be tailored to country contexts and guided by their overarching purpose.

COVID-19 associated with universities in England, October 2020-February 2022

OBJECTIVES

The aim of this study was to describe the epidemiology of COVID-19 cases at universities in England (October 2020-February 2022) and investigate factors associated with rates of COVID-19 among students during autumn/winter of 2021/22.

STUDY DESIGN

The study was an observational retrospective study using routine contact tracing data.

METHODS

Estimates of COVID-19 cases among students and staff at universities were described. Student cases aged 18-24 years were calculated as a percentage of all cases within that age group. Count regression was used to explore university characteristics associated with case numbers.

RESULTS

We identified 102,382 cases among students and 28,639 among staff. Student cases reflected trends in the wider population of the same age group, but the observed fraction aged 18-24 years who were students was consistently below the expected level (32%). Phased reopening of universities in March-May 2021 was associated with small peaks but low absolute numbers. Russell group membership, campus universities, and higher student proportions in halls of residence were all associated with increased case numbers.

CONCLUSIONS

COVID-19 case numbers among students in England varied considerably. At no time were the observed case numbers as high as expected from community prevalence. Characteristics of universities associated with higher case rates can inform future guidance for higher education settings.

Role of Adjuvant Radiotherapy in Acinic Cell Carcinoma of the Salivary Glands: A Systematic Review

A systematic review was carried out to evaluate if adjuvant radiotherapy for acinic cell carcinomas (ACCs) of salivary glands improves survival. Twelve retrospective studies published between 2000 and 2020 that analysed the effect of radiotherapy on salivary gland neoplasms and ACCs of salivary glands and met the inclusion criteria were included in the review. The overall quality of the studies was moderate to low. There was no high-quality evidence for improved survival with radiotherapy for ACCs of the salivary gland. Some evidence suggests that there may be an advantage for patients with high-grade tumours, but these data should be interpreted with caution due to the small number of patients and low-quality evidence. Good quality of evidence is lacking. Recommendation for adjuvant radiotherapy for tumours with poor prognostic factors will require discussion and shared decision-making with the patients.

Characteristics of women presenting with hepatitis B at antenatal care services in London, 2008-2018

BACKGROUND

To support interventions to prevent mother-to-child transmission of hepatitis B and fill gaps in surveillance, the Enhanced Surveillance of Antenatal Hepatitis B (ESAHB) programme was implemented in London from 2008 to 2018 to collect demographic information on women who tested positive for hepatitis B during antenatal screening. We describe the epidemiology of hepatitis B in pregnancy, as reported to ESAHB.

METHODS

The characteristics of pregnant women living with hepatitis B were described and rates were calculated by year, local authority and residence deprivation decile (1 being most deprived). Poisson regression tested the association between pregnant women living with hepatitis B and deprivation decile.

RESULTS

Between 2008 and 2018, 8879 women living with hepatitis B in London (0.35 per 1000 women) reported 11 193 pregnancies. Annual hepatitis B rates remained stable, but there was strong evidence for an inverse association between rate and deprivation decile (P < 0.001). The majority of women in the cohort presented late to antenatal care, were born outside the UK in a hepatitis B endemic area or required an interpreter for consultations.

CONCLUSIONS

ESAHB provided important data to inform service quality improvements for women living with hepatitis B. This analysis highlights the link between deprivation and hepatitis B.

Oral histories document community mobilisation to participate in decision-making regarding a hazardous waste thermal treatment facility

Colfax, Louisiana hosts a commercial hazardous waste thermal treatment (TT) facility, which treats fireworks, explosives, and military ordnances by open-burn/open-detonation one mile from the edge of the nearest community. Seventy-one percent of Colfax's residents are Black, and forty-six percent live below poverty, indicating the community's structural vulnerability. This community-based study originated at the behest of Colfax community members. We hypothesized that the close relationships among members of this enclave may have enhanced the community's ability to mobilize in opposition to the TT facility. We conducted semi-structured oral history interviews with nineteen community members and examined the social and interorganizational networks used by the Colfax community to claim its role in decision-making regarding the TT facility after years of exclusion from this process. Interview transcripts were analyzed through the lens of community capacity theory to gain insight into how interactions among community members about the environmental hazards led to social mobilization and improved participation in the decision-making process using codes for communication, organization, and outcome. Additionally, we reviewed Louisiana Department of Environmental Quality records for complaints about the facility to gauge public participation. One notable theme across several interviews was exclusion from the initial decision-making process related to the facility. However, interviewees noted a sustained effort was made among community members to educate themselves about the facility, organize a response through neighbor-to-neighbor contact, and take action by submitting formal complaints and participating in public hearings. Through the lens of environmental justice, this study illustrates an evolving condition of procedural justice.

HTS driven by fluorescence lifetime detection of FRET identifies activators and inhibitors of cardiac myosin

Small molecules that bind to allosteric sites on target proteins to alter protein function are highly sought in drug discovery. High-throughput screening (HTS) assays are needed to facilitate the direct discovery of allosterically active compounds. We have developed technology for high-throughput time-resolved fluorescence lifetime detection of fluorescence resonance energy transfer (FRET), which enables the detection of allosteric modulators by monitoring changes in protein structure. We tested this approach at the industrial scale by adapting an allosteric FRET sensor of cardiac myosin to high-throughput screening (HTS), based on technology provided by Photonic Pharma and the University of Minnesota, and then used the sensor to screen 1.6 million compounds in the HTS facility at Bristol Myers Squibb. The results identified allosteric activators and inhibitors of cardiac myosin that do not compete with ATP binding, demonstrating high potential for FLT-based drug discovery.

Health disparities among older adults following tropical cyclone exposure in Florida

Tropical cyclones (TCs) pose a significant threat to human health, and research is needed to identify high-risk subpopulations. We investigated whether hospitalization risks from TCs in Florida (FL), United States, varied across individuals and communities. We modeled the associations between all storms in FL from 1999 to 2016 and over 3.5 million Medicare hospitalizations for respiratory (RD) and cardiovascular disease (CVD). We estimated the relative risk (RR), comparing hospitalizations during TC-periods (2 days before to 7 days after) to matched non-TC-periods. We then separately modeled the associations in relation to individual and community characteristics. TCs were associated with elevated risk of RD hospitalizations (RR: 4.37, 95% CI: 3.08, 6.19), but not CVD (RR: 1.04, 95% CI: 0.87, 1.24). There was limited evidence of modification by individual characteristics (age, sex, or Medicaid eligibility); however, risks were elevated in communities with higher poverty or lower homeownership (for CVD hospitalizations) and in denser or more urban communities (for RD hospitalizations). More research is needed to understand the potential mechanisms and causal pathways that might account for the observed differences in the association between tropical cyclones and hospitalizations across communities.

A205 EVALUATING THE ASSOCIATION BETWEEN PERIPHERAL BLOOD EOSINOPHILS AND DRUG RESPONSE IN CROHN'S DISEASE: CONTINUING ANALYSIS

Background

Th2 cytokines, IL-5 and IL-13 enhance peripheral and mucosal eosinophil survival, recruitment and degranulation, facilitating inflammation in Crohn's Disease. In a preliminary analysis, peripheral eosinophilia (PBE) is seen to have an association with rates of steroid response and anti-TNF response in CD patients. Participants with high PBE (> 200 cells/μL) appear to be more steroid-responsive but less responsive to Th1-targeting anti-TNF therapies. We hypothesize the pattern of PBE at CD diagnosis can help identify distinct subsets within a larger CD population and correlate with response to treatments such as prednisone or anti-TNFs.

Purpose

We aim to evaluate the pattern of PBE of CD patients at time of diagnosis (prior to drug exposure) and with each subsequent treatment; and if baseline PBE or any changes seen with drug exposures are predictive of treatment response.

Method

A retrospective cohort study is ongoing with CD patients exposed to glucocorticoids and an anti-TNF seen at 3 hospitals affiliated with University of Western Ontario. Patients were identified using administrative databases and reviewed for biochemical data (complete blood count) and disease activity (Harvey Bradshaw Index) at baseline, before and after each drug exposure. Participants were classified as having high PBE (eosinophils>200 cells/μL) versus low PBE (eosinophils <200 cells/μL). To date, 350 patients have been screened. Subgroup analyses of PBE > 300 cells/μL, and differences between female and male patients will be carried out.

Result(s)

46 of 200 CD patients are included in the continuing analysis with a mean age of 45 years. 26 had PBE >200 cells/μL at baseline and 20 did not. The median number therapies used was 4 (IQR=0.75). All received glucocorticoids followed by an anti-TNF. There was no difference in the occurrence of hospitalization or surgery between the two groups. Overall 50% participants with high PBE >200 and >300 cells/μL had clinical response to glucocorticoid exposure, seen as a 3-point decrease in HBI compared to 45%, 47% in the low PBE cohort (n=13/26 vs. n=9/20 p=0.77; n=6/12 vs. n=16/34 p=1.0 respectively). With subsequent anti-TNF exposure, PBE rebounded in 7 participants. 36% patients in the high PBE group required anti-TNF dose escalation versus 24% in the low PBE group (n=9/25 vs. n=5/21, p=0.52). The proportion of patients with anti-TNF discontinuation was similar in both groups (high PBE 19.2%, n=5/26 vs. low PBE 15%, n=3/20, p=1.0). Men had higher steroid response rates compared to women in both high and low PBE groups (n=6/8 vs. n=8/18 p=0.21; n=4/9 vs. 4/11 p=1.0 respectively).

Conclusion(s)

Peripheral eosinophilia is seen in varying degrees in CD patients. Participants with high PBE are more steroid-responsive. High PBE patients overall were less responsive to anti-TNF therapies, requiring more dose-escalation and discontinued anti-TNF treatment. Completion of this study will help clarify the association between PBE in CD and treatment response.

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None

Disclosure of Interest

None Declared

A174 A NOVEL MECHANISM OF CROHN’S DISEASE SEVERITY IN WOMEN: EVALUATING THE IMPACT OF AN ESTROGEN-FARNESOID X RECEPTOR INTERACTION ON INTESTINAL BARRIER FUNCTION

Background

Crohn’s disease (CD) is associated with deficits in intestinal barrier function. Activation of bile acid-sensing nuclear receptor Farnesoid X receptor (NR1H4, FXR) is associated with protective effects against reduced intestinal barrier function; namely through promoting tight junction complex genes (TJCGs) and reducing expression of inflammatory cytokines. The FXR -1G>T variant is associated with decreased FXR activation and increased risk of, and early progression to, CD-related surgery in females only. It is hypothesized an estrogen-FXR interaction is mediating this effect.

Purpose

We aimed to assess the combined effect of estrogen and FXR genetic variation on intestinal barrier function using a cell-based model and its impact in a clinical cohort.

Method

Caco-2 cells were characterized for expression of TJCGs (zonula occludens-1, occludin, junctional adhesion molecule A, and claudin-1 and claudin-2), FXR, and nuclear estrogen receptors (ERα, ERβ) by qPCR. The influence of FXR activation on TJCGs was characterized by incubation of Caco-2 cells with chenodeoxycholic acid (CDCA). FXR-knockout stable Caco-2 line was developed using CRISPR-Cas9 methods and verified by qPCR and genotyping. The effect of estradiol on expression of TJCGs in FXR-knockout and wildtype Caco-2 cell monolayers was compared by qPCR. Future experiments include comparison of FXR-knockout and wildtype monolayer permeability with estrogen exposure by transwell permeability assay.

The effect of FXR genotype and exogenous estrogen CD severity (surgery, hospitalization, fistulizing disease) was evaluated in our female cohort by multivariate analysis.

Result(s)

Increased expression of TJCGs was seen in native Caco-2 monolayers incubated with CDCA. FXR-knockout cell line was then successfully created and confirmed. FXR-knockout cells showed decreased expression of TJCGs with the exception of zonula occludens-1. Estradiol exposure resulted in a dose-dependent decline in TJCGs expression in the wildtype Caco-2 cell line, however this effect was lost in the FXR-knockout cell line.

Preliminary analysis of patient cohort data (n=359) showed exogenous estrogen was associated with lower surgery risk (OR = 0.603, 95% CI= 0.373–0.964, p < 0.05; Fischer’s exact test) and trended towards decreasing fistulizing disease risk in a multiple logistic regression model which included FXR genotype. The association of FXR genotype with increased surgery risk was also confirmed in this logistic regression model.

Conclusion(s)

Herein, we show that FXR activity affects expression of TJCGs, and this effect is attenuated by estrogen interactions. Our patient cohort preliminary analysis confirmed an increased CD severity risk associated with FXR genotype and demonstrated a trend of decreasing CD severity with exogenous estrogen exposure. Further studies will assess the mechanisms by which FXR and estrogen interact to influence intestinal permeability.

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Other

Please indicate your source of funding;

Department of Medicine, Western University

Disclosure of Interest

D. Taylor: None Declared, L. Donovan: None Declared, J. Choi: None Declared, R. Kim: None Declared, U. Schwarz: None Declared, A. Wilson Consultant of: Consulting fees from Fresenius Kabi, Speakers bureau of: Speaking fees from Takeda and Pfizer

A104 INVISIBLE COLONIC MALIGNANCY AND POSSIBLE IDIOSYNCRATIC DRUG-INDUCED LIVER INJURY FROM VEDOLIZUMAB IN A PATIENT WITH ULCERATIVE COLITIS, PRIMARY SCLEROSING CHOLANGITIS AND AUTOIMMUNE HEPATITIS OVERLAP SYNDROME

Background

Inflammatory bowel disease (IBD) is characterized by chronic inflammation of the gastrointestinal tract. Due to an increased risk of developing colorectal cancer, regular surveillance for dysplastic lesions via colonoscopy is recommended. Invisible dysplasia is the abnormal development of cells noted on pathology with no visible lesion seen during colonoscopy. Primary sclerosing cholangitis (PSC) is an immune-mediated liver disease leading to progressive stricturing and fibrosis of the bile ducts. There is significant association between PSC and IBD, as up to 80% of patients with PSC having underlying IBD. Drug induced liver injury (DILI) is a common cause of acute liver failure in most Western countries. Most cases of DILI are self-limited, with resolution of laboratory and clinical findings after cessation of the offending agent.

Purpose

To describe a case of invisible colonic malignancy and possible idiosyncratic drug-induced liver injury from vedolizumab (VDZ) in a patient with ulcerative colitis (UC), PSC and autoimmune hepatitis (AIH) overlap syndrome.

Method

Patient consent was obtained. Information from electronic records was extracted, including admission notes and procedural reports. A literature review was performed using Pubmed.

Result(s)

A 32-year-old Caucasian female with UC on VDZ with PSC and AIH had multiple colonoscopies performed demonstrating multifocal low-grade dysplasia. However, she remained resistant to surgery. She presented to clinic with tea-coloured urine, fatigue, and scleral icterus. Investigations revealed conjugated hyperbilirubinemia with elevation in hepatocellular liver enzymes. Imaging was consistent with large duct PSC, and liver biopsy showed grade 2 chronic hepatitis raising the possibility of large bile duct obstruction. She underwent liver transplant assessment and VDZ was held. Her bilirubin and liver enzymes recovered. Given multiple colonoscopies showing multifocal dysplastic changes and the patient declining other biologics, she would ultimately undergo total proctocolectomy with end ileostomy. Pathology demonstrated mucinous adenocarcinoma with a signet ring component.

Conclusion(s)

Both mucinous adenocarcinoma and signet ring carcinoma are more aggressive malignancies associated with poor prognosis. Found more often in younger patients, they are often diagnosed in later stages with lymphovascular invasion. Here, there was no evidence of metastases in any of the 40 lymph nodes examined, which indicated more favourable prognosis.

The mechanism by which VDZ potentially causes liver injury is unknown. Multiple therapies for PSC-AIH overlap and IBD were entertained as causative agents. However, significant improvement in clinical symptoms and serologic parameters following cessation of VDZ was temporally suggestive.

This case simultaneously highlights the importance of both timely colectomy in IBD patients with high-risk features during surveillance and early recognition and cessation of potential causative medications which induce liver injury.

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None

Disclosure of Interest

None Declared

Primary school mobile dental program in New South Wales, Australia: protocol for the evaluation of a state government oral health initiative

BACKGROUND

Socioeconomically disadvantaged children are disproportionately affected by oral disease. Mobile dental services help underserved communities overcome barriers to accessing health care, including time, geography, and trust. The NSW Health Primary School Mobile Dental Program (PSMDP) is designed to provide diagnostic and preventive dental services to children at their schools. The PSMDP is mainly targeted toward high-risk children and priority populations. This study aims to evaluate the program's performance across five local health districts (LHDs) where the program is being implemented.

METHODS

The evaluation will use routinely collected administrative data, along with other program-specific data sources, from the district public oral health services to conduct a statistical analysis that determines the reach and uptake of the program, its effectiveness, and the associated costs and cost-consequences. The PSMDP evaluation program utilises data from Electronic Dental Records (EDRs) and other data sources, including patient demographics, service mix, general health, oral health clinical data and risk factor information. The overall design includes cross-sectional and longitudinal components. The design combines comprehensive output monitoring across the five participating LHDs and investigates the associations between socio-demographic factors, service patterns and health outcomes. Time series analysis using difference-in-difference estimation will be conducted across the four years of the program, involving services, risk factors, and health outcomes. Comparison groups will be identified via propensity matching across the five participating LHDs. An economic analysis will estimate the costs and cost-consequences for children who participate in the program versus the comparison group.

DISCUSSION

The use of EDRs for oral health services evaluation research is a relatively new approach, and the evaluation works within the limitations and strengths of utilising administrative datasets. The study will also provide avenues to improve the quality of data collected and system-level improvements to better enable future services to be aligned with disease prevalence and population needs.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Clinical handover communication at maternity shift changes and women's safety in Banjul, the Gambia: a mixed-methods study

Background

Clinical handover is a vital communication process for patient safety; transferring patient responsibility between healthcare professionals (HCPs). Exploring handover processes in maternity care is fundamental for service quality, addressing continuity of care and maternal mortality.

Methods

This mixed-methods study was conducted in all three maternity hospitals in Banjul, The Gambia. Shift-to-shift maternity handovers were observed and compared against a standard investigating content and environment. Semi-structured interviews and focus group discussions with doctors, midwives and nurses explored handover experience.

Results

One hundred ten nurse/midwife shift-to-shift handovers were observed across all shift times and maternity wards; only 666 of 845 women (79%) were handed over. Doctors had no scheduled handover. Shift-leads alone gave/received handover, delayed [median 35 min, IQR 24–45] 82% of the time; 96% of handovers were not confidential and 29% were disrupted. Standardised guidelines and training were lacking.

A median 6 of 28 topics [IQR 5–9] were communicated per woman. Information varied significantly by time, high-risk classification and location. For women in labour, 10 [IQR 8–14] items were handed-over, 8 [IQR 5–11] for women classed ‘high-risk’, 5 [IQR 4–7] for ante/postnatal women (p < 0.001); > 50% had no care management plan communicated.

Twenty-one interviews and two focus groups were conducted. Facilitators and barriers to effective handover surrounding three health service factors emerged; health systems (e.g. absence of formalised handover training), organisation culture (e.g. absence of multidisciplinary team handover) and individual clinician factors (e.g. practical barriers such as transportation difficulties in getting to work).

Conclusion

Maternity handover was inconsistent, hindered by contextual barriers including lack of team communication and guidelines, delays, with some women omitted entirely. Findings alongside HCPs views demonstrate feasible opportunities for enhancing handover, thereby improving women's safety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05052-9.

National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

Midwives' and maternity support workers' perceptions of the impact of the first year of the COVID-19 pandemic on respectful maternity care in a diverse region of the UK: a qualitative study

OBJECTIVES

To explore midwives' and maternity support workers' perceptions of the impact of the COVID-19 pandemic on maternity services and understand factors influencing respectful maternity care.

DESIGN

A qualitative study. Eleven semistructured interviews were conducted (on Zoom) and thematically analysed. Inductive themes were developed and compared with components of respectful maternity care.

SETTING

Maternity services in a diverse region of the United Kingdom.

PARTICIPANTS

Midwives and maternity support workers who worked during the first year of the COVID-19 pandemic.

RESULTS

The findings offer insights into the experiences and challenges faced by midwives and maternity support workers during the first year of the COVID-19 pandemic in the UK (March 2020-2021). Three core themes were interpreted that impacted respectful maternity care: (1) communication of care, (2) clinical care and (3) support for families. 1. Midwives and maternity support workers felt changing guidance impaired communication of accurate information. However, women attending appointments alone encouraged safeguarding disclosures. 2. Maternity staffing pressures worsened and delayed care provision. The health service's COVID-19 response was thought to have discouraged women's engagement with maternity care. 3. Social support for women was reduced and overstretched staff struggled to fill this role. The continuity of carer model of midwifery facilitated supportive care. COVID-19 restrictions separated families and were considered detrimental to parents' mental health and newborn bonding. Overall, comparison of interview quotes to components of respectful maternity care showed challenges during the early COVID-19 pandemic in upholding each of the 10 rights afforded to women and newborns.

CONCLUSIONS

Respectful maternity care was impacted through changes in communication, delivery of clinical care and restrictions on social support for women and their infants in the first year of the COVID-19 pandemic. Future guidance for pandemic scenarios must make careful consideration of women's and newborns' rights to respectful maternity care.

Tocolytics for delaying preterm birth: a network meta-analysis (0924)

BACKGROUND

Preterm birth is the leading cause of death in newborns and children. Tocolytic drugs aim to delay preterm birth by suppressing uterine contractions to allow time for administration of corticosteroids for fetal lung maturation, magnesium sulphate for neuroprotection, and transport to a facility with appropriate neonatal care facilities. However, there is still uncertainty about their effectiveness and safety.

OBJECTIVES

To estimate relative effectiveness and safety profiles for different classes of tocolytic drugs for delaying preterm birth, and provide rankings of the available drugs.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov (21 April 2021) and reference lists of retrieved studies.

SELECTION CRITERIA

We included all randomised controlled trials assessing effectiveness or adverse effects of tocolytic drugs for delaying preterm birth. We excluded quasi- and non-randomised trials. We evaluated all studies against predefined criteria to judge their trustworthiness.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed the trials for inclusion and risk of bias, and extracted data. We performed pairwise and network meta-analyses, to determine the relative effects and rankings of all available tocolytics. We used GRADE to rate the certainty of the network meta-analysis effect estimates for each tocolytic versus placebo or no treatment.

MAIN RESULTS

This network meta-analysis includes 122 trials (13,697 women) involving six tocolytic classes, combinations of tocolytics, and placebo or no treatment. Most trials included women with threatened preterm birth, singleton pregnancy, from 24 to 34 weeks of gestation. We judged 25 (20%) studies to be at low risk of bias. Overall, certainty in the evidence varied. Relative effects from network meta-analysis suggested that all tocolytics are probably effective in delaying preterm birth compared with placebo or no tocolytic treatment. Betamimetics are possibly effective in delaying preterm birth by 48 hours (risk ratio (RR) 1.12, 95% confidence interval (CI) 1.05 to 1.20; low-certainty evidence), and 7 days (RR 1.14, 95% CI 1.03 to 1.25; low-certainty evidence). COX inhibitors are possibly effective in delaying preterm birth by 48 hours (RR 1.11, 95% CI 1.01 to 1.23; low-certainty evidence). Calcium channel blockers are possibly effective in delaying preterm birth by 48 hours (RR 1.16, 95% CI 1.07 to 1.24; low-certainty evidence), probably effective in delaying preterm birth by 7 days (RR 1.15, 95% CI 1.04 to 1.27; moderate-certainty evidence), and prolong pregnancy by 5 days (0.1 more to 9.2 more; high-certainty evidence). Magnesium sulphate is probably effective in delaying preterm birth by 48 hours (RR 1.12, 95% CI 1.02 to 1.23; moderate-certainty evidence). Oxytocin receptor antagonists are probably effective in delaying preterm birth by 48 hours (RR 1.13, 95% CI 1.05 to 1.22; moderate-certainty evidence), are effective in delaying preterm birth by 7 days (RR 1.18, 95% CI 1.07 to 1.30; high-certainty evidence), and possibly prolong pregnancy by 10 days (95% CI 2.3 more to 16.7 more). Nitric oxide donors are probably effective in delaying preterm birth by 48 hours (RR 1.17, 95% CI 1.05 to 1.31; moderate-certainty evidence), and 7 days (RR 1.18, 95% CI 1.02 to 1.37; moderate-certainty evidence). Combinations of tocolytics are probably effective in delaying preterm birth by 48 hours (RR 1.17, 95% CI 1.07 to 1.27; moderate-certainty evidence), and 7 days (RR 1.19, 95% CI 1.05 to 1.34; moderate-certainty evidence). Nitric oxide donors ranked highest for delaying preterm birth by 48 hours and 7 days, and delay in birth (continuous outcome), followed by calcium channel blockers, oxytocin receptor antagonists and combinations of tocolytics. Betamimetics (RR 14.4, 95% CI 6.11 to 34.1; moderate-certainty evidence), calcium channel blockers (RR 2.96, 95% CI 1.23 to 7.11; moderate-certainty evidence), magnesium sulphate (RR 3.90, 95% CI 1.09 to 13.93; moderate-certainty evidence) and combinations of tocolytics (RR 6.87, 95% CI 2.08 to 22.7; low-certainty evidence) are probably more likely to result in cessation of treatment. Calcium channel blockers possibly reduce the risk of neurodevelopmental morbidity (RR 0.51, 95% CI 0.30 to 0.85; low-certainty evidence), and respiratory morbidity (RR 0.68, 95% CI 0.53 to 0.88; low-certainty evidence), and result in fewer neonates with birthweight less than 2000 g (RR 0.49, 95% CI 0.28 to 0.87; low-certainty evidence). Nitric oxide donors possibly result in neonates with higher birthweight (mean difference (MD) 425.53 g more, 95% CI 224.32 more to 626.74 more; low-certainty evidence), fewer neonates with birthweight less than 2500 g (RR 0.40, 95% CI 0.24 to 0.69; low-certainty evidence), and more advanced gestational age (MD 1.35 weeks more, 95% CI 0.37 more to 2.32 more; low-certainty evidence). Combinations of tocolytics possibly result in fewer neonates with birthweight less than 2500 g (RR 0.74, 95% CI 0.59 to 0.93; low-certainty evidence). In terms of maternal adverse effects, betamimetics probably cause dyspnoea (RR 12.09, 95% CI 4.66 to 31.39; moderate-certainty evidence), palpitations (RR 7.39, 95% CI 3.83 to 14.24; moderate-certainty evidence), vomiting (RR 1.91, 95% CI 1.25 to 2.91; moderate-certainty evidence), possibly headache (RR 1.91, 95% CI 1.07 to 3.42; low-certainty evidence) and tachycardia (RR 3.01, 95% CI 1.17 to 7.71; low-certainty evidence) compared with placebo or no treatment. COX inhibitors possibly cause vomiting (RR 2.54, 95% CI 1.18 to 5.48; low-certainty evidence). Calcium channel blockers (RR 2.59, 95% CI 1.39 to 4.83; low-certainty evidence), and nitric oxide donors probably cause headache (RR 4.20, 95% CI 2.13 to 8.25; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Compared with placebo or no tocolytic treatment, all tocolytic drug classes that we assessed (betamimetics, calcium channel blockers, magnesium sulphate, oxytocin receptor antagonists, nitric oxide donors) and their combinations were probably or possibly effective in delaying preterm birth for 48 hours, and 7 days. Tocolytic drugs were associated with a range of adverse effects (from minor to potentially severe) compared with placebo or no tocolytic treatment, although betamimetics and combination tocolytics were more likely to result in cessation of treatment. The effects of tocolytic use on neonatal outcomes such as neonatal and perinatal mortality, and on safety outcomes such as maternal and neonatal infection were uncertain.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Co-production of a CArdiac Brief INtervention (CABIN) for patients prior to discharge following acute myocardial infarction (AMI)

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Public Health Agency Northern Ireland, Research and Development PhD Fellowship

Background

Recovery from AMI can be challenging for patients without adequate psychosocial support to overcome anxiety, address misconceptions and initiate lifestyle change (1,2). Reduced length of stay has minimised the opportunity for nurses to evaluate patients’ holistic needs and initiate effective in-hospital interventions (3). Patients and nurses discussed these challenges openly and worked together in this co-design study to develop a brief intervention for the pre-discharge period.

Method

A multi-site, co-design project was conducted with an exploratory phase of interviewing and focus groups with patients and staff involved in CR. The data from this exploratory phase informed a series of working-group meetings during which this intervention was developed.

Results

The CABIN (CArdiac Brief INtervention) offers brief, reassuring and compassionate discussions alongside educational content. CABIN consists of 8 components as seen in figure 1. It is designed to be used by nursing staff in the acute setting with patients following their AMI. Staff delivering the intervention must have full understanding of the local CR programme to offer practical advice if necessary.

Conclusion

CABIN provides a tangible means to emotionally support patients in the acute phase of recovery following AMI. It is envisaged that CABIN will empower acute clinical nursing staff to address the emotional needs of patients in a way which will encourage attendance at CR and subsequent recovery.

Using co-design to create user-friendly material promoting cardiac rehabilitation

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Public Health Agency Northern Ireland, Research and Development PhD Fellowship

Background

Cardiac Rehabilitation (CR) participation rates remain stagnant across Europe at around 40%(1) , with similar low uptake in Northern Ireland. Patients in our Steering Group confirmed that misconceptions about CR and lack of clear explanations negatively influence their decision to attend. Patients can feel overwhelmed by the experience of a cardiac event and the importance of CR is easily overlooked. Co-production of a short information film could better inform patients, family and the public.

Methods

Focus groups and interviews with N=58. Patients and carers informed 2 co-design workshops identifying the need for an information film to be available to cardiac patients and their families. Between July and November 2021, virtual multidisciplinary staff and patient groups developed the film with all members contributing to the script, voice content and film footage. A professional film company produced the 90 second infomercial with direction from patients and CR professionals.

Results

The information film portrays the experiences of a male and female patient. Elements of CR that were perceived as attractive components by patients in the codesign workshops are portrayed including; one to one interactions between staff and patients, the diversity of CR teams, and comradery between patients. The film is designed to be viewed on multiple devices, in hospital and at home following discharge.

Conclusion

Providing information about CR through the media of film may help to dispel misconceptions of CR and promote its attractiveness to patients. The effectiveness of this film awaits evaluation following dissemination to staff and patients this year.

Inclusion body myositis: The interplay between ageing, muscle degeneration and autoimmunity

Inclusion body myositis (IBM) is a slowly progressive muscle disease affecting ageing individuals. IBM presents with a distinctive pattern of weakness involving the quadriceps and finger flexor muscles, although other muscles including pharyngeal muscles become affected over time. Pathological hallmarks of IBM include autoimmune features, including endomysial infiltration by highly differentiated T cells, as well as degenerative features marked by intramyofibre protein aggregates organised into inclusion bodies. Despite some progress in understanding the cellular pathways involved in IBM, it remains untreatable, and the progression of the disease leads to progressive weakness, disability, wheelchair dependency and loss of independence. Therefore, there is an urgent need to improve our understanding of the underlying mechanisms and pathways involved in this disease to identify new treatment targets. Here, we discuss the current understanding of aetiopathogenesis, the interrelationship between autoimmunity and degeneration, and how ageing is a major influencer of both these features.

Systematic review and narrative synthesis of the impact of Appreciative Inquiry in healthcare

BACKGROUND

Appreciative Inquiry is a motivational, organisational change intervention, which can be used to improve the quality and safety of healthcare. It encourages organisations to focus on the positive and investigate the best of 'what is' before thinking of 'what might be', deciding 'what should be' and experiencing 'what can be'. Its effects in healthcare are poorly understood. This review seeks to evaluate whether Appreciative Inquiry can improve healthcare.

METHODS

Major electronic databases and grey literature were searched. Two authors identified reports of Appreciative Inquiry in clinical settings by screening study titles, abstracts and full texts. Data extraction, in duplicate, grouped outcomes into an adapted Kirkpatrick model: participant reaction, attitudes, knowledge/skills, behaviour change, organisational change and patient outcomes.

RESULTS

We included 33 studies. One randomised controlled trial, 9 controlled observational studies, 4 qualitative studies and 19 non-controlled observational reports. Study quality was generally poor, with most having significant risk of bias. Studies report that Appreciative Inquiry impacts outcomes at all Kirkpatrick levels. Participant reaction was positive in the 16 studies reporting it. Attitudes changed in the seventeen studies that reported them. Knowledge/skills changed in the 14 studies that reported it, although in one it was not universal. Behaviour change occurred in 12 of the 13 studies reporting it. Organisational change occurred in all 23 studies that reported it. Patient outcomes were reported in eight studies, six of which reported positive changes and two of which showed no change.

CONCLUSION

There is minimal empirical evidence to support the effectiveness of Appreciative Inquiry in improving healthcare. However, the qualitative and observational evidence suggests that Appreciative Inquiry may have a positive impact on clinical care, leading to improved patient and organisational outcomes. It is, therefore, worthy of consideration when trying to deliver improvements in care. However, high-quality studies are needed to prove its effects.

PROSPERO REGISTRATION NUMBER

CRD42015014485.

Sexual and Reproductive Health Needs Assessment & Interventions in a Female Psychiatric Intensive Care Unit

Introduction

This quality improvement project was a collaboration between an adult, inpatient female psychiatric intensive care unit (PICU) in South London and the Sexual and Reproductive Health Rights, Inclusion and Empowerment (SHRINE) programme. SHRINE is a London-based programme delivering SRH care to any individual with serious mental illness, substance misuse and/or learning disability.

Objectives

The primary aim of this quality improvement project was to assess patients’ sexual and reproductive (SRH) needs, and the acceptability of providing SRH assessments in a female PICU setting. Secondary aims were to explore the barriers to access and the feasibility of providing SRH assessments and SHRINE interventions in the PICU.

Methods

A bi-monthly SRH in-reach clinic and a nurse led SRH referral pathway were implemented on the PICU over a seven-month period. Within a quality improvement framework, a staff training needs assessment was performed, training delivered, a protocol developed, staff attitudes explored, and patient and carer engagement sought.

Results

30% of women were identified as having unmet SRH needs and proceeded to a specialist appointment, representing a 2.5-fold increase in unmet need detection. 42% of women were assessed, representing a 3.5-fold increase in uptake. 21% of women initiated SRH interventions of which 14% had all their SRH needs met.

Conclusions

Results identified SRH needs for PICU admissions are greater than realised. Staff highlighted the acceptability and importance of SRH care, if interventions are appropriately timed and the patient’s individual risk profile considered. Providing a nurse-led referral pathway for an SRH in-reach clinic is acceptable, feasible and beneficial for PICU patients.

Disclosure

No significant relationships.

Antimicrobial prescribing and antimicrobial resistance surveillance in equine practice

BACKGROUND

Antimicrobial resistance (AMR) is an increasingly serious threat to human and animal health, therefore responsible use of antimicrobials in equine practice is vital. There is a need to have accurate, up to date data on antimicrobial prescribing in equine practice in the UK.

OBJECTIVES

To characterise current antimicrobial prescribing practices by equine veterinarians and to describe surveillance, audit processes and identification of AMR.

STUDY DESIGN

Online cross-sectional, questionnaire-based survey.

METHODS

An online questionnaire targeting veterinarians who treat horses in the UK and Europe was distributed. The questionnaire collected data on participants' country of origin, practice policies, prescribing practices including use of high priority critical antimicrobials. Four common clinical case-based scenarios were included to further explore prescribing practice. Responses were compared using both descriptive statistics and multivariable logistic regression models.

RESULTS

Questionnaires were completed by 264 veterinarians from Europe (n=33/264) and the UK (n=231/264); 87% respondents worked only with horses and 67% worked at premises with hospitalisation facilities. Approximately half of respondents (54.4%) had a written antimicrobial use or stewardship policy within their practice. Over half of respondents did not perform any environmental surveillance (54.2%), audit of clinical infections (53.1%) or audit of infection control (57.1%). Potentiated sulphonamides were cited as the most used antimicrobial, although 44% reported using enrofloxacin in the last year and 66% used 3^rd or 4^th generation cephalosporins. Prophylactic antimicrobials before clean surgery were frequently/always prescribed by 48% respondents and 24% respondents frequently/always prescribed antimicrobials post-operatively in clean surgery.

MAIN LIMITATIONS

Potential selection bias of respondents, given individuals volunteered to take part in the survey.

CONCLUSIONS

Compared to a previous similar study conducted in 2009, overall antimicrobial usage appeared to be declining in clinical scenarios and a greater proportion of practices now have stewardship policies. However, the use of high priority critical antimicrobials is still relatively common in equine practice in the UK and Europe.

A163 EVALUATING THE ASSOCIATION BETWEEN PERIPHERAL BLOOD EOSINOPHILS AND DRUG RESPONSE IN CROHN’S DISEASE: A PRELIMINARY REPORT

Background

Th1, Th2, and Th17 immune pathways are variably activated in inflammatory bowel disease (IBD). The degree to which pathway having a more dominant role in propagating Crohn’s disease (CD) is not considered when selecting a treatment strategy. Th2 cytokines, IL-5 and IL-13 enhance eosinophil survival, recruitment and degranulation, facilitating inflammation. Mucosal eosinophilia has been documented in CD and its presence is a surrogate marker of Th2 pathway activation. Peripheral eosinophilia has an established role in asthma to help prognosticate treatment response to Th2-cytokine-specific therapies. We hypothesize the pattern of peripheral blood eosinophils (PBE) at CD diagnosis will identify distinct subsets within a larger CD population and correlate with response to treatments such as prednisone or anti-TNFs.

Aims

We aim to evaluate the pattern of PBE of CD patients at time of diagnosis (prior to drug exposure) and with each subsequent treatment; and if baseline PBE or any changes seen with drug exposures are predictive of treatment response.

Methods

A retrospective cohort study is ongoing with CD patients exposed to glucocorticoids and an anti-TNF seen at one of 3 hospitals affiliated with University of Western Ontario. Patients were identified using administrative databases and reviewed for biochemical data (complete blood count) and disease activity (Harvey Bradshaw Index) at baseline as well as before and after each drug exposure. Participants were classified as having high PBE (eosinophils >200 cells/μl) versus low PBE (eosinophils <200 cells/μl).

Results

To date,10 of 200 CD patients are included in the preliminary analyses with a mean age of 47. 8 had PBE >200 cells/μL at baseline, while 2 did not. The median number therapies used was 4 (IQR=0.75). All received glucocorticoids followed by an anti-TNF. There was no difference in the occurrence of hospitalization or surgery between the two cohorts. Overall 75% (n=6/8) participants with high PBE had clinical response to glucocorticoid exposure, seen as a 3-point decrease in HBI compared to 0% (n=0/2, p=0.5) in the low PBE cohort. With subsequent anti-TNF exposure, PBE rebounded in 6 participants. More patients in the high PBE group required anti-TNF dose escalation versus the low PBE group (63%, n=5/8 versus 50%, n=1/2, p=0.99). The proportion of patients with anti-TNF discontinuation was similar in both groups (high PBE, 50%, n=4/8 versus low PBE, 50%, n=1/2, p=1.00).

Conclusions

Peripheral eosinophilia is seen in varying degrees in CD patients. Participants with high PBE appear to be more steroid-responsive which is typical for Th2-mediated pathways. They were less responsive to Th1-targeting anti-TNF therapies, requiring more dose-escalation and discontinued anti-TNF treatment. Completion of this study will help clarify the association between PBE in CD and treatment response.

Funding Agencies

None

A142 IMPACT OF HLADQA1*05G>A GENETIC-SCREENING FOR OPTIMAL ANTI-TNF THERAPY IN INFLAMMATORY BOWEL DISEASE: A PRELIMINARY REPORT

Background

Genetic variation in the human leukocyte antigen ( HLA) gene is strongly associated with the formation of anti-drug antibodies to tumor necrosis factor-alpha antagonists (anti-TNF) in inflammatory bowel disease (IBD). It is also associated anti-TNF loss of response and treatment discontinuation.

Aims

We aimed to evaluate the utility of preemptive HLADQA1*05G&gt;A screening to reduce the incidence of treatment-related adverse events in an IBD population by lessening the need for combination therapy in those who do not carry the risk allele. We also assessed for the occurrence of anti-TNF anti-drug antibody (ADA) formation, anti-TNF loss of response, treatment discontinuation compared to an unscreened population.

Methods

A non-randomized open label study is ongoing in IBD patients being considered for anti-TNF therapy. Participants received either pre-treatment HLADQA1*05G&gt;A screening (prospective-screening group, n=25/110 recruited), with the addition of one of azathioprine or methotrexate to anti-TNF therapy (combination therapy) if identified as a high risk variant carrier (G/A or A/A) or received combination therapy without undergoing prospective HLADQA1*05A&gt;G screening (control group, n=25/110 recruited). All participants will be followed for up to 1 year and observed for the occurrence of any adverse drug events, formation of anti-TNF drug antibodies (ADA), anti-TNF loss of response and anti-TNF discontinuation.

Results

To date, the prevalence of HLADQA1*05 G/A and A/A was 20% in the prospective-screening group and thus 20% (n=5/25) received combination therapy and 80% (n=20) received anti-TNF monotherapy. All participants in the control group (n=25/25) received combination therapy. Considering all groups, 78% (n=39/50) received infliximab, while 22% (n=11/50) received adalimumab. To date, the median follow-up period is 5 (IQR=4) months. Fewer adverse drug events have been reported in the prospective-screening group versus the control group (16.7% vs 33.3%, odds ratio 0.40, 95%CI=0.12–1.56, p=0.18). Anti-TNF ADA formation and treatment discontinuation were similar between groups (prospective-screening, 0% versus control, 4.2%). A higher proportion of controls experienced anti-TNF loss of response (16.7% vs 8.3%, p=0.38).

Conclusions

Preemptive HLADQA1*05G&gt;A screening appears to reduce the need for combination therapy when using anti-TNF agents in an IBD population. Fewer drug-related adverse events are reported to date in the screened cohort without a concomitant increase in deleterious outcomes such as ADA formation or anti-TNF discontinuation. Completion of this study will help define whether or not HLADQA1*05G&gt;A-screening is a clinically-actionable and relevant tool for guiding the application of combination therapy in IBD.

Funding Agencies

Lawson Health Research Institute

Demographic, clinical, and service-use characteristics related to the clinician's recommendation to transition from child to adult mental health services

PURPOSE

The service configuration with distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) may be a barrier to continuity of care. Because of a lack of transition policy, CAMHS clinicians have to decide whether and when a young person should transition to AMHS. This study describes which characteristics are associated with the clinicians' advice to continue treatment at AMHS.

METHODS

Demographic, family, clinical, treatment, and service-use characteristics of the MILESTONE cohort of 763 young people from 39 CAMHS in Europe were assessed using multi-informant and standardized assessment tools. Logistic mixed models were fitted to assess the relationship between these characteristics and clinicians' transition recommendations.

RESULTS

Young people with higher clinician-rated severity of psychopathology scores, with self- and parent-reported need for ongoing treatment, with lower everyday functional skills and without self-reported psychotic experiences were more likely to be recommended to continue treatment. Among those who had been recommended to continue treatment, young people who used psychotropic medication, who had been in CAMHS for more than a year, and for whom appropriate AMHS were available were more likely to be recommended to continue treatment at AMHS. Young people whose parents indicated a need for ongoing treatment were more likely to be recommended to stay in CAMHS.

CONCLUSION

Although the decision regarding continuity of treatment was mostly determined by a small set of clinical characteristics, the recommendation to continue treatment at AMHS was mostly affected by service-use related characteristics, such as the availability of appropriate services.

Long-term outcomes of intravenous drug use associated infective endocarditis: a contemporary 20-year study

Introduction

Intravenous drug use (IVDU) associated infective endocarditis (IE) is a clinically challenging case. Not only can the natural history of IE in the IVDU population be significantly different, making detection a diagnostic dilemma, additional social factors associated with this population can drastically change management, including suitability for surgery or long-term intravenous access for antibiotics Furthermore, the rates of IVDU are increasing globally, leading to increasing incidence of IVDU associated IE.

Purpose

With a lack of clear mangement guidelines for IVDU associated IE, our study assesses the differences in presentation, management and long-term prognosis of IE between the IVDU population and the non-IVDU population to help guide future care.

Methods

This is an observational cohort study on a prospectively collected database of 350 patients treated for IE at our centre between 1999 and 2015. Patients were followed-up until death or January 2021. The primary outcome was all-cause mortality. Continuous variables were compared using unpaired t-test. Categorical variables were compared using Chi-square test when sample size was &gt;5 or Fisher's exact test when sample size was ≤5. Long-term survival data was analysed using Kaplan-Meier survival curves.

Results

The IVDU population was younger, more likely to have concurrent infections and other substance use, while the non-IVDU population was older with a higher level of overall comorbidity. IVDU patients were more likely to become reinfected (p-value=0.034) but had better long-term survival compared to the non-IVDU population (p&lt;0.001). Survival estimates at 15-years were 64.98% (95% CI: 50.94–75.92%) for the IVDU population compared to 26.67% (95% CI: 19.76–34.05%) for the non-IVDU population (p-value&lt;0.0001).

Conclusion

Despite having higher levels of reinfection, IVDU patients have better long-term outcomes of IE compared to non-IVDU patients. Therefore, IVDU patients should not have blanket restrictions on the management they are offered unless the individual has clear contraindications to a particular therapy.

Funding Acknowledgement

Type of funding sources: None.