The business case for hospital mobility programs in the veterans health care system: Results from multi-hospital implementation of the STRIDE program

OBJECTIVE

To conduct a business case analysis for Department of Veterans Affairs (VA) program STRIDE (ASsisTed EaRly MobIlization for hospitalizeD older VEterans), which was designed to address immobility for hospitalized older adults.

DATA SOURCES AND STUDY SETTING

This was a secondary analysis of primary data from a VA 8-hospital implementation trial conducted by the Function and Independence Quality Enhancement Research Initiative (QUERI). In partnership with VA operational partners, we estimated resources needed for program delivery in and out of the VA as well as national implementation facilitation in the VA. A scenario analysis using wage data from the Bureau of Labor Statistics informs implementation decisions outside the VA.

STUDY DESIGN

This budget impact analysis compared delivery and implementation costs for two implementation strategies (Replicating Effective Programs [REP]+CONNECT and REP-only). To simulate national budget scenarios for implementation, we estimated the number of eligible hospitalizations nationally and varied key parameters (e.g., enrollment rates) to evaluate the impact of uncertainty.

DATA COLLECTION

Personnel time and implementation outcomes were collected from hospitals (2017-2019). Hospital average daily census and wage data were estimated as of 2022 to improve relevance to future implementation.

PRINCIPAL FINDINGS

Average implementation costs were $9450 for REP+CONNECT and $5622 for REP-only; average program delivery costs were less than $30 per participant in both VA and non-VA hospital settings. Number of walks had the most impact on delivery costs and ranged from 1 to 5 walks per participant. In sensitivity analyses, cost increased to $35 per participant if a physical therapist assistant conducts the walks. Among study hospitals, mean enrollment rates were higher among the REP+CONNECT hospitals (12%) than the REP-only hospitals (4%) and VA implementation costs ranged from $66 to $100 per enrolled.

CONCLUSIONS

STRIDE is a low-cost intervention, and program participation has the biggest impact on the resources needed for delivering STRIDE.

TRIAL REGISTRATION

ClinicalsTrials.gov NCT03300336. Prospectively registered on 3 October 2017.

COVID-19 vaccines and adverse events of special interest: A multinational Global Vaccine Data Network (GVDN) cohort study of 99 million vaccinated individuals

BACKGROUND

The Global COVID Vaccine Safety (GCoVS) Project, established in 2021 under the multinational Global Vaccine Data Network™ (GVDN®), facilitates comprehensive assessment of vaccine safety. This study aimed to evaluate the risk of adverse events of special interest (AESI) following COVID-19 vaccination from 10 sites across eight countries.

METHODS

Using a common protocol, this observational cohort study compared observed with expected rates of 13 selected AESI across neurological, haematological, and cardiac outcomes. Expected rates were obtained by participating sites using pre-COVID-19 vaccination healthcare data stratified by age and sex. Observed rates were reported from the same healthcare datasets since COVID-19 vaccination program rollout. AESI occurring up to 42 days following vaccination with mRNA (BNT162b2 and mRNA-1273) and adenovirus-vector (ChAdOx1) vaccines were included in the primary analysis. Risks were assessed using observed versus expected (OE) ratios with 95 % confidence intervals. Prioritised potential safety signals were those with lower bound of the 95 % confidence interval (LBCI) greater than 1.5.

RESULTS

Participants included 99,068,901 vaccinated individuals. In total, 183,559,462 doses of BNT162b2, 36,178,442 doses of mRNA-1273, and 23,093,399 doses of ChAdOx1 were administered across participating sites in the study period. Risk periods following homologous vaccination schedules contributed 23,168,335 person-years of follow-up. OE ratios with LBCI > 1.5 were observed for Guillain-Barré syndrome (2.49, 95 % CI: 2.15, 2.87) and cerebral venous sinus thrombosis (3.23, 95 % CI: 2.51, 4.09) following the first dose of ChAdOx1 vaccine. Acute disseminated encephalomyelitis showed an OE ratio of 3.78 (95 % CI: 1.52, 7.78) following the first dose of mRNA-1273 vaccine. The OE ratios for myocarditis and pericarditis following BNT162b2, mRNA-1273, and ChAdOx1 were significantly increased with LBCIs > 1.5.

CONCLUSION

This multi-country analysis confirmed pre-established safety signals for myocarditis, pericarditis, Guillain-Barré syndrome, and cerebral venous sinus thrombosis. Other potential safety signals that require further investigation were identified.

"I'll meet you at our bench": adaptation, innovation and resilience among VCSE organisations who supported marginalised and minoritised communities during the Covid-19 pandemic in Northern England - a qualitative focus group study

BACKGROUND

The Covid-19 pandemic has exacerbated pre-existing inequalities and increased adversity and challenges for vulnerable and marginalised communities worldwide. In the UK, the Voluntary Community and Social Enterprise (VCSE) sector play a vital role in supporting the health and wellbeing of people who are marginalised or experiencing multiple complex needs. However, only a small number of studies have focused on the impact that Covid-19 had on the VCSE sector.

METHODS

As part of a Health Inequalities Impact Assessment (HIIA), we conducted qualitative focus groups with staff and volunteers from five organisations to examine short, medium and longer-term impacts of Covid-19 upon the VCSE sector in Northern England. Nine online focus groups were conducted between March and July 2021.

FINDINGS

Focus group transcripts were analysed using Framework Analysis and yielded three central themes: (1) exacerbation of pre-existing inequalities, adversity and challenges for vulnerable and marginalised populations; (2) the 'price' of being flexible, innovative and agile for VCSE staff and volunteers; and (3) the voluntary sector as a 'lifeline' - organisational pride and resilience.

CONCLUSIONS

While the voluntary sector 'adapted at pace' to provide support during Covid-19 and in its continued aftermath, this resilience has potentially come at the cost of workforce and volunteer wellbeing, compounded by political obstacles and chronic shortage in funding and support. The VCSE sector has a vital role to play in the post-lockdown 'levelling up' agenda. The expertise, capacity and resilience of VCSE organisations, and their ability to respond to Covid-19, should be celebrated, recognised and supported adequately to maintain its resilience. To not do so threatens the sector's sustainability and risks jeopardising attempts to involve the sector in addressing the social determinants of health.

mRNAs encoding self-DNA reactive cGAS enhance the immunogenicity of lipid nanoparticle vaccines

Lipid nanoparticle (LNP)-encapsulated mRNAs have emerged as effective vaccination tools to stimulate immunity. The most common application of this technology is to deliver mRNAs that encode antigenic proteins to dendritic cells (DCs), which then stimulate antigen-specific lymphocyte responses. It is unclear whether other immunostimulatory DC activities necessary for vaccine efficacy, beyond antigen presentation, can be induced via mRNA-encoded proteins. Herein, we report an mRNA encoding a self-DNA reactive variant of the enzyme cyclic GMP-AMP synthase (cGAS), known as cGAS∆N. cGAS∆N produces the cyclic dinucleotide cGAMP upon binding intra-mitochondrial DNA. cGAMP binds the protein STING, which activates innate immune responses that stimulate T cells. We found that when delivered to DCs via LNPs, mRNA-encoded cGAS∆N induced the upregulation of chemokine receptors, T cell costimulatory molecules, major histocompatibility complex proteins, pro-inflammatory cytokines and type I interferons from murine and human DCs. These activities exceeded the immunostimulatory activities of mRNA-encoded antigens delivered via LNPs. Co-immunization of mice with antigen-LNPs and cGAS∆N-LNPs led to the robust production of antigen-specific IFNγ-producing T cells. These T cell responses were durable and circulated through the lymphatics, blood, and lungs. Immunizations with antigen-LNPs alone, akin to what are used in the clinic, stimulated weak and transient T cell responses. Antibody responses to antigen-LNPs were biased towards type I isotypes when co-injected with cGAS∆N-LNPs, as compared to immunizations with antigen-LNPs alone. These findings establish the enzyme cGAS∆N as a catalytic adjuvant, which may prove useful in enhancing the immunogenicity of nucleic acid-based vaccines. IMPORTANCE Nucleic acid-based vaccines hold promise in preventing infections and treating cancer. The most common use of this technology is to encode antigenic proteins on mRNAs that are delivered to cells via lipid nanoparticle (LNP) formulations. In this study, we discovered that immunostimulatory proteins can also be encoded on mRNAs in LNPs. We found that an active mutant of the enzyme cGAS, referred to as cGAS∆N, acts as a catalytic adjuvant in LNP-encapsulated mRNA vaccines. The delivery of cGAS∆N mRNA via LNPs in combination with antigen mRNA-LNPs led to durable antigen-specific IFNγ-producing T cells that exceeded the efficiency of antigen-LNPs similar to those currently used in the clinic. This strategy did not compromise B cell responses; rather it induced Th1-biased antibody isotypes. This work unveils new vaccine design strategies using mRNA-encoded catalytic adjuvants that could be ideal for generating CD8+ T cell and B cell responses for immunotherapies.

Group physical therapy for knee osteoarthritis: protocol for a hybrid type III effectiveness-implementation trial

BACKGROUND

Knee osteoarthritis (OA) is a leading cause of chronic pain and disability and one of the most common conditions treated in outpatient physical therapy (PT). Because of the high and growing prevalence of knee OA, there is a need for efficient approaches for delivering exercise-based PT to patients with knee OA. A prior randomized controlled trial (RCT) showed that a 6-session Group Physical Therapy Program for Knee OA (Group PT) yields equivalent or greater improvements in pain and functional outcomes compared with traditional individual PT, while requiring fewer clinician hours per patient to deliver. This manuscript describes the protocol for a hybrid type III effectiveness-implementation trial comparing two implementation packages to support delivery of Group PT.

METHODS

In this 12-month embedded trial, a minimum of 16 Veterans Affairs Medical Centers (VAMCs) will be randomized to receive one of two implementation support packages for their Group PT programs: a standard, low-touch support based on Replicating Effective Programs (REP) versus enhanced REP (enREP), which adds tailored, high-touch support if sites do not meet Group PT adoption and sustainment benchmarks at 6 and 9 months following launch. Implementation outcomes, including penetration (primary), adoption, and fidelity, will be assessed at 6 and 12 months (primary assessment time point). Additional analyses will include patient-level effectiveness outcomes (pain, function, satisfaction) and staffing and labor costs. A robust qualitative evaluation of site implementation context and experience, as well as site-led adaptations to the Group PT program, will be conducted.

DISCUSSION

To our knowledge, this study is the first to evaluate the impact of tailored, high-touch implementation support on implementation outcomes when compared to standardized, low-touch support for delivering a PT-based intervention. The Group PT program has strong potential to become a standard offering for PT, improving function and pain-related outcomes for patients with knee OA. Results will provide information regarding the effectiveness and value of this implementation approach and a deeper understanding of how healthcare systems can support wide-scale adoption of Group PT.

TRIAL REGISTRATION

This study was registered on March 7, 2022 at ClinicalTrials.gov (identifier NCT05282927 ).

Planning Considerations for the Primary Lung Tumor Stereotactic Body Radiation Therapy Followed by Concurrent Mediastinal Radiotherapy for Locally-Advanced Non-Small Cell Lung Cancer

PURPOSE/OBJECTIVE(S)

Phase III prospective randomized trial of primary lung tumor stereotactic body radiation therapy followed by concurrent mediastinal chemoradiation for locally-advanced non-small cell lung cancer (NRG LU-008), designed to lower the rates of radiation pneumonitis and improve the progression-free survival, is expected to become active nationally in July 2023. Due to the specific nature of the cases selected for this trial, a new approach to treatment planning had to be developed to satisfy the conditions of the trial. Levice Cancer Institute (Atrium Health, North Carolina) ran the initial Phase II trial and investigated several approaches, providing recommendations for the future dosimetry planning approach.

MATERIALS/METHODS

A total of 60 patients were selected for the initial trial and treated with a combination of SBRT treatment to the primary tumor (50-54 Gy in 3-5 fractions) and conventional IMRT treatment to 60 Gy to the involved lymph nodes for patients with stage 3 or unresectable stage II NSCLC, combined with chemotherapy. Depending on the location of the primary tumor, all cases could be subdivided into no overlap between the SBRT and IMRT targets, adjacent targets, and overlapping targets. All SBRT plans were done with a 6X-FFF beam, advanced dose calculation algorithm, and 0.1 cm grid size. IMRT targets were primarily treated with VMAT plans, though a minority of cases were planned with the DMLC technique, with a 6X beam, advanced dose calculation algorithm, and 0.25 cm grid size. Various approaches to the planning included target cropping, avoidance via adjusting optimization objectives and utilizing the base dose of the SBRT plan to optimize the dose for the IMRT nodal plan. Various geometries utilized in the plan included a variation in the number of arcs, covered arc angles, and the number of beams.

RESULTS

A significant reduction in the side effects was achieved throughout the trial, with only three patients experiencing grade 3 or higher pneumonitis, 3 patients experiencing grade 3 or higher cardiotoxicity, and 1 patient experiencing grade 3 esophagitis. For targets with no significant overlap between the primary tumor and nodal target, standard planning techniques proved to be sufficient. For the overlapping targets, the planning approach of utilizing 2 arcs, >180-degree coverage, for the SBRT plan, and using ¼ of the base SBRT dose to plan the IMRT nodal plan provided the best target coverage while achieving sufficient OAR sparing.

CONCLUSION

Planning the joint SBRT-IMRT plan in the cases of a significant target overlap requires a careful approach, but is feasible with the proposed guideline and should be achievable for any center electing to participate in the NRG LU-008 trial.

Ready, set, go! The role of organizational readiness to predict adoption of a family caregiver training program using the Rogers' diffusion of innovation theory

BACKGROUND

Caregivers FIRST is an evidence-based program addressing gaps in caregivers' skills. In 2020, the Veterans Health Administration Caregiver Support Program (CSP) nationally endorsed Caregivers FIRST, offering credit in leadership performance plans to encourage all VA medical centers (VAMCs) to implement locally. This study examines the association of organizational readiness with VAMC adoption of Caregivers FIRST.

METHODS

In a cohort observational study, we surveyed CSP managers about their facilities' readiness to implement using the Organizational Readiness for Implementing Change (ORIC) instrument and compared change commitment and change efficacy domains among VAMCs "adopters" defined as delivering Caregivers FIRST within 1 year of the national announcement to those that did not ("non-adopters"). Within "adopters," we categorized time to adoption based on Rogers' diffusion of innovation theory including "innovators," "early adopters," "early majority," "late adopters," and "laggards." Organizational readiness and site characteristics (facility complexity, staffing levels, volume of applications for caregiver assistance services) were compared between "adopters," "non-adopters," and between time to adoption subcategories. Separate logistic regression models were used to assess whether ORIC and site characteristics were associated with early adoption among "adopters."

RESULTS

Fifty-one of 63 (81%) VAMCs with CSP manager survey respondents adopted Caregivers FIRST during the first year. ORIC change commitment and efficacy were similar for "adopters" and "non-adopters." However, sites that adopted earlier (innovators and early adopters) had higher ORIC change commitment and efficacy scores than the rest of the "adopters." Logistic regression results indicated that higher ORIC change commitment (odds ratio [OR] = 2.57; 95% confidence interval [CI], 1.11-5.95) and ORIC change efficacy (OR = 2.60; 95% CI, 1.12-6.03) scores were associated with increased odds that a VAMC was an early adopter (categorized as an "innovator," "early adopter", or "early majority"). Site-level characteristics were not associated with Caregivers FIRST early adoption.

CONCLUSIONS

To our knowledge, this study is the first to prospectively assess organizational readiness and the timing of subsequent program adoption. Early adoption was associated with higher ORIC change commitment and change efficacy and not site-level characteristics. These findings yield insights into the role of organizational readiness to accelerate program adoption.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03474380. Registered on March 22, 2018.

Incorporating TechQuity in Virtual Care Within the Veterans Health Administration: Identifying Future Research and Operations Priorities

BACKGROUND

The Covid-19 pandemic dramatically changed healthcare delivery, driving rapid expansion of synchronous (i.e., real-time) audio-only and video telehealth, otherwise known as virtual care. Yet evidence describes significant inequities in virtual care utilization, with certain populations more dependent on audio-only virtual care than video-based care. Research is needed to inform virtual care policies and processes to counteract current inequities in access and health outcomes.

OBJECTIVE

Given the importance of incorporating equity into virtual care within the Veterans Health Administration (VHA), we convened a Think Tank to identify priorities for future research and virtual care operations focused on achieving equitable implementation of virtual care within the VHA.

METHODS

We used participatory activities to engage clinicians, researchers, and operational partners from across the VHA to develop priorities for equitable implementation of virtual care. We refined priorities through group discussion and force-ranked prioritization and outlined next steps for selected priorities.

KEY RESULTS

Think Tank participants included 43 individuals from the VHA who represented diverse geographical regions, offices, and backgrounds. Attendees self-identified their associations primarily as operations (n = 9), research (n = 28), or both (n = 6). We identified an initial list of 63 potential priorities for future research and virtual care operations. Following discussion, we narrowed the list to four priority areas: (1) measure inequities in virtual care, (2) address emerging inequities in virtual care, (3) deploy virtual care equitably to accommodate differently abled veterans, and (4) measure and address potential adverse consequences of expanded virtual care. We discuss related information, data, key partners, and outline potential next steps.

CONCLUSIONS

This Think Tank of research and operational partners from across the VHA identified promising opportunities to incorporate equity into the design and implementation of virtual care. Although much work remains, the priorities identified represent important steps toward achieving this vital goal.

Delivery outcomes as a result of snoring as determined by standard sleep surveys

Background

Sleep-disordered breathing (SDB), is an umbrella term that encompasses obstructive sleep apnea (OSA), central sleep apnea (CSA) and hypoventilation. is common but studies in the pregnant population are limited. Data suggests relationships between OSA and preeclampsia, but the relationship between snoring and pregnancy outcomes is unknown.

Methods

A prospective study of 2224 singleton pregnancies was undertaken. Women were questioned using the Berlin Questionnaire (BQ- 2 or more categories where the score is positive.) and the Epworth Sleepiness Scale (ESS >10/24), the results compared with pregnancy outcomes with regard to hypertension in pregnancy.

Results

Women having symptoms raising the possibility of OSA defined by the BQ with a score >7 was 45.5%, and using ESS with a score >10, was 36%. The birth and neonatal outcomes for self-reported snoring and increased daytime sleepiness showed increased adverse outcomes notably increased caesarean section rates and low APGAR scores but not birth before 37 weeks of gestation.

Conclusion

Using questionnaires designed for the general population, the prevalence of possible undiagnosed OSA is high in the pregnant population. The increased adverse delivery and neonatal outcomes for self-reported snoring and increased daytime sleepiness with these tools indicated the need for further investigation of the links between snoring SDB and pregnancy outcomes.

INZ-701, a recombinant ENPP1-Fc protein, effectively treats and prevents neointimal proliferation in WT and ENPP1 Deficient mice

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Inozyme Pharma

Inactivating mutations in ENPP1, which encodes the ecto-nucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1), underlie the rare inherited disorder, generalized arterial calcification of infancy (GACI)/autosomal recessive hypophosphatemic rickets type 2 (ARHR2) also known as ENPP1 Deficiency. ENPP1 Deficiency is characterized by calcification of large and medium sized arteries and marked neointimal proliferation of arteries, leading to arterial stenosis and severe cardiovascular and skeletal complications. ENPP1 Deficiency is associated with a 50% mortality rate in the first six months of life, and there are no approved treatments.

Previous research demonstrated that INZ-701 protein prevented arterial calcification in an ENPP1 deficient mouse model (Enpp1 asj/asj). This study was designed to determine whether INZ-701 can prevent neointimal proliferation in WT and an ENPP1 deficient mouse model (ttw/ttw). Carotid ligation was performed to induce intimal proliferation in the mice.

In the preventive arm of the study, INZ-701 (10mg/kg) or vehicle was administered subcutaneously every other day starting in 6-week-old ttw/ttw-mice. Carotid ligation was performed in these mice at the age of 7 weeks and dosing continued for another 2 weeks. Carotid intimal and medial area caudal from the ligation were analyzed by histomorphometry 14 days and 21 days after carotid ligation. In the therapeutic arm of the study, INZ-701 (10 mg/kg) or vehicle was administered subcutaneously every other day starting 7 days after carotid ligation, when intimal proliferation had already developed, in 8-week-old ttw/ttw-mice. After one week of treatment, histomorphometry was performed.

Fourteen days after carotid ligation, ttw/ttw-mice preventatively treated with INZ-701 showed a significantly reduced intimal area (p<0.001) and intimal/medial (I/M) ratio (p<0.001) compared to those treated with vehicle. This effect was also observed in mice treated with INZ-701, which were treated for 28 days and were subsequently dissected 21 days after carotid ligation. Interestingly, similar effects of INZ-701 were found in WT mice in the preventative study.  In the therapeutic arm of the study, subcutaneous injection of INZ-701 beginning at 7 days post carotid ligation also led to a significant reduction in the I/M ratio (p<0.001) in the INZ-701 treated group compared to vehicle treated ttw/ttw-mice.

These findings demonstrate that INZ-701 prevents neointimal proliferation after carotid injury in a murine model of ENPP1 Deficiency. INZ-701 is hypothesized to restore circulating levels of AMP and adenosine, both potent inhibitors of intimal hyperplasia. Neointimal proliferation is a key feature in the pathophysiology of ENPP1 Deficiency and our results build on prior evidence to support the potential of INZ-701 to treat this rare and life-threatening disease.

Individual and program Characteristics May Drive Variability in Outcomes After Caregivers Participate in a Tailored Support Intervention

Critically needed programs designed to support family caregivers have shown inconsistent reductions in stress and burden. To explore drivers of improvement in caregiver outcomes after participation in a support intervention we analyzed data from a one-on-one, tailored problem-solving intervention targeting caregiver wellbeing (2015–2019, n = 503). We explored data patterns across 21 individual, household, and program-level variables using elastic net regression to identify drivers of improvements, and their relative importance. Baseline subjective burden, baseline depressive symptom scores, baseline caregiver problem solving, African American race, and site and coach fixed effects were the most consistent drivers of changes across the explored caregiver outcomes. Caregiver and program characteristics may be promising avenues to target to decrease distress and burden during intervention design. Interventions focusing on highly distressed caregivers may lead to greater improvements. More research is needed to identify how site or interventionists characteristics drive positive intervention effects.

Prioritizing Support Offered to Caregivers by Examining the Status Quo and Opportunities for Enhancement When Using Web-Based Self-reported Health Questionnaires: Descriptive Qualitative Study

Background

The Rosalynn Carter Institute for Caregivers (RCI) offers evidence-based interventions to promote caregivers’ health and well-being. Trained coaches regularly meet with caregivers to offer education and instructions to improve caregiver health, build skill sets, and increase resilience. Two of these interventions, RCI Resources for Enhancing Alzheimer's Caregiver Health (REACH) and Operation Family Caregiver (OFC), use a set of caregiver-reported questionnaires to monitor caregivers’ health status and needs.

Objective

This study aims to describe how web-based assessment questionnaires are used to identify and monitor caregiver status in the RCI REACH and OFC programs and outlines perceived enhancements to the web-based system that could support caregiver-coach encounters by directing priorities.

Methods

This was a descriptive, qualitative study. Data were collected via semistructured interviews with caregivers and coaches in the RCI REACH and OFC programs from July 2020 to October 2020. During the interviews, participants were asked to describe how the assessment questionnaires were used to inform caregiver-coach encounters, perceived usefulness of enhancements to web-based display, and preference for the structure of score results. The interviews were recorded, transcribed, and coded using structural and interpretive codes from a structured codebook. Qualitative content analysis was used to identify themes and summarize the results.

Results

A total of 25 caregivers (RCI REACH: 13/25, 52%; OFC: 12/25, 48%) and 11 coaches (RCI REACH: 5/11, 45%; OFC: 6/11, 55%) were interviewed. Most caregivers indicated that the assessment questions were relevant to their caregiving experience. Some caregivers and coaches indicated that they thought the assessment should be administered multiple times throughout the program to evaluate the caregiver progress. Overall, caregivers did not want their scores to be compared with those of other caregivers, and there was heterogeneity in how caregivers preferred to view their results at the question or topic level. Coaches were uncertain as to which and how much of the results from the self-reported questionnaires should be shared with caregivers. Overall, the results were very similar, regardless of program affiliation (RCI REACH vs OFC).

Conclusions

Web-based and procedural enhancements were identified to enrich caregiver-coach encounters. New and enhanced strategies for using web-based assessment questionnaires to direct priorities in the caregiver-coach encounters included integrating figures showing caregiver progress at the individual caregiver level, ability to toggle results through different figures focused on individual versus aggregate results, and support for interpreting scores. The results of this qualitative study will drive the next steps for RCI’s web-based platform and expand on current standards for administering self-reported questionnaires in clinical practice settings.

Identifying family and unpaid caregivers in the electronic health record: A descriptive analysis (Preprint)

Background

Most efforts to identify caregivers for research use passive approaches such as self-nomination. We describe an approach in which electronic health records (EHRs) can help identify, recruit, and increase diverse representations of family and other unpaid caregivers.

Objective

Few health systems have implemented systematic processes for identifying caregivers. This study aimed to develop and evaluate an EHR-driven process for identifying veterans likely to have unpaid caregivers in a caregiver survey study. We additionally examined whether there were EHR-derived veteran characteristics associated with veterans having unpaid caregivers.

Methods

We selected EHR home- and community-based referrals suggestive of veterans’ need for supportive care from friends or family. We identified veterans with these referrals across the 8 US Department of Veteran Affairs medical centers enrolled in our study. Phone calls to a subset of these veterans confirmed whether they had a caregiver, specifically an unpaid caregiver. We calculated the screening contact rate for unpaid caregivers of veterans using attempted phone screening and for those who completed phone screening. The veteran characteristics from the EHR were compared across referral and screening groups using descriptive statistics, and logistic regression was used to compare the likelihood of having an unpaid caregiver among veterans who completed phone screening.

Results

During the study period, our EHR-driven process identified 12,212 veterans with home- and community-based referrals; 2134 (17.47%) veteran households were called for phone screening. Among the 2134 veterans called, 1367 (64.06%) answered the call, and 813 (38.1%) veterans had a caregiver based on self-report of the veteran, their caregiver, or another person in the household. The unpaid caregiver identification rate was 38.1% and 59.5% among those with an attempted phone screening and completed phone screening, respectively. Veterans had increased odds of having an unpaid caregiver if they were married (adjusted odds ratio [OR] 2.69, 95% CI 1.68-4.34), had respite care (adjusted OR 2.17, 95% CI 1.41-3.41), or had adult day health care (adjusted OR 3.69, 95% CI 1.60-10.00). Veterans with a dementia diagnosis (adjusted OR 1.37, 95% CI 1.00-1.89) or veteran-directed care referral (adjusted OR 1.95, 95% CI 0.97-4.20) were also suggestive of an association with having an unpaid caregiver.

Conclusions

The EHR-driven process to identify veterans likely to have unpaid caregivers is systematic and resource intensive. Approximately 60% (813/1367) of veterans who were successfully screened had unpaid caregivers. In the absence of discrete fields in the EHR, our EHR-driven process can be used to identify unpaid caregivers; however, incorporating caregiver identification fields into the EHR would support a more efficient and systematic identification of caregivers.

Trial Registration

ClincalTrials.gov NCT03474380; https://clinicaltrials.gov/ct2/show/NCT03474380

Outcomes of rapid digital transformation of large-scale communications during the COVID-19 pandemic

Objective This study examined the content and impact of a new digital communication medium, called a VIDCAST, implemented at a large hospital and health service when the COVID-19 pandemic was announced, and the key concerns held by staff at the time when the health service was preparing for the COVID-19 pandemic to arrive in this health service. Methods A mixed-methods approach was used. Thematic analysis of 20 transcripts of daily VIDCASTS broadcast between 30 March and 24 April 2020 was undertaken, in addition to descriptive analysis of feedback from an anonymous online survey. Results Survey feedback from 322 staff indicated almost universal satisfaction with this new communication method. The VIDCASTS provided a new COVID-safe method for the Executive to connect to staff at a time of uncertainty. Thematic analysis of the content of the VIDCASTS revealed three themes: 'Accurate Information', 'Reassurance and Support' and 'Innovation'. The Executive was able to reassure staff about what the organisation was doing to safeguard the health and wellbeing of all, and enabled an effective response to the pandemic. Conclusions The digital communication channel of VIDCASTS, rapidly operationalised at a major Australian hospital and health service in March 2020, provided important information and support for staff as it prepared for the anticipated COVID-19 surge. What is known about the topic? When the COVID-19 pandemic began, traditional face-to-face staff meetings were disrupted and many hospitals and their staff were left scrambling for information, and for reassurance about their safety, as they prepared to receive increasing numbers of COVID-19 patients. What does this paper add? The implementation of a digital communication tool was able to address many of the concerns raised by hospital staff in other geographic locations dealing with surging COVID-19 cases and underpinned a globally leading COVID-19 response. What are the implications for practitioners? New digitised communication methods provided an effective vehicle to inform and support staff in the early stages of pandemic preparation.

INZ-701 Prevents Ectopic Tissue Calcification and Restores Bone Architecture and Growth in ENPP1-Deficient Mice

Ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) is the major enzyme that cleaves extracellular adenosine triphosphate (ATP) to generate pyrophosphate (PPi), an inorganic metabolite with potent anticalcification activity. Loss-of-function mutations cause hypopyrophosphatemia and lead to a state of ENPP1 deficiency, which has an acute infantile phase known as generalized arterial calcification of infancy (GACI) and a pediatric to adult phase known as autosomal-recessive hypophosphatemic rickets type 2 (ARHR2). ENPP1 deficiency manifests as ectopic calcification of multiple tissues, neointimal proliferation, premature mortality, impaired growth, and bone deformities. INZ-701, a human ENPP1-Fc protein, is in clinical development as an enzyme replacement therapy for the treatment of ENPP1 deficiency. The pharmacokinetic and pharmacodynamic profile and therapeutic effect of INZ-701 were investigated in Enpp1^asj/asj mice, a murine model of ENPP1 deficiency. Enpp1^asj/asj mice have undetectable plasma PPi, lower plasma phosphate, and higher FGF23 levels compared with wild-type (WT) mice. Enpp1^asj/asj mice on the acceleration diet, containing high phosphate and low magnesium, quickly develop clinical signs, including dehydration, rough hair coat, pinned ears, stiffed legs, and hunched back. Enpp1^asj/asj mice treated with vehicle had aforementioned clinical signs plus severe ectopic calcification in multiple tissues and bone defects, characteristics of the clinical phenotype observed in GACI and ARHR2 patients. Our results showed a durable PPi response for more than 3 days after a single dose of INZ-701. Treatment of ENPP1-deficient mice every other day with INZ-701 for 8 weeks restored circulating levels of PPi, prevented pathological calcification in all the tested organs, restored growth parameters, corrected bone defects, improved clinical signs, and decreased mortality in Enpp1^asj/asj mice, demonstrating the potential of INZ-701 to treat ENPP1 deficiency. © 2021 American Society for Bone and Mineral Research (ASBMR).

Accelerating Implementation of Virtual Care in an Integrated Health Care System: Future Research and Operations Priorities

BACKGROUND

Virtual care is critical to Veterans Health Administration (VHA) efforts to expand veterans' access to care. Health care policies such as the Veterans Access, Choice, and Accountability (CHOICE) Act and the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act impact how the VHA provides care. Research on ways to refine virtual care delivery models to meet the needs of veterans, clinicians, and VHA stakeholders is needed.

OBJECTIVE

Given the importance of virtual approaches for increasing access to high-quality VHA care, in December 2019, we convened a Think Tank, Accelerating Implementation of Virtual Care in VHA Practice, to consider challenges to virtual care research and practice across the VHA, discuss novel approaches to using and evaluating virtual care, assess perspectives on virtual care, and develop priorities to enhance virtual care in the VHA.

METHODS

We used a participatory approach to develop potential priorities for virtual care research and activities at the VHA. We refined these priorities through force-ranked prioritization and group discussion, and developed solutions for selected priorities.

RESULTS

Think Tank attendees (n = 18) consisted of VHA stakeholders, including operations partners (e.g., Office of Rural Health, Office of Nursing Services, Health Services Research and Development), clinicians (e.g., physicians, nurses, psychologists, physician assistants), and health services researchers. We identified an initial list of fifteen potential priorities and narrowed these down to four. The four priorities were (1) scaling evidence-based practices, (2) centralizing virtual care, (3) creating high-value care within the VHA with virtual care, and (4) identifying appropriate patients for virtual care.

CONCLUSION

Our Think Tank took an important step in setting a partnered research agenda to optimize the use of virtual care within the VHA. We brought together research and operations stakeholders and identified possibilities, partnerships, and potential solutions for virtual care.

Hemophagocytic Lymphohistiocytosis as the Initial Presentation of Subcutaneous Panniculitis-Like T-Cell Lymphoma: A Rare Case Responding to Cyclosporine A and Steroids

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a rare peripheral cytotoxic T-cell lymphoma, clinically resembling panniculitis. Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening syndrome of immune overactivation, triggered by underlying conditions. SPTCL presenting with HLH may represent a severe and rapidly progressive disease course. Currently, there is no standardized approach to treatment of HLH secondary to underlying SPTCL. A 34-year-old Asian male presented with a several months history of high fevers, weight loss, and nonpruritic purple discoloration of the skin. He had a skin biopsy showing atypical lymphohistiocytic panniculitis with dermal mucinosis and erythrophagocytosis consistent with SPTCL. The patient was initiated on treatment with dexamethasone and cyclosporine A. Almost immediate improvement of his skin lesions was noted and laboratory abnormalities trended toward baseline within 2 weeks. He noted complete symptom resolution after 3 months on therapy. SPTCL may be treated effectively with cyclosporine A and steroids to achieve rapid clinical and symptom management of this rare malignancy.

Development and Validation of a Method for Determination of Caffeine in Diuretic Tablets and Capsules by High-Performance Thin-Layer Chromatography on Silica Gel Plates with a Concentration Zone Using Manual Spotting and Ultraviolet Absorption Densitometry

A new quantitative method using silica gel high-performance thin-layer chromatography plates with channels and a concentration zone, manual application of standards and samples, development with methanol–ethyl acetate (15 + 85) mobile phase, and ultraviolet absorption densitometry is reported for the determination of caffeine in diuretic pharmaceutical preparations. Tablet and capsule products containing potassium salicylate, acetaminophen, and salicylamide as active ingredients were analyzed to test the applicability of the new method, and precision, accuracy, linearity, limits of detection and quantitation, and selectivity were validated. The milligrams of caffeine in each tablet ranged from 48.0 to 51.0, and the milligrams in each capsule from 37.9 to 40.3. Within-day precision was 1.48 and 1.78% (n = 6), and interday precision 0.723 and 1.26% (n = 5) for analysis of 2 tablets and 2 capsules, respectively. Accuracy validation of the tablet and capsule results produced errors of 1.0 and 1.9% for spiked blank analyses and 2.6 and 3.5% for standard addition analyses, respectively. A comparative study using a caffeine standard solution and a multicomponent analgesic tablet solution containing caffeine, acetaminophen, and acetylsalicylic acid showed that manual application on the concentration zone, instrumental application on the concentration zone, and instrumental application on the silica gel gave quite similar results in terms of number of theoretical plates, resolution, limit of detection, and linearity.

Adaptation and Implementation of a Family Caregiver Skills Training Program: From Single Site RCT to Multisite Pragmatic Intervention

PURPOSE

We describe an approach to rapidly adapt and implement an education and skills improvement intervention to address the needs of family caregivers of functionally impaired veterans-Helping Invested Families Improve Veterans' Experience Study (HI-FIVES).

DESIGN

Prior to implementation in eight sites, a multidisciplinary study team made systematic adaptations to the curriculum content and delivery process using input from the original randomized controlled trial (RCT); a stakeholder advisory board comprised of national experts in caregiver education, nursing, and implementation; and a veteran/caregiver engagement panel. To address site-specific implementation barriers in diverse settings, we applied the Replicating Effective Programs implementation framework.

FINDINGS

Adaptations to HI-FIVES content and delivery included identifying core/noncore curriculum components, reducing instruction time, and simplifying caregiver recruitment for clinical settings. To enhance curriculum flexibility and potential uptake, site personnel were able to choose which staff would deliver the intervention and whether to offer class sessions in person or remotely. Curriculum materials were standardized and packaged to reduce the time required for implementation and to promote fidelity to the intervention.

CONCLUSIONS

The emphasis on flexible intervention delivery and standardized materials has been identified as strengths of the adaptation process. Two key challenges have been identifying feasible impact measures and reaching eligible caregivers for intervention recruitment.

CLINICAL RELEVANCE

This systematic implementation process can be used to rapidly adapt an intervention to diverse clinical sites and contexts. Nursing professionals play a significant role in educating and supporting caregivers and care recipients and can take a leading role to implement interventions that address skills and unmet needs for caregivers.

Long-term effects of an early-life exposure of fathead minnows to sediments containing bitumen. Part I: Survival, deformities, and growth

The aim of this study was to investigate the long-term effects of a short exposure to natural sediments within the Athabasca oil sand formation to critical stages of embryo-larval development in fathead minnows (Pimephales promelas). Three different sediments were used: Ref sediment from the upper Steepbank River tested at 3 g/L (containing 12.2 ng/g ∑PAHs), and two bitumen-rich sediments tested at 1 and 3 g/L; one from the Ells River (Ells downstream, 6480 ng/g ∑PAHs) and one from the Steepbank River (Stp downstream, 4660 ng/g ∑PAHs). Eggs and larvae were exposed to sediments for 21 days, then transferred to clean water for a 5-month grow-out and recovery period. Larval fish had significantly decreased survival after exposure to 3 g/L sediment from Stp downstream, and decreased growth (length and weight at 16 days post hatch) in Ells and Stp downstream sediments at both 1 and 3 g/L. Decreased tail length was a sensitive endpoint in larval fish exposed to Ells and Stp downstream sediments for 21 days compared to Ref sediment. After the grow-out in clean water, all growth effects from the bitumen-containing sediments recovered, but adult fish from Stp downstream 3 g/L sediment had significant increases in jaw deformities. The study shows the potential for fish to recover from the decreased growth effects caused by sediments containing oil sands-related compounds, but that some effects of the early-life sediment exposure occur later on in adult fish.

Constraining the Neutron Star Compactness: Extraction of the ^{23}Al(p,γ) Reaction Rate for the rp Process

The ^{23}Al(p,γ)^{24}Si reaction is among the most important reactions driving the energy generation in type-I x-ray bursts. However, the present reaction-rate uncertainty limits constraints on neutron star properties that can be achieved with burst model-observation comparisons. Here, we present a novel technique for constraining this important reaction by combining the GRETINA array with the neutron detector LENDA coupled to the S800 spectrograph at the National Superconducting Cyclotron Laboratory. The ^{23}Al(d,n) reaction was used to populate the astrophysically important states in ^{24}Si. This enables a measurement in complete kinematics for extracting all relevant inputs necessary to calculate the reaction rate. For the first time, a predicted close-lying doublet of a 2_{2}^{+} and (4_{1}^{+},0_{2}^{+}) state in ^{24}Si was disentangled, finally resolving conflicting results from two previous measurements. Moreover, it was possible to extract spectroscopic factors using GRETINA and LENDA simultaneously. This new technique may be used to constrain other important reaction rates for various astrophysical scenarios.

Experiences of Kidney Transplant Recipients as Patient Navigators

BACKGROUND AND OBJECTIVE

The use of trained kidney transplant recipients as patient navigators resulted in increased completion of the steps in the transplant process by dialysis patients. We sought to understand the experiences of these patient navigators.

SETTING AND PARTICIPANTS

Six kidney transplant recipients were hired and employed by transplant centers in Ohio, Kentucky, and Indiana. The transplant navigators received formal training as peer educators, met with dialysis patients on a regular basis, and provided tailored education and assistance about transplantation to each patient. They worked closely with the pretransplant coordinators and social workers to learn the details of each patient's transplant work-up.

METHODOLOGY

We queried navigators using open-ended questions to learn about their experiences. Navigator responses were coded and common themes identified. A thematic auditor reviewed and refined the coding.

RESULTS

Two primary categories of themes emerged about the navigator experience: 1. practical comments that supported programmatic or implementation observations of the navigators, and 2. affective comments that reflected a shared experience among the navigators and patients. The navigators were able to fill voids in the transplant process that were not fulfilled by other caregivers. This was accomplished by a natural bond based upon a shared experience (of dialysis and kidney failure) between the navigator and the patient. The patient and navigator became experiential partners.

CONCLUSION

Kidney transplant recipients trained as patient navigators fill the role of a nontraditional medical provider, offer support during the transplant process, and provide an added benefit to complement routine dialysis and nephrology care.

A Standardized Donor Designation Ratio to Assess the Performance of Driver's License Agencies

Evaluating Department of Motor Vehicles (DMV) locations based on the percent of patrons who register as donors does not account for individual characteristics that may influence willingness to donate. We reviewed the driver's licenses of 2997 randomly selected patients at an urban medical system to obtain donor designation, age, gender, and DMV location and linked patient addresses with census tract data on race, ethnicity, income, and education. We then developed a Standardized Donor Designation Ratio (SDDR) (ie, the observed number of donors at each DMV divided by the expected number of donors based on patient demographic characteristics). Overall, 1355 (45%) patients were designated as donors. Donor designation was independently associated with younger age, female gender, nonblack race, and higher income. Across 18 DMVs, the proportion of patients who were donors ranged from 30% to 68% and SDDRs ranged from 0.82 to 1.17. Among the 6 facilities in the lowest tertile by SDDR, 3 were in the lowest tertile by percent donation. In conclusion, there is a great deal of variation across DMVs in rates of organ donor designation. SDDRs that adjust for DMV patron characteristics are distinct measures that may more accurately describe the performance of DMVs in promoting organ donation.

Assessing the delivery of alcohol screening and brief intervention in sexual health clinics in the north east of England

Background

Risky drinking is associated with risky sexual experiences, however the relationship between alcohol and sex is complex. The aim of the study was to assess the feasibility of delivering alcohol screening and brief interventions in genitourinary medicine (GUM) clinics. The objectives were to; understand the levels of alcohol use amongst patients; report on the number of alcohol interventions delivered; and to analyse the relationship between alcohol use with demographic data as well as diagnosed sexually transmitted infections (STIs) to see if there were any associations.

Methods

All new patients attending GUM between April 2012 and March 2013 self-completed the Alcohol Use Disorder Identification Test (AUDIT) prior to their clinical consultation. Where appropriate (scoring 8+ on AUDIT) the clinician would deliver up to 2–3 min of alcohol brief intervention. Descriptive statistics, t-tests, ANOVA and logistic regression were carried out as appropriate.

Results

AUDIT scores were available for 90% of all new patients (3058/3390) with an average mean score of 7.75. Of those who drank alcohol, 44% were categorised as being AUDIT positive, including 2% who had a score indicative of probable alcohol dependence (20+). 55 % (n = 638) of patients who screened positive on the AUDIT received a brief intervention whilst 24% (n = 674) of drinkers were diagnosed with a STI. Logistic regression modelling revealed that males, younger age groups and those of ‘white’ ethnicity were more likely to score positive on AUDIT. Patients classified as non-students, living in deprivation quintiles one to four and categorised as probable alcohol dependence on the AUDIT were more likely to be diagnosed with an STI.

Conclusion

It is possible to embed alcohol screening into routine practice within sexual health services however further work is required to embed brief interventions particularly amongst increasing risk drinkers. If resources are limited, services may consider more targeted rather than universal alcohol screening to specific population groups. The study was undertaken in one GUM service in the North East of England and therefore findings may not be generalizable. The study did not assess efficacy of alcohol brief intervention in this setting.

Observation of the Isovector Giant Monopole Resonance via the ^{28}Si(^{10}Be,^{10}B^{*}[1.74 MeV]) Reaction at 100 AMeV

The (^{10}Be,^{10}B^{*}[1.74  MeV]) charge-exchange reaction at 100  AMeV is presented as a new probe for isolating the isovector (ΔT=1) nonspin-transfer (ΔS=0) response of nuclei, with ^{28}Si being the first nucleus studied. By using a secondary ^{10}Be beam produced by fast fragmentation of ^{18}O nuclei at the NSCL Coupled Cyclotron Facility, applying the dispersion-matching technique with the S800 magnetic spectrometer to determine the excitation energy in ^{28}Al, and performing high-resolution γ-ray tracking with the Gamma-Ray Energy Tracking In-beam Nuclear Array (GRETINA) to identify the 1022-keV γ ray associated with the decay from the 1.74-MeV T=1 isobaric analog state in ^{10}B, a ΔS=0 excitation-energy spectrum in ^{28}Al was extracted. Monopole and dipole contributions were determined through a multipole-decomposition analysis, and the isovector giant dipole resonance and isovector giant monopole resonance (IVGMR) were identified. The results show that this probe is a powerful tool for studying the elusive IVGMR, which is of interest for performing stringent tests of modern density functional theories at high excitation energies and for constraining the bulk properties of nuclei and nuclear matter. The extracted distributions were compared with theoretical calculations based on the normal-modes formalism and the proton-neutron relativistic time-blocking approximation. Calculated cross sections based on these strengths underestimate the data by about a factor of 2, which likely indicates deficiencies in the reaction calculations based on the distorted wave Born approximation.

Is Signature Size Associated With Organ Donor Designation on Driver's Licenses?

INTRODUCTION

Previous studies suggest that large signature size is associated with narcissistic characteristics. By contrast, organ donation is an indicator of altruism. Because altruism and narcissism may be viewed as opposites, we sought to determine if smaller signature size is associated with willingness to be an organ donor.

METHODS

Using a cross-sectional study design, we reviewed the health records of 571 randomly selected primary care patients at a large urban safety-net medical system to obtain their demographic and medical characteristics. We also examined driver's licenses that were scanned into electronic health records as part of the patient registration process. We measured signature sizes and obtained the organ donor designation from these driver's licenses.

RESULTS

Overall, 256 (45%) patients were designated as donors on their driver's licenses. Signature size averaged 113.3 mm(2) but varied greatly across patients (10th percentile 49.1 mm(2), 90th percentile 226.1 mm(2)). On multivariate analysis, donor designation was positively associated with age 18-34 years, non-black race, having private insurance, and not having any comorbid conditions. However, signature size was not associated with organ donor designation.

CONCLUSIONS

Signature size is not associated with verified organ donor designation. Further work is needed to understand the relationship between personality types and willingness to be an organ donor.

Elevated carbon dioxide has limited acute effects on Lepomis macrochirus behaviour

The current study investigated the behavioural response of Lepomis macrochirus following exposures to elevated carbon dioxide (CO₂ ). For this, L. macrochirus were held at ambient pCO₂ (160 μatm pCO₂ ) for 7 days, then exposed to elevated pCO₂ (8300 μatm pCO₂ ) for 5 days, and then returned to ambient conditions for a further 5 days to recover. At the end of each exposure period, several behavioural metrics were quantified (boldness, lateralization and activity). Data showed no change in lateralization and most metrics associated with performance and boldness. During the boldness test, however, average velocity, velocity in the thigmotaxis (outer) zone and proportion of activity in the thigmotaxis zone increased with pCO₂ exposure. During post-exposure, average velocity of L. macrochirus decreased. In addition, individual rank was repeatable during the pre-exposure and post-exposure period in three of the 17 metrics investigated (average velocity in the middle zone, average velocity near object and total shuttles to the object zone), but not during the CO₂ exposure period, suggesting that elevated pCO₂ disrupted some behavioural performances. Overall, this study found elevated pCO₂ caused disruption to behaviours of freshwater fishes such as L. macrochirus and effects do not appear to be as serious as has been shown for marine fishes.

Infectious disease models in zebrafish

In recent years, the zebrafish (Danio rerio) has developed as an important alternative to mammalian models for the study of hostpathogen interactions. Because they lack a functional adaptive immune response during the first 4-6weeks of development, zebrafish rely upon innate immune responses to protect against injuries and infections. During this early period of development, it is possible to isolate and study mechanisms of infection and inflammation arising from the innate immune response without the complications presented by the adaptive immune response. Zebrafish possess several inherent characteristics that make them an attractive option to study hostpathogen interactions, including extensive sequence and functional conservation with the human genome, optical clarity in larvae that facilitates the high-resolution visualization of host cell-microbe interactions, a fully sequenced and annotated genome, robust forward and reverse genetic tools and techniques (e.g., CRISPR-Cas9 and TALENs), and amenability to chemical studies and screens. Here, we describe methods for studying hostpathogen interactions both through systemic infections and through localized infections that allow analysis of host cell response, migration patterns, and behavior. Each of the methods described can be modified for use in downstream applications that include ecotoxicant studies and chemical screens.

Expression and Perception of Nonverbal Cues to Mood in Parkinson’s Disease

Date Presented 4/8/2016

Findings show people with Parkinson’s disease (PD) do not display many cues to their mood, and raters tend to use more expressive cues in making judgments than were valid. Findings emphasize a need to help clients with PD produce verbal and nonverbal cues that can be accurately interpreted by others.

Primary Author and Speaker: Sarah Gunnery

Additional Authors and Speakers: Rachel Henige, Caitlin Sullivan, Sophia Hur, Shu-Mei Wang, Tondalaya Brainard, Jenna Eldridge, Linda Tickle-Degnen

Awareness With Recall: A Systematic Review

This article provides a systematic review of awareness with recall, also called intraoperative awareness. Major topics of this review include the incidence and causes of this phenomenon, in addition to an examination of current strategies for prevention of intraoperative awareness. Awareness with recall creates substantial physical and/or psychological distress for the patient, representing a continued threat to patient safety. Factors related to cases of awareness include those of the patient, surgical procedure, anesthesia provider, and system in which providers deliver care. Anesthesia providers today consider use of electroencephalographic depth-of-anesthesia monitors such as the bispectral index monitor (BIS, Covidien, now Medtronic), as a potential tool for preventing awareness. This Journal course explores evidence related to the utility and limitations of this monitor in clinical practice. It also reviews evidence-based practices that may decrease the incidence of awareness with recall, including avoidance of muscle relaxants and protocol-driven approaches to awareness prevention.

Evolution and functional significance of derived sternal ossification patterns in ornithothoracine birds

The midline pattern of sternal ossification characteristic of the Cretaceous enantiornithine birds is unique among the Ornithodira, the group containing birds, nonavian dinosaurs and pterosaurs. This has been suggested to indicate that Enantiornithes is not the sister group of Ornithuromorpha, the clade that includes living birds and their close relatives, which would imply rampant convergence in many nonsternal features between enantiornithines and ornithuromorphs. However, detailed comparisons reveal greater similarity between neornithine (i.e. crown group bird) and enantiornithine modes of sternal ossification than previously recognized. Furthermore, a new subadult enantiornithine specimen demonstrates that sternal ossification followed a more typically ornithodiran pattern in basal members of the clade. This new specimen, referable to the Pengornithidae, indicates that the unique ossification pattern observed in other juvenile enantiornithines is derived within Enantiornithes. A similar but clearly distinct pattern appears to have evolved in parallel in the ornithuromorph lineage. The atypical mode of sternal ossification in some derived enantiornithines should be regarded as an autapomorphic condition rather than an indication that enantiornithines are not close relatives of ornithuromorphs. Based on what is known about molecular mechanisms for morphogenesis and the possible selective advantages, the parallel shifts to midline ossification that took place in derived enantiornithines and living neognathous birds appear to have been related to the development of a large ventral keel, which is only present in ornithuromorphs and enantiornithines. Midline ossification can serve to medially reinforce the sternum at a relatively early ontogenetic stage, which would have been especially beneficial during the protracted development of the superprecocial Cretaceous enantiornithines.

β+ Gamow-Teller transition strengths from 46Ti and stellar electron-capture rates

The Gamow-Teller strength in the β(+) direction to (46)Sc was extracted via the (46)Ti(t,(3)He + γ) reaction at 115  MeV/u. The γ-ray coincidences served to precisely measure the very weak Gamow-Teller transition to a final state at 991 keV. Although this transition is weak, it is crucial for accurately estimating electron-capture rates in astrophysical scenarios with relatively low stellar densities and temperatures, such as presupernova stellar evolution. Shell-model calculations with different effective interactions in the pf shell-model space do not reproduce the experimental Gamow-Teller strengths, which is likely due to sd-shell admixtures. Calculations in the quasiparticle random phase approximation that are often used in astrophysical simulations also fail to reproduce the experimental Gamow-Teller strength distribution, leading to strongly overestimated electron-capture rates. Because reliable theoretical predictions of Gamow-Teller strengths are important for providing astrophysical electron-capture reaction rates for a broad set of nuclei in the lower pf shell, we conclude that further theoretical improvements are required to match astrophysical needs.

PP162. sFlt-1 controlled by CPAP in a pregnant patient with chronic hypertension

INTRODUCTION

Preeclampsia is recognised as the leading cause of perinatal mortality and morbidity worldwide. Interest has been increasing recently as to the possible impact of sleep disordered breathing (SDB) on the mechanisms of preeclampsia, possibly by augmenting placental hypoxia during sleep. A biomarker of preeclampsia, sFlt-1, has also come to prominence in recent years and is postulated to be a good predictor of preeclampsia as well as a strong indicator of the severity of the disease.

OBJECTIVES

The aim of this study was to investigate the effect of CPAP treatment for SDB on sFlt-1 concentrations during pregnancy.

METHODS

Patients were recruited from the outpatients' clinic in Campbelltown Hospital, Campbelltown, NSW in the first half of 2011. The levels of sFlt-1 in four pregnant women, with or without hypertensive disorders of pregnancy, and with or without SDB were measured using ELISA.

RESULTS

Women with SDB and chronic hypertension or preeclampsia had higher levels of sFlt-1 and a greater percentage increase of this marker, and CPAP treatment appeared to attenuate the rise of sFlt-1 as shown in the table below.

CONCLUSION

Elevated sFlt-1 was associated with untreated SDB in those with chronic hypertension. This study provides feasibility for a larger scale study to occur, to further examine the validity of the hypothesis that CPAP treatment has a beneficial effect on sFLt-1 levels and therefore, may lower the risk and severity of preeclampsia.

PP154. Relationship between recorded and reported snoring during pregnancy: Objective measurement versus questionnaire responses

INTRODUCTION

Snoring is a common symptom of sleep disordered breathing (SDB), a condition that is present in 4% of the general population. SDB is identified by snoring and repetitive cessation of breathing during sleep accompanied by repetitive hypoxia and has been found to be associated with hypertension, stroke and heart attack. There is not depth of knowledge examining the association between SDB and pregnancy outcomes.

OBJECTIVES

To examine the prevalence of self reported snoring in pregnancy and the potential association between self reported snoring and the development of Hypertensive Disorders of Pregnancy (HDP) within a larger cohort from a prevalence of SDB in pregnancy study.

METHODS

Questionnaires were administered to pregnant women attending an outpatient's antenatal clinic. The self reported snoring is a component of the Epworth scale. Pregnancy progression and outcome data were collected on all participants and analyse by IBM SPSS v.20™ utilising Chi-square analysis, Student T test and logistic regression analysis. HDP diagnoses were in alignment with the SOMANZ (2009) diagnostic criteria.

RESULTS

Questionnaires were administered and outcomes collected on 2023 pregnancies. Snoring was reported by 49.2% of women. HDP affected 10.1% of the cohort, 3.3% of whom were preeclamptic. Of the pregnancies affected by HDP self reported snoring occurred in 57.7% in comparison to 43.3% who do not report snoring (p<0.001).

CONCLUSION

This would indicate that there is an association between self reported snoring and the development of HDP. Further analysis will be undertaken to model the effect of other potential risk factors such as maternal age, parity, pre-pregnancy BMI and other co morbidities.