Effects of free versus restricted arm movements on postural control in normal and modified sensory conditions in young and older adults

The purpose of this study was to explore the effects of arm movements on postural control when standing under different sensory conditions in healthy young and older adults. Fifteen young (mean ± SD age; 21.3 ± 4.2 years) and 15 older (mean ± SD age; 73.3 ± 5.0 years) adults completed the modified Romberg test, which uses four task manipulations (i.e. eyes open and eyes closed on a firm and foam surface) to compromise the fidelity of sensory feedback mechanisms. Each participant completed the tasks under two arm movement conditions: restricted and free arm movements. Centre of pressure (COP) range and frequency were calculated to characterise postural performance and strategy, respectively. Older adults showed greater COP range with restricted compared to free arm movements during all modified sensory conditions, with these effects most prominent in the medio-lateral (ML) plane (all p < .05, Cohen's d = 0.69-1.61). Compared to the free arm movement condition, there was an increase in ML displacement and frequency when arm movements were restricted during only the most challenging (i.e. vestibular dominant) task in young adults (all p < .05, d = 0.645-0.83). Finally, main age effects for the arm restriction cost (p < .05) indicates a greater reliance on an upper body strategy in older compared to young adults, independent of sensory availability/accuracy. These findings indicate that older adults compensate for the loss of accuracy in sensory input by increasing reliance on upper body movement strategies.

Implementing a cirrhosis order set in a tertiary healthcare system: a theory-informed formative evaluation

BACKGROUND

Standardized order sets are a means of increasing adherence to clinical practice guidelines and improving the quality of patient care. Implementation of novel quality improvement initiatives like order sets can be challenging. Before the COVID-19 pandemic, we conducted a formative evaluation to understand healthcare providers' perspectives on implementing clinical changes and the individual, collective and organizational contextual factors that might impact implementation at eight hospital sites in Alberta, Canada.

METHODS

We utilized concepts from the Consolidated Framework for Implementation Research (CFIR) and Normalisation Process Theory (NPT) to understand the context, past implementation experiences, and perceptions of the cirrhosis order set. Eight focus groups were held with healthcare professionals caring for patients with cirrhosis. Data were coded deductively using relevant constructs of NPT and CFIR. A total of 54 healthcare professionals, including physicians, nurses, nurse practitioners, social workers and pharmacists and a physiotherapist, participated in the focus groups.

RESULTS

Key findings revealed that participants recognized the value of the cirrhosis order set and its potential to improve the quality of care. Participants highlighted potential implementation challenges, including multiple competing quality improvement initiatives, feelings of burnout, lack of communication between healthcare provider groups, and a lack of dedicated resources to support implementation.

CONCLUSIONS

Implementing a complex improvement initiative across clinician groups and acute care sites presents challenges. This work yielded insights into the significant influence of past implementation of similar interventions and highlighted the importance of communication between clinician groups and resources to support implementation. However, by using multiple theoretical lenses to illuminate what and how contextual and social processes will influence uptake, we can better anticipate challenges during the implementation process.

Exploring how arm movement moderates the effect of task difficulty on balance performance in young and older adults

Emerging evidence highlights that arm movements exert a substantial and functionally relevant contribution on quiet standing balance control in young adults. Ageing is associated with "non-functional" compensatory postural control strategies (i.e., lower limb co-contraction), which in turn, may increase the reliance on an upper body strategy to control upright stance. Thus, the primary purpose of this study was to compare the effects of free versus restricted arm movements on balance performance in young and older adults, during tasks of different difficulty. Fifteen young (mean ± SD age; 21.3 ± 4.2 years) and fifteen older (mean ± SD age; 73.3 ± 5.0 years) adults performed bipedal, semi-tandem and tandem balance tasks under two arm position conditions: restricted arm movements and free arm movements. Centre of pressure (COP) amplitude and frequency were calculated as indices of postural performance and strategy, respectively. Especially in older adults, restriction of arm movement resulted in increased sway amplitude and frequency, which was primarily observed for the mediolateral direction. Further, increasing balance task difficulty raised the arm restriction cost (ARC; a new measure to quantify free vs. restricted arm movement differences in postural control) that was more prominent in older adults. These findings indicate the ARC provides a measure of reliance on the upper body for balance control and that arm movement is important for postural control in older adults, especially during tasks of greater difficulty.

A64 THE UPTAKE AND IMPACT OF AN ELECTRONIC CIRRHOSIS ADMISSION ORDER SET: AN EARLY EXPERIENCE AT A SINGLE CENTRE

Background

Cirrhosis is a chronic disease that confers high morbidity and mortality. It is a leading cause for hospital admissions and leads to significant healthcare resource utilization. Several guidelines outline recommendations to provide best practice to hospitalized patients with cirrhosis. Despite studies supporting a reduction in mortality when guideline based care is followed, this is achieved in less than 50% of hospitalized patients with cirrhosis¹. Standardized electronic order sets can be a potential tool to improving clinical outcomes and bridging this gap in care.

Purpose

Since March 2021, an electronic cirrhosis admission order set has been available for at our hospital site. Using administrative data, we aimed to describe our early experience with: a) order set uptake by various services, b) characteristics of the population in which the order set was used versus not used, and explore c) the impact of order set use on in-hospital mortality.

Method

In this single centre cohort study, patients with cirrhosis were identified based an administrative data algorithm containing codes for cirrhosis and complications. This data was used to retrieve parameters such as patient age, sex, primary admitting service, resource intensity weight (RIW), Charlson comorbidity index (CCI) and in-hospital mortality. The chi-squared test and independent samples t-test were used to compare characteristics of patients in whom the order set was used versus not used. Multivariable logistic regression was used to determine the impact of order set use on in-hospital mortality. P value significance was established at <0.05.

Result(s)

A total of 825 patients were included in the analysis. The overall mean age (standard deviation) of patients was 58.5 (14.2) years with 57.5% being male. Average length of stay was 11.3 days with a mean CCI of 3.2 (2.3) and RIW of 3.3 (7.2). The primary admitting service was Gastroenterology in 36.1%, Internal Medicine in 35.6% and other services in 28.3% of cases. Of those admitted, the order set was used in 27.2% of cases. The overall in-hospital mortality of patients was 14.2%.

Mean age, sex and CCI were not significantly different in patients admitted with the order set versus without. In patients admitted with the order set compared to without, RIW was significantly lower (2.06 (2.62) versus 3.80 (8.2), p<0.001), as was length of stay (9.5 (11.8) days compared to 12.0 (18.6) days, p =0.03) and in-hospital mortality (8.5% versus 16.3%, p =0.003). On multivariable regression analysis (Table 1), after adjustment for age, RIW and CCI, use of the order set was associated with lower in-hospital mortality (odds ratio 0.53 (95% CI 0.3 to 0.9), p=0.02).

Image

Conclusion(s)

Uptake of the electronic cirrhosis admission order set was modest at only 27% of eligible admissions. Although it appears to be associated with lower in-hospital mortality, a chart review is in process to assess if this association still holds after accounting for the impact of additional confounders.

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Disclosure of Interest

None Declared

1215 IMPROVING THE QUALITY OF ANTICIPATORY CARE PLANNING FOR PATIENTS WITH RECURRENT ASPIRATION PNEUMONIA

Introduction

Recurrent episodes of aspiration pneumonia (RAP) are a significant problem in frail patients leading to high re-hospitalization and mortality. Anticipatory care planning (ACP) enables improved quality of life and end of life care. We reviewed the assessment, ACP discussions and communication with Primary Care in these patients.

Methods

We used a PDSA methodology, reviewing 116 patients with RAP referred to Speech and Language Therapy (SLT) in Elderly Medicine wards over six months, including the winter. Educational interventions were implemented. An illustrative case and pre-intervention results were presented at an online hospital-wide seminar and subsequently at an online departmental medical staff teaching session. Post-intervention analysis of 10 patients with RAP admitted over two summer months was conducted. The second round of interventions included departmental induction teaching for newly rotated doctors and creating an electronic ACP document (RAP ACP) for inclusion within the medical record.

Results

Baseline data was collected from 116 patients (mean age 85, 47% female). After the educational interventions, data was collected from 10 patients (mean age 88, 70% female). Data is being collected from winter months after the second intervention. This will be available before the conference. Baseline data demonstrated the need for improvements in documentation of Mental Capacity Assessment (MCA) specific to feeding (21.5%), ACP completion (26.7%) and flagging patients suitable for the Gold Standards Framework (GSF) on discharge (15%). Following educational interventions, there was a substantial improvement in MCA documentation (80%). Furthermore, there was a marked improvement in the completion of ACP discussions (70%). Communication of patients eligible for GSF was similar (14.2%) post-intervention.

Conclusions

Educational interventions substantially improved the quality of individualised care provided to patients with RAP. Mortality was high in both groups, yet documentation of eligibility for GSF was low, prompting further interventions targeting discharge communication.

Practitioner and digitally delivered interventions for reducing hazardous and harmful alcohol consumption in people not seeking alcohol treatment: a systematic review and network meta-analysis

AIM

To compare the effectiveness of practitioner versus digitally delivered interventions for reducing hazardous and harmful alcohol consumption.

DESIGN

Systematic review and network meta-analysis comprising comprehensive search for randomised controlled trials, robust screening and selection methods and appraisal with the Cochrane Risk of Bias tool. Network meta-analyses were conducted in Stata using random effects, frequentist models. The confidence in network meta-analysis (CINeMA) tool was used to assess confidence in effect sizes.

SETTING

Online or community or health settings where the intervention was immediately accessible without referral.

PARTICIPANTS

Non treatment-seeking hazardous or harmful drinkers.

MEASUREMENTS

Primary outcome was mean difference in alcohol consumption (g/wk); secondary outcome was number of single high intensity drinking episodes. Baseline consumption was analysed as a covariate.

FINDINGS

Of 201 included trials (94 753 participants), 152 reported a consumption outcome that could be converted to grams/week; 104 reported number of single high intensity drinking episodes. At 1 and 6 months, practitioner delivered interventions reduced consumption more than digitally delivered interventions (1 month: -23 g/wk (95% CI, -43 to -2); 6 months: -14 g/wk [95% CI, -25 to -3]). At 12 months there was no evidence of difference between practitioner and digitally delivered interventions (-6 g/wk [95% CI, -24 to 12]). There was no evidence of a difference in single high intensity drinking episodes between practitioner and digitally delivered interventions at any time point. Effect sizes were small, but could impact across a population with relatively high prevalence of hazardous and harmful drinking. Heterogeneity was a concern. Some inconsistency was indicated at 1 and 6 months, but little evidence was apparent at 12 months.

CONCLUSION

Practitioner delivered interventions for reducing hazardous and harmful alcohol consumption are more effective than digitally delivered interventions up to 6 months; at 12 months there is no evidence of a difference.

Oral nutritional interventions in frail older people who are malnourished or at risk of malnutrition: a systematic review

BACKGROUND

Malnutrition worsens the health of frail older adults. Current treatments for malnutrition may include prescribed oral nutritional supplements, which are multinutrient products containing macronutrients and micronutrients.

OBJECTIVE

To assess the effectiveness and cost-effectiveness of oral nutritional supplements (with or without other dietary interventions) in frail older people who are malnourished or at risk of malnutrition.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Library, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and grey literature were searched from inception to 13 September 2021.

REVIEW METHODS

A systematic review and meta-analysis was conducted to evaluate the effectiveness and cost-effectiveness of oral nutritional supplements in frail older people (aged ≥ 65 years) who are malnourished or at risk of malnutrition (defined as undernutrition as per National Institute for Health and Care Excellence guidelines). Meta-analysis and network meta-analysis were undertaken, where feasible, along with a narrative synthesis. A cost-effectiveness review was reported narratively. A de novo model was developed using effectiveness evidence identified in the systematic review to estimate the cost-effectiveness of oral nutritional supplements.

RESULTS

Eleven studies (n = 822 participants) were included in the effectiveness review, six of which were fully or partly funded by industry. Meta-analyses suggested positive effects of oral nutritional supplements compared with standard care for energy intake (kcal) (standardised mean difference 1.02, 95% confidence interval 0.15 to 1.88; very low quality evidence) and poor mobility (mean difference 0.03, p < 0.00001, 95% confidence interval 0.02 to 0.04; very low quality evidence) but no evidence of an effect for body weight (mean difference 1.31, 95% confidence interval -0.05 to 2.66; very low quality evidence) and body mass index (mean difference 0.54, 95% confidence interval -0.03 to 1.11; very low quality evidence). Pooled results for other outcomes were statistically non-significant. There was mixed narrative evidence regarding the effect of oral nutritional supplements on quality of life. Network meta-analysis could be conducted only for body weight and grip strength; there was evidence of an effect for oral nutritional supplements compared with standard care for body weight only. Study quality was mixed; the randomisation method was typically poorly reported. One economic evaluation, in a care home setting, was included. This was a well-conducted study showing that oral nutritional supplements could be cost-effective. Cost-effectiveness analysis suggested that oral nutritional supplements may only be cost-effective for people with lower body mass index (< 21 kg/m2) using cheaper oral nutritional supplements products that require minimal staff time to administer.

LIMITATIONS

The review scope was narrow in focus as few primary studies used frailty measures (or our proxy criteria). This resulted in only 11 included studies. The small evidence base and varied quality of evidence meant that it was not possible to determine accurate estimates of the effectiveness or cost-effectiveness of oral nutritional supplements. Furthermore, only English-language publications were considered.

CONCLUSIONS

Overall, the review found little evidence of oral nutritional supplements having significant effects on reducing malnutrition or its adverse outcomes in frail older adults.

FUTURE WORK

Future research should focus on independent, high-quality, adequately powered studies to investigate oral nutritional supplements alongside other nutritional interventions, with longer-term follow-up and detailed analysis of determinants, intervention components and cost-effectiveness.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42020170906.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 51. See the NIHR Journals Library website for further project information.

146 GOLD STANDARD GOAL-SETTING: ARE WE HITTING THE MARK? IMPLEMENTING AN INTERDISCIPLINARY GOAL-SETTING PATHWAY IN STROKE REHABILITATION

Background

The cornerstone of rehabilitation is effective and realistic interdisciplinary goal-setting with patient and family engagement across the continuum of recovery. The Royal College of Physicians National Clinical Guidelines for Stroke (2016) highlights the importance of encouraging self-management and self-efficacy to support a more person-orientated approach. This quality improvement initiative aimed to introduce a structured interdisciplinary goal-setting pathway on a post-acute 14-bed stroke unit.

Methods

An interdisciplinary working group was established comprising of Physiotherapy, Occupational Therapy, Speech & Language Therapy, Medical Social Work and Nursing. Quality improvement methodology was used to sequentially implement change over a 6-month period. The restructure included the introduction of an initial and review goal-focused family meeting. An interdisciplinary tool was developed based on the East Kent Outcome System (EKOS). A series of workshops was delivered to support implementation.

Results

An interdisciplinary goal-setting pathway is currently being piloted for 6 months on the stroke unit. To date, 22 staff have been trained and 9 patients have progressed through the updated pathway. Analysis has provided useful clinical insights and qualitative feedback has been collated regarding the benefits of the early opportunity to meet the team, establishing patient’s personal goal priorities and clear timeframes.Furthermore, repeat trials followed by reflections have enabled the team to develop consistency and confidence in person-centred, interdisciplinary goal-setting. It is acknowledged that this initiative has been a significant change process for the team and that adjustments are being made, in line with the principles of quality improvement.

Conclusion

This person-orientated interdisciplinary process is evidence-based and in line with national standards and guidelines for stroke rehabilitation. Formal training in EKOS is planned and a clinical audit will follow the pilot phase to systematically evaluate the change in practice.

Effectiveness and cost-effectiveness of oral nutritional supplements in frail older people who are malnourished or at risk of malnutrition: a systematic review and meta-analysis

BACKGROUND

Current management of malnutrition can include prescribed oral nutritional supplements (ONS); however, there is uncertainty whether these supplements are effective in people who are older (≥65 years) and frail. We assessed the effectiveness, cost-effectiveness, and adherence and acceptability of ONS in frail older people who are malnourished or at risk of malnutrition.

METHODS

In this systematic review and meta-analysis, five bibliographic databases (MEDLINE, EMBASE, Cochrane Library, Scopus, and CINAHL) and grey literature sources were searched from inception to Sept 13, 2021, to identify studies assessing the effectiveness and cost-effectiveness of ONS (with or without other dietary interventions) in frail older people who are malnourished or at risk of malnutrition. Multiple reviewers independently did study screening, data extraction, and risk of bias assessment. Quality was assessed using version 1.0 of the Cochrane risk of bias tool for randomised controlled trials (RCTs), and the BMJ Drummond checklist was used to assess the quality of the included cost-effectiveness study. A meta-analysis was done for the effectiveness review; for the other reviews, a narrative synthesis approach was used. This systematic review and meta-analysis was registered on PROSPERO, CRD42020170906.

FINDINGS

Of 8492 records retrieved and screened, we included 11 RCTs involving 822 participants, six of which were fully or partly funded by industry. For the majority of the outcomes for which meta-analyses were possible (11/12), Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) assessments suggested that the evidence was of very low certainty. Results suggested that ONS might have a slightly positive effect on energy (kcal) intake (standardised mean difference 1·02 [95% CI 0·15 to 1·88]; I²=87%; four studies), protein intake (standardised mean difference 1·67 [-0·03 to 3·37; I²=97%; four studies), and mobility (mean difference 0·03 [0·02 to 0·04]; I²=0%; four studies), compared with standard care. Narrative syntheses suggested that the effect of ONS on quality of life, compared with standard care, was mixed. In the identified studies, there was very little information related to active components, determinants, or acceptability of interventions. One economic evaluation, done in a care home setting, showed that ONS could be cost-effective.

INTERPRETATION

We found little evidence of ONS reducing malnutrition or its associated adverse outcomes in older people who are frail. High-quality, non-industry-funded, adequately powered studies reporting on short-term and long-term health outcomes, determinants, and participant characteristics are needed.

FUNDING

UK National Institute of Health and Care Research (NIHR) Health Technology Assessment (NIHR128729).

Residual disease after primary surgery for advanced epithelial ovarian cancer: expert elicitation exercise to explore opinions about potential impact of publication bias in a planned systematic review and meta-analysis

OBJECTIVES

We consider expert opinion and its incorporation into a planned meta-analysis as a way of adjusting for anticipated publication bias. We conduct an elicitation exercise among eligible British Gynaecological Cancer Society (BGCS) members with expertise in gynaecology.

DESIGN

Expert elicitation exercise.

SETTING

BGCS.

PARTICIPANTS

Members of the BGCS with expertise in gynaecology.

METHODS

Experts were presented with details of a planned prospective systematic review and meta-analysis, assessing overall survival for the extent of excision of residual disease (RD) after primary surgery for advanced epithelial ovarian cancer. Participants were asked views on the likelihood of different studies (varied in the size of the study population and the RD thresholds being compared) not being published. Descriptive statistics were produced and opinions on total number of missing studies by sample size and magnitude of effect size estimated.

RESULTS

Eighteen expert respondents were included. Responders perceived publication bias to be a possibility for comparisons of RD <1 cm versus RD=0 cm, but more so for comparisons involving higher volume suboptimal RD thresholds. However, experts' perceived publication bias in comparisons of RD=0 cm versus suboptimal RD thresholds did not translate into many elicited missing studies in Part B of the elicitation exercise. The median number of missing studies estimated by responders for the main comparison of RD<1 cm versus RD=0 cm was 10 (IQR: 5-20), with the number of missing studies influenced by whether the effect size was equivocal. The median number of missing studies estimated for suboptimal RD versus RD=0 cm was lower.

CONCLUSIONS

The results may raise awareness that a degree of scepticism is needed when reviewing studies comparing RD <1 cm versus RD=0 cm. There is also a belief among respondents that comparisons involving RD=0 cm and suboptimal thresholds (>1 cm) are likely to be impacted by publication bias, but this is unlikely to attenuate effect estimates in meta-analyses.

462 - Renforcement des capacités des acteurs de riposte de la COVID-19 en Afrique de l'Ouest - Expérience de l'Organisation Ouest Africaine de la Santé (OOAS)

Contexte

En mars 2020, l'avènement de la pandémie COVID-19 et les mesures de restriction mises en place afin de la contenir limitaient l'organisation des formations physiques. Le besoin de mise à jour des connaissances, compétences et pratiques des agents de riposte des pays de l'Afrique de l'Ouest a conduit l'Organisation Ouest Africaine de la Santé, à mettre en place un programme de formations en ligne au profit des acteurs de riposte de l'Afrique de l'Ouest.

Méthodes

Il s'est agit de la revue des rapports des formations organisées et des expériences vécues par les organisateurs de ces formations. Cette revue a pris en compte les résultats des pré et post-test qui étaient réalisées au cours de la formation.

Résultats

De mars à juillet 2020, 33 formations ont été organisées dans les trois langues officielles de l'Afrique de l'Ouest (17 francophones, 14 anglophones et 02 lusophones). Les formations ont couvert l’épidémiologie/surveillance, le diagnostic du laboratoire, la prise en charge des cas, la communication sur les risques, la prévention et du contrôle infections. Le contenu des formations était basé sur les guides internationaux édités et les formateurs étaient des experts expérimentés. Les bénéficiaires au nombre de 3241, venaient de tous les niveaux du système de santé et étaient des médecins, des infirmiers, des aides-soignants, des biologistes, des hygiénistes, des communicateurs et acteurs de la surveillance. Les évaluations pré et post test ont permis de noter l'amélioration dans l'acquisition des connaissances dans 92 % des cas des formations.

Discussions/Conclusion

Cette expérience, qui était une innovation en Afrique de l'Ouest, a contribué à la mise à niveau des acteurs. Les leçons tirées vont aider au développement du programme de renforcement continu des capacités professionnelles en Afrique de l'Ouest.

Déclaration de liens d'intérêts

Les auteurs déclarent ne pas avoir de liens d'intérêts.

Representation of Racial and Ethnic Minority Populations in Dementia Prevention Trials: A Systematic Review

Despite older racial and ethnic minorities (REMs) being more likely to develop dementia they are underrepresented in clinical trials focused on neurological disorders. Inclusion of REMs in dementia prevention studies is vital to reducing the impact of disparities in dementia risk. We conducted a systematic review to characterize the number of REM enrolled in brain health and prevention randomized controlled trials (RCTs). RTCs published from January 1, 2004 to April 21, 2020 were included. Participants were normal cognitive adults aged 45 years and older who participated in a Phase II or Phase III U.S. based preventative trial. Analyses were performed to examine differences in trial characteristics between RCTs that did and those that did not report race/ethnicity and to calculate the pooled proportion of each racial/ethnic group in randomized brain healthy prevention trials. A total of 42 studies consisting of 100,748 participants were included in the final analyses. A total of 26 (62%) reported some racial/ethnic identity data. The pooled proportion of REM participants was 0.256 (95% CI, 0.191, 0.326). There is a lack of racial/ethnic reporting of participants and REMs remain underrepresented in brain health prevention RCTs.

A88 UNDERSTANDING NURSE PERCEPTIONS OF CARING FOR PATIENTS WITH ALCOHOL USE DISORDER: A CROSS-SECTIONAL STUDY

Background

Alcohol Use Disorder (AUD), the problematic consumption of alcohol, affects 107 million people worldwide. AUD increases morbidity and mortality and has a substantial impact on daily functioning including quality of life, relationships and employment. AUD is particularly detrimental in patients who already have liver damage like cirrhosis. The management of AUD includes screening, brief intervention and referral to treatment for psychological and pharmacotherapy based treatment. People with AUD have frequent interactions with the healthcare system. These interactions represent opportunities to engage patients with therapy. As front-line workers who have maximal contact with patients, nurses practicing in acute care are in an ideal position to initiate AUD related discussion with patients. Prior to the design of an educational intervention to increase nursing engagement with AUD screening and brief intervention, there is a need to understand baseline knowledge, attitudes and perceptions in this group.

Aims

The aim of the present study was to explore the knowledge, attitudes and perceptions of nurses caring for patients with cirrhosis and AUD.

Methods

We conducted a cross-sectional survey using the Survey of Attitudes and Perceptions (SAP). The SAP is derived from a validated tool to assess attitudes and perceptions towards patients with AUD. Anonymous surveys were distributed on inpatient medicine units across 5 geographic zones in Alberta between September 2019-March 2020. Data were analyzed using descriptive and inferential statistics.

Results

A total of 93 nurses from 7 inpatient medicine units across Alberta participated in the study. The majority of participants were Registered Nurses (74.9%), who practiced in an urban setting (69%), and had worked in their role for an average of 9.9 years. Few (22.6%) participants reported any prior structured education on caring for patients with AUD, with the majority reporting limited knowledge of alcohol and effects of alcohol consumption. Though most reported that caring for patients with AUD was part of their professional role, only 15.7% felt motivated to work with this group of patients. Responses to individual questions or sub-domains of the survey did not significantly differ by length or time in professional role, or practice setting.

Conclusions

Our results indicate that nurses have limited knowledge on caring for patients with AUD. Given the importance of AUD in the development and progression of cirrhosis as well as the frequency of hospitalizations for patients with cirrhosis, increasing nurse knowledge of AUD is crucial to improving the quality of care for these patients. The results of this study will be used to inform the development of an educational intervention to increase nursing knowledge of caring for patients with cirrhosis and AUD.

Funding Agencies

Alberta Innovates

A78 “CHALLENGING PERSPECTIVES:” UNDERSTANDING CLINICIANS VIEWS ON MANAGING ALCOHOL USE DISORDER AND CIRRHOSIS

Background

Alcohol use disorder (AUD) is one of the leading etiologies for liver cirrhosis and liver transplantation. Few individuals with AUD receive guideline-based care in the form of screening, brief intervention, referral to treatment, or prescription of anti-relapse pharmacotherapies. We interviewed clinicians across Alberta to assess the current experience and perceived barriers to managing AUD in people who have cirrhosis.

Aims

The aim of this project is to summarize these findings to inform the development of an educational intervention.

Methods

We used a qualitative descriptive approach to explore the experiences of clinicians who provide care for patients with cirrhosis and AUD in Alberta. We conducted semi-structured interviews directed by an interview guide. Interviews were recorded and transcribed verbatim. We used an inductive thematic analysis approach whereby transcripts were coded, with codes grouped into larger categories, then themes.

Results

Sixteen clinicians participated in this study. Many participants acknowledged that they do not use a standardized approach to screening, brief intervention, and referral to treatment. Through thematic analysis we identified three themes surrounding barriers to managing AUD in patients with cirrhosis: (i) Practicing within knowledge constraints, (ii) Navigating limited resources and system challenges, and (iii) Acknowledging the complexity of patients who have cirrhosis and AUD.

Conclusions

This research presents the perspectives of clinicians who manage people who have AUD and cirrhosis. Our results indicate that significant barriers exist that affect how clinicians manage AUD in the context of cirrhosis, including limited knowledge and resources, systemic challenges, and patient complexity. The information gathered in this investigation will be used to develop an accredited educational intervention that will delve deeper into these issues in order to have the greatest impact on clinicians who routinely interface with this patient population.

Funding Agencies

Alberta Innovates Health Solutions

A87 CHANGES IN CLINICIAN KNOWLEDGE, COMFORT, PREPAREDNESS, AND ATTITUDES ABOUT ALCOHOL USE DISORDER AND CIRRHOSIS AFTER A BRIEF EDUCATIONAL INTERVENTION

Background

Alcohol use disorder (AUD) is increasing in prevalence and has a substantial impact on morbidity and mortality in people with cirrhosis. The use of screening, brief intervention and referral to treatment (SBIRT) and relapse prevention medications (e.g. acamprosate) are recommended by recent guidelines. Unfortunately, many clinicians report insufficient training to feel confident using these interventions

Aims

We aimed to compare the effect of a brief educational intervention on AUD knowledge, comfort, attitudes, and preparedness in clinicians who provide care to patients with cirrhosis.

Methods

Clinicians were invited to participate in a 1.5-hour educational session conducted by a hepatologist and addiction medicine specialist. The session included information about SBIRT and pharmacotherapy. Pre-training knowledge, comfort, and practice behaviors were assessed using previously published questions. Baseline attitudes were measured using the Short Alcohol and Alcohol Problems Perception Questionnaire. Participants were invited to repeat the questionnaires immediately post-training and statistical analysis conducted.

Results

Eighty-two clinicians attended the session. Among the 38 attendees who completed both the pre- and post-questionnaires, 34% were GIs/internists, 45% were family medicine physicians, and the remainder (21%) did not specify or were not prescribers. Scores for self-reported intention and preparedness to treat AUD, comfort, and knowledge improved significantly from the pre-training phase. Attitudes also improved from the pre-training phase, with significant improvements in the SAAPPQ subscales of role adequacy (p=0.03) and motivation (p=0.04).

Conclusions

Recognizing the small sample size, a brief educational session demonstrated promising results in the promotion of knowledge, attitudes, preparedness, and comfort for clinicians managing AUD in patients with cirrhosis. Feedback from these sessions will be used to design an accredited educational series for roll-out in 2022.

Funding Agencies

Alberta Innovates Health Solutions

A208 ASSESSING FEASIBILITY AND ACCEPTABILITY OF AN ONLINE MIND-BODY WELLNESS PROGRAM FOR PRIMARY BILIARY CHOLANGITIS

Background

Persons with primary biliary cholangitis (PBC) experience significantly higher rates of fatigue, stress, anxiety, depression, and impaired health related quality of life (HRQOL) as compared to the general population. While online wellness programming has been shown to be effective in decreasing fatigue and improving mental wellness in a variety of chronic disease populations, limited data is available for PBC.

Aims

This pilot study aimed to assess the hypothesis that a 12-week, online, mind-body wellness program would be feasible (assessed through adherence and retention) and acceptable in people with PBC. We also aimed to explore indicators of impact on measures of wellbeing.

Methods

Persons with PBC were recruited across Alberta and British Columbia in January 2021. The program included a 20–30 minute video containing low intensity mindful movement, meditation, and breathwork (goal 2–3 times/week) as well as a weekly behaviour change tip, PBC tip from a physician, and PBC nutrition tip. The online programming was accompanied by brief (10-minute) once weekly phone check-ins from a member of the study team, and optional once monthly zoom group sessions hosted by the Canadian PBC Society. Satisfaction and adherence were assessed at the end of the study using a survey. The pre-post exploratory efficacy assessment included: fatigue (Modified Fatigue Impact Scale), perceived stress (Perceived Stress Scale), anxiety and depression (Hospital Anxiety and Depression Scale), and HRQOL (PBC-40). Using a qualitative descriptive approach, we conducted semi-structured interviews at the end of the study to explore experiences with the intervention, and gather feedback for improvement.

Results

Participants (N = 32) completed baseline surveys and 29 (91%) were retained to end-of-study. Twenty-five (86%) adhered to the program goal of carrying out the mind-body practice at least 2–3 days per week. Comparing baseline to end-of-study, significant reductions were observed in fatigue (13%, p=0.004), anxiety (30%, p=0.005), and depression (28%, p=0.022), and significant improvements were observed in the PBC-40 itch (22%, 0.043), fatigue (13%, 0.005), cognitive (17%, 0.006), and emotional (18%, 0.001) domains. Eleven individuals participated in qualitative interviews, reporting an increase in energy, a more positive outlook, and increased knowledge of PBC. Feedback supported acceptability (satisfaction score of 90%), with fatigue cited as the primary barrier to increased program participation.

Conclusions

These findings suggest that a 12-week online mind-body intervention is feasible and acceptable to persons with PBC and has promising impact on efficacy. Recognizing the limitations of a single-arm study with a small sample size, a future RCT will be designed using this feedback.

Funding Agencies

MITACS Accelerate, Canadian PBC Society

Odderon Exchange from Elastic Scattering Differences between pp and pp[over ¯] Data at 1.96 TeV and from pp Forward Scattering Measurements

We describe an analysis comparing the pp[over ¯] elastic cross section as measured by the D0 Collaboration at a center-of-mass energy of 1.96 TeV to that in pp collisions as measured by the TOTEM Collaboration at 2.76, 7, 8, and 13 TeV using a model-independent approach. The TOTEM cross sections, extrapolated to a center-of-mass energy of sqrt[s]=1.96  TeV, are compared with the D0 measurement in the region of the diffractive minimum and the second maximum of the pp cross section. The two data sets disagree at the 3.4σ level and thus provide evidence for the t-channel exchange of a colorless, C-odd gluonic compound, also known as the odderon. We combine these results with a TOTEM analysis of the same C-odd exchange based on the total cross section and the ratio of the real to imaginary parts of the forward elastic strong interaction scattering amplitude in pp scattering for which the significance is between 3.4σ and 4.6σ. The combined significance is larger than 5σ and is interpreted as the first observation of the exchange of a colorless, C-odd gluonic compound.

P–738 Fertility Preservation: Comparative analysis about the knowledge of the topic between two female populations in Argentina and the United States

Study question

Is there any difference in the knowledge that women in Córdoba (Argentina) and South Carolina (United States) have about fertility preservation, according to their socioeconomic and educational level?

Summary answer

Scarce knowledge about fertility preservation in both populations was registered. Only sectors of higher socioeconomic and educational level responded correctly with values close to 60%.

What is known already

There are numerous factors that may motivate the need to preserve fertility in young individuals. These factors can be grouped into two causes: social (postponement of motherhood, gender change, etc.), or medical (oncological or surgical treatments). In these situations, it is important that society in general has access to information about fertility and the possibilities of preserving it, if necessary. On the other hand, in each country and region in particular the information on this topic is distributed in different ways, which could generate differences in the level of knowledge on these issues in different population groups.

Study design, size, duration

Descriptive quantitative study. A total of 3,041 answers were obtained, 88.8% from Argentina and 10.00% from the United States. An 83.72% (2,521) of the answers were made by women.

Participants/materials, setting, methods

A closed-ended questionnaire of 20 questions was designed (segmentation and aspects of knowledge about fertility and its preservation) and distributed to different sectors of society through social networks. The survey was answered by people from Córdoba (Argentina) and South Carolina (US), of both sexes and different age groups, educational levels (basic/higher) and socioeconomic levels (medium-low/high). All answers were collected through SurveyMonkey and were analyzed using calculation programs and statistical tools (Excel 2016, Statistica 8.0).

Main results and the role of chance

Data showed that the 47.98% of Argentine women and 42.68% of American women surveyed do not know the age at which fertility begins to decline. The group with the highest percentage of incorrect answers (61.11%) for this question was that of Argentine women who had no previous experience with assisted fertility and come from the lower-middle social class. When asked about the knowledge about the factors that affect fertility, only 55% of Argentine women answered correctly, compared to 64.85% of American women. For the Argentine group, the proportion of correct answers increased to 62.23% for higher education level and to 56.60% for higher socioeconomic level. Regarding whether they know what fertility preservation procedure consists of, only 47.98% of Argentine women and 42.68% of American women answered correctly. On the other hand, 69.37% of the former and 63.18% of the latter do not know which biological materials can be cryopreserved. Finally, only 25.68% of women in Argentina know about the extent of their medical coverage in terms of fertility preservation procedures, while this percentage is 7.95% for the US population.

Limitations, reasons for caution

The comparison between the two countries may be challenged by the inequality in the response rate to the survey. However, even the smaller number of responses obtained in the USA is sufficient to obtain valid conclusions.

Wider implications of the findings: The level of misinformation registered in this study could imply reduced chances of achieving pregnancy in the future, especially for older women, those who wish to postpone motherhood or those who must undergo cancer treatments. This work provides important information in the politics designing promoting information access on fertility preservation.

Trial registration number

.

P–739 Fertility and its Preservation: Comparative Analysis about the Knowledge between Two Populations of Doctors and Health Professionals from Argentina and the United States

Study question

Is there any difference in the knowledge that doctors and health professionals from Córdoba (Argentina) and South Carolina (USA) have about fertility preservation or about when it should be applied?

Summary answer

Both populations have enough knowledge about some aspects of fertility preservation, but its training must be improved so they can give adequate counseling

What is known already

During the last decades, it has been observed that more young individuals need/decide to preserve fertility, whether for social or medical reasons. This presents a new challenge for the medical community, since, faced with this situation, it is important that society in general has access to information about fertility and the possibilities of preserving it, if necessary. To this end, it is essential that doctors and other health professionals have valid knowledge of the subject and are able to communicate it to their patients.

Study design, size, duration

Descriptive quantitative study. A total of 721 answers were obtained, 88.7% from Argentina and 11.3% from the United States. 28.43% (205) were doctors and 71.57% (516) were other health professionals.

Participants/materials, setting, methods

A closed-ended questionnaire of 20 questions was designed (segmentation and aspects about fertility preservation) and distributed to society through social networks. The survey was answered by people from Córdoba (Argentina) and South Carolina (US), of both sexes and different age, educational and socioeconomic levels. Only those with a medical degree or involved in some medical-related activity were selected. All answers were collected through SurveyMonkey and analyzed using calculation programs and statistical tools (Excel–2016, Statistica 8.0).

Main results and the role of chance

Data showed percentages of correct answers greater than 70% in all groups for the questions that analyze what factors can affect fertility, what situations can determine the need to preserve it, and what is the appropriate age for a woman to cryopreserve her eggs. On average, 82.4% of doctors and 72.87% of other health professionals know when it is the right time for patients diagnosed with cancer to receive information about the possibility of preserving their fertility. However, on average between both countries, only 34.63% of doctors has information about the legal medical coverage of their patients, while the 39.51% is completely unaware of their country’s laws. Finally, the percentages of professionals who do not know what material can be cryopreserved in girls who need to undergo oncological treatments reach 46.34 and 64.33% (doctors and other health professionals respectively).

Limitations, reasons for caution

The comparison between the two countries may be challenged by the inequality in the response rate to the survey. However, even the smaller number of responses obtained in the USA is sufficient to obtain valid conclusions.

Wider implications of the findings: Both populations have sufficient information about factors which affect fertility and its preservation, especially in cancer situations. Misinformation in health personnel about these aspects directly affects possibilities of achieving future pregnancies for patients. Continuous updating and guidance should be a priority, as well as information dissemination and adequate medical counseling.

Trial registration number

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A75 IMPLEMENTING A CIRRHOSIS ORDER SET: A QUALITATIVE ANALYSIS OF PROVIDER-IDENTIFIED BARRIERS AND FACILITATORS

Background

Cirrhosis is the leading cause of mortality and morbidity in individuals with gastrointestinal disease. Multiple care gaps exist for hospitalized patients with cirrhosis, resulting in high rates of re-hospitalization (e.g. 44% at 90 days in Alberta). The Cirrhosis Care Alberta (CCAB) is a 4-year multi-component pragmatic trial with an aim to reduce acute-care utilization by implementing an electronic order set and supporting education across eight hospital sites in Alberta.

Aims

As part of the pre-implementation evaluation, this qualitative study analyzed data from provider focus groups to identify barriers and facilitators to implementation.

Methods

We conducted focus groups at eight hospital sites with a total of 54 healthcare providers (3–12 per site). A semi-structured interview guide based upon constructs of the Consolidated Framework for Implementation Research (CFIR) and Normalization Process Theory (NPT) frameworks was used to guide the focus groups. Focus groups were recorded and transcribed verbatim. Data was analyzed thematically and inductively.

Results

Five major themes emerged across all eight sites: (i) understanding past implementation experiences, (ii) resource challenges, (iii) competing priorities among healthcare providers, (iv) system challenges, and (v) urban versus rural differences. Site-specific barriers included perceived lack of patient flow, time restraints, and concerns about the quality and quantity of past implementation interventions. Facilitators included passionate project champions, and an ample feedback process.

Conclusions

Focus groups were useful for identifying pre-implementation barriers and facilitators of an electronic orders set. Findings from this study are being refined to address the influence of COVID-19, and the data will be used to inform the intervention roll-out at each of the sites.

Funding Agencies

Alberta Innovates

Mycoplasma Genitalium And Streptococcus Agalactiae Colonization In Pregnant Women: An Emerging Relationship

Introduction/Objective

Mycoplasma genitalium has been identified as an emerging sexually transmitted infection (STI) causing cervicitis, pelvic inflammatory disease and other gynecologic pathology. The prevalence of M. genitalium in pregnant women has not been determined, nor has frequency of co-infection with Streptococcus agalactiae (GBS). Neonatal sepsis caused by GBS is associated with black race and young maternal age with approximately 10%-30% of pregnant women colonized. The aim of this retrospective study was to investigate the possible association between M. genitalium infection and colonization with GBS in a large cohort of pregnant women from a tertiary care center in Houston, Texas.

Methods

Remnant endocervical samples collected from pregnant women attending clinics at the Baylor College of Medicine between September 2019 and December 2019 were screened for M. genitalium by transcription mediated amplification (Hologic, Inc. Marlborough, MA). Demographic, STI co-infection [Human papillomavirus (types 16,18), Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, and Herpes simplex virus], and GBS status data were recorded. Fisher’s exact test was performed for statistical analysis.

Results

719 total samples were collected and tested for M. genitalium. Of these, 41 (5.7%) were positive. The mean age of infected women was younger than noninfected women (24.9 vs. 28.1 years respectively p = 0.0004). More black women (34.2%) were infected with M. genitalium compared to white (14.6%) or other (51.2%) (p = 0.0003).

Rates of GBS colonization was significantly higher among women infected with M. genitalium compared to women who tested negative (58.3% vs. 16.1% respectively p = 0.002) and increased compared to national reported rates of GBS colonization. M. genitalium also showed a significant association with T. vaginalis (p=0.03), but no other STI co- infections studied.

Conclusion

Our data demonstrates that infection with M. genitalium may be associated with persistent GBS colonization. Further prospective studies are needed to further elucidate this relationship.

Barriers to management of diabetes foot ulcer: Experiential note from a setting with free medical services

The imperative need for behavioral agreement to overcome barriers of self-management of diabetes foot complication was recently articulated. A few journals have done parallel publications, which thereby stresses the significance of the issue. This article is to add to the "Overcoming barriers to self-management: the person-centred diabetes foot behavioural agreement". It presents experiential note with four tabulated cases of clients who have access to free state-of-the-art medical service; and non-adherence as a barrier to self-management is not due to affordances. It is to draw attention to the deliberately non-adherent patients where behavioral agreement process should be really driven by the client as in the real context of person-centered therapy.

Highly multimodal structure of high topological charge extreme ultraviolet vortex beams

Optical beams carrying orbital angular momentum are a very active field of research for their prospective applications, especially at short wavelengths. We consider here such beams produced through high-harmonic generation (HHG) in a rare gas and analyze the characterization of their high-charge vortex structure by an extreme ultraviolet Hartmann wavefront sensor. We show that such HHG beams are generally composed of a set of numerous vortex modes. The sensitivity of the intensity and phase of the HHG beam to the infrared laser aberrations is investigated using a deformable mirror.

Impact of the size of the lesion in prenatal neural tube defect repair on imaging, neurosurgical and motor outcomes: a retrospective cohort study

OBJECTIVES

(1) To compare brain findings between large and non-large neural tube defect (NTD); (2) to evaluate the impact of large lesion on the surgical parameters; (3) to study any associations between the size of the lesions and brain findings 6 weeks postoperatively and neurological short-term outcomes.

DESIGN

Retrospective cohort study.

SETTING

Texas Children's Hospital, between 2011 and 2018.

POPULATION

Patients who underwent prenatal NTD repair.

METHODS

Large lesion was defined when the lesion's surface was >75th centile of our cohorts' lesions.

MAIN OUTCOME MEASURES

Time of referral: ventriculomegaly and anatomical level of the lesion; surgery: duration and need for relaxing incisions. 6 weeks postoperative: hindbrain herniation (HBH) and ventriculomegaly. After delivery: dehiscence, need for hydrocephalus treatment and motor function.

RESULTS

A total of 99 patients were included, 25 of whom presented with large lesions. Type of lesion and ventriculomegaly were comparable between individuals with large and non-large lesions. Individuals with large lesions were associated with increased need for relaxing incisions by 5.4 times (95% CI 1.3-23.2, P = 0.02). Six weeks postoperatively, having a large lesion decreased by ten times the likelihood of having a postoperative reversal of HBH (odds ratio = 0.1, 95% CI 0.1-0.4, P < 0.01). At birth, larger lesions increased the risk for repair dehiscence by 6.1 times (95% CI 1.6-22.5, P < 0.01) and the risk of dehiscence or leakage of cerebrospinal fluid at birth by 5.5 times (95% CI 1.6-18.9, P < 0.01).

CONCLUSION

Prenatal repair of patients with large NTD presents a lower proportion of HBH reversal 6 weeks after the surgery, a higher risk of dehiscence and a higher need for postnatal repair.

TWEETABLE ABSTRACT

Evaluation of the size of fetal NTD can predict adverse neurological outcomes after prenatal NTD repair.

AB1353-HPR EMPOWERING LEARNERS TO “OWN” THEIR PERFORMANCE: PRESENTING EDUCATIONAL PERFORMANCE DATA BACK TO LEARNERS AS A COMPONENT OF AND RATIONALE FOR SUBSEQUENT EDUCATION

Background:

Beginning in 2016, RMEI created multiple accredited online education focused on RA and designed for rheumatologists. In 2018, the educational scope expanded to include live meetings, starting with a symposium at EULAR. For all programming from 2016-18 (6 courses, in both live and online settings), educational content was developed based on performance data from the previous RA courses. During the 2019 EULAR symposium, we presented the outcomes findings - from both the 2018 symposium and online courses – to the assembled rheumatologists, identifying ongoing educational gaps observed in their specialty population. The rationale: to create continuity between symposia over time by demonstrating incremental improvements and continuing areas of need, while also endowing learners with a greater sense of ownership and investment in forthcoming educational content.

Objectives:

To evaluate the impact of presenting learner’s educational performance data to them before education addressing persistent gaps identified in their performance the year prior.

Methods:

Data collected during the 2018 EULAR symposium was analyzed to understand the underlying drivers impacting poor performance in an identified area of ongoing educational need (cycling versus switching TNF inhibitors). A linear regression model was run including all non-related curriculum, demographic, and evaluation questions as possible drivers against those related low-scoring (at Post-Test) curriculum questions. The content of RMEI’s 2019 symposium at EULAR was developed to address the identified significant drivers to improve population proficiency in cycling versus switching. In addition to developing content based on the above findings, that data was also presented to learners in poster format prior to their participation in the 2019 symposium. During the period between on-site registration and the start of the symposium, attendees had the opportunity to explore data-driven insights, via audio-guided posters located around the meeting room. These insights included discussion of 2018 data analysis, identified drivers of poor performance, introduced the iterative data-driven methodology employed, and rationale behind content development for the 2019 symposium. At the conclusion of the 2019 symposium learners were asked to describe the impact/relevance of being presented with their performance data, their intention of incorporating course content into practice, and what specifically they intended to change.

Results:

Data was collected on 135 clinicians (primarily physicians who actively treat patients with rheumatoid arthritis) who attended, and participated in, the symposium. With specific regard to the impact of seeing their own data presented back to them, 80% reported that seeing the learner data from the 2018 symposium enhanced their current learning experience. Further, 86% reported that they intended to incorporate course content into their clinical practice. Specifically, this population reported an intent to change their treatment approach and patient education practices.

Conclusion:

Education is only as effective as the degree to which the audience is engaged. While year over year data from 2016 through 2018 demonstrated that an iterative approach facilitated the meaningful and necessary reinforcement of challenging concepts, learners in prior years were not aware of the methodological underpinnings of the educational offerings. Presenting this population with findings derived from their performance - as a rationale for the education they were about to participate in proved a compelling motivator for active learner engagement, and may have had a positive influence on the degree to which learners implemented course content into their clinical practice.

Disclosure of Interests:

None declared

Patient deprivation and perceived scan burden negatively impact the quality of whole-body MRI

AIM

To evaluate the association between the image quality of cancer staging whole-body magnetic resonance imaging (WB-MRI) and patient demographics, distress, and perceived scan burden.

MATERIALS AND METHODS

A sample of patients recruited prospectively to multicentre trials comparing WB-MRI with standard scans for staging lung and colorectal cancer were invited to complete two questionnaires. The baseline questionnaire, administered at recruitment, collated data on demographics, distress and co-morbidity. The follow-up questionnaire, completed after staging investigations, measured perceived WB-MRI scan burden (scored 1 low to 7 high). WB-MRI anatomical coverage, and technical quality was graded by a radiographic technician and grading combined to categorise the scan as "optimal", "sub-optimal" or "degraded". A radiologist categorised 30 scans to test interobserver agreement. Data were analysed using the chi-square, Fisher's exact, t-tests, and multinomial regression.

RESULTS

One hundred and fourteen patients were included in the study (53 lung, 61 colorectal; average age 65.3 years, SD=11.8; 66 men [57.9%]). Overall, 45.6% (n=52), scans were classified as "optimal" quality, 39.5% (n=45) "sub-optimal", and 14.9% (n=17) as "degraded". In adjusted analyses, greater deprivation level and higher patient-reported scan burden were both associated with a higher likelihood of having a sub-optimal versus an optimal scan (odds ratio [OR]: 4.465, 95% confidence interval [CI]: 1.454 to 13.709, p=0.009; OR: 1.987, CI: 1.153 to 3.425, p=0.013, respectively). None of the variables predicted the likelihood of having a degraded scan.

CONCLUSIONS

Deprivation and patients' perceived experience of the WB-MRI are related to image quality. Tailored protocols and individualised patient management before and during WB-MRI may improve image quality.

Generation of nonlinear internal waves by flow over topography: Rotational effects

We use the forced Ostrovsky equation to investigate the generation of internal waves excited by a constant background current flowing over localized topography in the presence of background rotation. As is now well known in the absence of background rotation, the evolution scenarios fall into three cases, namely subcritical, transcritical, and supercritical. Here an analysis of the linearized response divides the waves into steady and unsteady waves. In all three cases, steady waves occur downstream but no steady waves can occur upstream, while unsteady waves can arise upstream only when there is a negative minimum of the group velocity. The regions occupied by the steady and unsteady waves are determined by their respective group velocities. When the background current is increased, the wave number of the steady waves decreases. In addition, the concavity (canyon or sill), the topographic width, and the relative strength of the rotation play an important role in the generation mechanism. Nonlinear effects modulate the wave amplitude and lead to the emergence of coherent wave packets. All these findings are confirmed by numerical simulations.

P2272Determinants of left ventricular ATP availability measured in vivo and ex vivo in patients with severe aortic stenosis: correlation of creatine kinase activity with LVEF and ATP diffusion distance

Introduction

The transition to systolic failure in severe aortic stenosis (AS) increases mortality. There are currently no reliable markers of transition, and the guideline LVEF <50% threshold for intervention in asymptomatic severe AS does not capture all subjects at increased risk. In animal models, reduced ATP delivery capacity through creatine kinase (CK) is important, with modest increases in CK capacity conferring cardioprotection. ATP may also diffuse (independent of CK) from mitochondria to the contractile site. We have performed the first human study to test whether ATP diffusion distance relates to CK activity and whether CK activity is reduced in low LVEF severe AS.

Methods

19 patients with severe AS, LVEF ≥55% (AS-pEF, mean±SD LVEF 63±5%, mean gradient 48±14 mmHg) and 10 with severe AS, LVEF <55% (AS-rEF, LVEF 42±8%, mean gradient 32±11) underwent 31P-MRS for CK rate constant (kf) and phosphocreatine/ATP (PCr/ATP) ratio, and MRI for LV volumes. LV biopsies were taken during AVR and analysed for CK total activity, CK isoforms, total creatine, and citrate synthase (CS) activity. 9 biopsies also underwent serial block face scanning electron microscopy and mitochondria-sarcomere 3D distance distributions were plotted. Results were compared to 24 controls (LVEF 61±4%), of which 4 had LV biopsy (3 severe MS, 1 LA myxoma, MS-pEF). Surgical patients had flow-limiting atheroma excluded with invasive angiography and prior myocardial infarction excluded with late gadolinium enhancement MRI.

Results

When compared to controls, both CK total activity and CS activity were lower in AS-pEF (by 27% and 23% respectively, both p<0.05, Panels A-B). Although PCr/ATP reduced in AS-pEF (by 20%, p<0.001, panel C), kf (panel D) and CK flux estimated by kf × total creatine were not different. CK-MB expression reduced in AS-pEF (19 vs 27% of total CK, p=0.003), reflecting compensatory increases in CK-MM (p=0.26) and CK-BB (p=0.18) in the face of reduced CK activity.

AS-rEF was associated with further reduction in both CK and CS activities (by 32% and 22% respectively, both p<0.05, Panels A-B), but no differences in PCr/ATP, CK kf or relative CK isozyme expression were seen. There were no significant between-group differences in total creatine (Panel E). Overall this suggests that CK reserve and oxidative capacity potentially reduce in pressure overload, with further falls commensurate with systolic dysfunction.

When median mitochondria-sarcomere ATP diffusion distances were plotted against CK total activity a strong positive correlation was observed (r=0.86, p=0.003, Panel F). This suggests a compensatory reduction in diffusion distance develops when CK activity falls.

Conclusions

Transition to failure in severe AS is associated with lower oxidative capacity and maximal ATP delivery capacity through CK. Despite compensatory falls in ATP diffusion distance and altered CK isozyme expression, these changes may underlie susceptibility to EF decline in AS.

Acknowledgement/Funding

British Heart Foundation Clinical Research Training Fellowship (FS/15/80/31803) and Programme Grant (RG/18/12/34040).

Interventions for treating recurrent stress urinary incontinence after failed minimally invasive synthetic midurethral tape surgery in women

BACKGROUND

Surgery is a common treatment modality for stress urinary incontinence (SUI), usually offered to women for whom conservative treatments have failed. Midurethral tapes have superseded colposuspension because cure rates are comparable and recovery time is reduced. However, some women will not be cured after midurethral tape surgery. Currently, there is no consensus on how to manage the condition in these women.This is an update of a Cochrane Review first published in 2013.

OBJECTIVES

To assess the effects of interventions for treating recurrent stress urinary incontinence after failed minimally invasive synthetic midurethral tape surgery in women; and to summarise the principal findings of economic evaluations of these interventions.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 9 November 2018). We also searched the reference lists of relevant articles.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials in women who had recurrent stress urinary incontinence after previous minimally invasive midurethral tape surgery. We included conservative, pharmacological and surgical treatments.

DATA COLLECTION AND ANALYSIS

Two review authors checked the abstracts of identified studies to confirm their eligibility. We obtained full-text reports of relevant studies and contacted study authors directly for additional information where necessary. We extracted outcome data onto a standard proforma and processed them according to the guidance in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We included one study in this review. This study was later reported in an originally unplanned secondary analysis of 46 women who underwent transobturator tape for recurrent SUI after one or more previous failed operations. We were unable to use the data, as they were not presented according to the nature of the first operation.We excluded 12 studies, five because they were not randomised controlled trials (RCTs) and four because previous incontinence surgery was not performed using midurethral tape. We considered a further three to be ineligible because neither the trial report nor personal communication with the trialists could confirm whether any of the participants had previously undergone surgery with tape.We had also planned to develop a brief economic commentary summarising the principal findings of relevant economic evaluations but supplementary systematic searches did not identify any such studies.

AUTHORS' CONCLUSIONS

There were insufficient data to assess the effects of any of the different management strategies for recurrent or persistent stress incontinence after failed midurethral tape surgery. No published papers have reported exclusively on women whose first operation was a midurethral tape. Evidence from further RCTs and economic evaluations is required to address uncertainties about the effects and costs of these treatments.

C-42 Is “Clinical Impairment” Normative in College Populations? Identifying Base Rates of Self-Reported Impairment in a Non-Treatment Seeking Population

Objective

Individuals presenting with concerns of Attention Deficit Hyperactivity Disorder (ADHD) report impairment and may seek academic or disability accommodations related to perceived impairment. Problematically, the legal definition of impairment remains poorly understood by clinicians, and there is little consensus regarding credibility of self-reported impairment. Furthermore, many impairments reported by individuals seeking evaluation for ADHD appear to be general and non-specific, but base rates of reports of these impairments in non-treatment seeking populations remain unclear. We examined base rates of impairment associated with ADHD in a sample of non-treatment seeking college students.

Method

Participants were undergraduate students who completed online surveys (N = 175). Participants who failed measures of validity, reported a past diagnosis of ADHD, or endorsed clinically significant symptoms of ADHD were excluded from analyses (final N = 89). Participants largely identified as white (88.8%) and female (85.4). Participants completed measures of impairment (Barkley Functional Impairment Scale) and ADHD symptoms (Conners’ Adult Attention Rating Scale). Base rates of clinically significant impairment among this sample were analyzed.

Results

Clinically significant levels of impairment were reported at high levels within the following categories; at home (15.1%), interacting with strangers (13.5%) and friends (20.2%), performing daily self-care (7.9%), and managing health (12.4%).

Conclusions

Base rates of clinically significant self-reported impairment are high among a non-clinical, non-treatment seeking sample of college students without ADHD symptoms. Results raise questions about the validity of self-reported impairment in diagnostic decision making, suggesting that experiences of difficulty in these areas may be normative among college populations and not specific to ADHD.

A-82 Neuropsychological Assessment in the Age of Technology: Comparing Traditional Paper versus Electronic Administration

Objective

As society becomes more interconnected with technology, it is important to examine how traditional “paper and pencil” administered neuropsychological tests can be utilized in digital electronic forms (e.g., computers, touch screen tablets, and smartphones). Literature has shown somewhat mixed outcomes for the validity of computerized tests. Gathering data electronically has been found to reduce human error in both test administration and in data collection itself. Digitizing carries benefits in the research field where electronic administration may make it possible to gather data on a larger scale numerically and geographically. However, in some conversions to digital versions of a task, changes may be made to the stimuli and procedure that might seemingly be benign, but could activate different cognitive responses, potentially compromising construct validity. This study examined the comparability of paper and electronic forms of the Stroop task, which is used widely and has been previously validated in paper form.

Method

Electronic Stroop tests were examined for concurrent validity with a paper version. Two touch-screen based apps were examined: BrainBaseline for the iPad and EncephalApp for smartphone. Young and older adults (n = 58) completed paper and an electronic version of the Stroop.

Results

Correlation analyses revealed a significant, but modest relationship between paper Stroop and the BrainBaseline version (r = .54; p = .001), while the EncephalApp correlation was non-significant (r = .44; p = .18).

Conclusions

These results need to be verified in a larger sample, but the implication is that some paper and electronic versions of cognitive tests are not necessarily interchangeable, and caution should be used.

Incarcerated paraesophageal hernia complicated by pancreatic damage and unusual comorbidity: Two retrospective case series

•

We present two cases of paraesophageal hernia that both needed total gastrectomy due to gangrene.

•

Both patients had clinical relevant comorbidities, respectively trisomy 21 and hereditary spastic paresis.

•

Due to compression from the dilated stomach one of the patients developed ischemia of the pancreas with leakage of peptidases which in turn caused anastomotic dehisence and intraabdominal abscess.

•

The pancreatic damage and anastomotic leakage was treated conservatively with repeated stenting and percutaeous drainage.

•

Immediate diagnosis and treatment for incarcerated paraesophageal hernias are vital to reduce morbidity and mortality.

Introduction: About 1% of paraesophageal hernias (PEH) require emergency surgery due to obstruction or gangrene. We present two complicated cases of incarcerated PEH.

Presentation of cases: A patient aged 18 with trisomy 21 was admitted after four days of vomiting and epigastric pain. CT scan revealed a large PEH. The stomach was massively dilated with compression of adjacent viscera and the celiac trunk. The stomach was repositioned laparoscopically and deflated by endoscopy in an attempt to avoid resection. During second look laparoscopy a gastrectomy was necessary. The patient was reoperated for intestinal obstruction, and treated for dehiscence of the esophagojejunostomy and a pancreatic fistula. A patient aged 65 with hereditary spastic paresis had two days history of emesis and epigastric pain. Upon arrival he was hemodynamically unstable and a CT scan revealed perforation of the herniated stomach. A subtotal gastrectomy without reconstruction was performed with vacuum closure of the abdomen. Later a gastrectomy was completed with a Roux-en-Y reconstruction. Except from reoperation for wound dehiscence after 14 days, the recovery was uneventful.

Discussion: Trisomy 21 and hereditary spastic paresis may increase the risk of developing PEH. Challenges in regard to symptom evaluation may delay diagnosis. The pressure of the dilated stomach can give rise to ischemic and mechanical damage from compression of major blood vessels and organs. Urgent diagnosis and gastric deflation is required.

Conclusions: In patients with known PEH or with comorbidity that may increase the risk of PEH, this diagnosis should be considered early on.

[Funding for national ethics committees for health research in Member States of the Economic Community of West African States]

BACKGROUND

The financing of national research ethics committees for health is a decisive factor in their proper functioning and independence. Little information is available concerning the funding of these committees in West Africa.

AIM

To analyze the funding of national research ethic committees for health in the Member States of the Economic Community of West African States.

METHODS

A review of the documents from two regional workshops with the participation of the representatives of the national ethics committees of each ECOWAS Member State was carried out. These workshops enabled the collection and validation of data on the status of national ethics committees. These data were used to conduct a descriptive analysis of the funding sources of the committees.

RESULTS

Three sources of funding for national ethics committees were identified. The first source was the support of the state or a national structure. The second source was the fee for reviewing the submitted protocols and the last source was the support of external donors. The collection of audit fees and the support of external donors were the main sources of funding for most of the national committees. In only one state, there were no fees for review of submitted protocols and all the ethic committee member were motivated by the government.

CONCLUSION

In order to ensure the autonomy and independence of the national committees, state support for the funding of these committees should improve. The establishment of a regional network and its recognition by the Assembly of Ministers of Health of ECOWAS allowed for advocacy by WAHO, which should help achieve better results in the future.

North European comparison of treatment strategy and survival in older patients with resectable gastric cancer: A EURECCA upper gastrointestinal group analysis

BACKGROUND

As older gastric cancer patients are often excluded from randomized clinical trials, the most appropriate treatment strategy for these patients remains unclear. The current study aimed to gain more insight in treatment strategies and relative survival of older patients with resectable gastric cancer across Europe.

METHODS

Population-based cohorts from Belgium, Denmark, The Netherlands, Norway, and Sweden were combined. Patients ≥70 years with resectable gastric cancer (cT1-4a, cN0-2, cM0), diagnosed between 2004 and 2014 were included. Resection rates, administration of chemotherapy (irrespective of surgery), and relative survival within a country according to stage were determined.

RESULTS

Overall, 6698 patients were included. The percentage of operated patients was highest in Belgium and lowest in Sweden for both stage II (74% versus 56%) and stage III disease (57% versus 25%). For stage III, chemotherapy administration was highest in Belgium (44%) and lowest in Sweden (2%). Three year relative survival for stage I, II, and III disease in Belgium was 67.8% (95% CI:62.8-72.6), 41.2% (95% CI:37.3-45.2), 17.8% (95% CI:12.5-24.0), compared with 56.7% (95% CI:51.5-61.7), 31.3% (95% CI:27.6-35.2), 8.2% (95% CI:4.4-13.4) in Sweden. There were no significant differences in treatment strategies of patients with stage I disease.

CONCLUSION

Substantial treatment differences are observed across North European countries for patients with stages II and III resectable gastric cancer aged 70 years or older. In the present comparison, treatment strategies with a higher proportion of patients undergoing surgery seemed to be associated with higher survival rates for patients with stages II or III disease.

International comparison of treatment strategy and survival in metastatic gastric cancer

Background

In the randomized Asian REGATTA trial, no survival benefit was shown for additional gastrectomy over chemotherapy alone in patients with advanced gastric cancer with a single incurable factor, thereby discouraging surgery for these patients. The purpose of this study was to evaluate treatment strategies for patients with metastatic gastric cancer in daily practice in five European countries, along with relative survival in each country.

Methods

Nationwide population‐based data from Belgium, Denmark, the Netherlands, Norway and Sweden were combined. Patients with primary metastatic gastric cancer diagnosed between 2006 and 2014 were included. The proportion of gastric resections performed and the administration of chemotherapy (irrespective of surgery) within each country were determined. Relative survival according to country was calculated.

Results

Overall, 15 057 patients with gastric cancer were included. The proportion of gastric resections varied from 8·1 per cent in the Netherlands and Denmark to 18·3 per cent in Belgium. Administration of chemotherapy was 39·2 per cent in the Netherlands, compared with 63·2 per cent in Belgium. The 6‐month relative survival rate was between 39·0 (95 per cent c.i. 37·8 to 40·2) per cent in the Netherlands and 54·1 (52·1 to 56·9) per cent in Belgium.

Conclusion

There is variation in the use of gastrectomy and chemotherapy in patients with metastatic gastric cancer, and subsequent differences in survival.

The VCCC Research & Education Lead Program: Collective Leadership in Cancer Across Multiple Organisations

Background and context: The Victorian Comprehensive Cancer Centre (VCCC) is Australia´s first formally constituted comprehensive cancer center, based on NCI principles. It is an alliance of 10 organizations: 7 hospitals, 2 medical research institutes and a university, based in Melbourne, Australia. A key goal for the VCCC is to create meaningful collaborations across partner organizations. Aim: The VCCC established the Research & Education Lead (R & E Lead) Program to build leadership capability who can harness the critical mass of talent across the VCCC alliance to work toward optimal integration of cancer research and education into routine patient care. Strategy/Tactics: This VCCC Research & Education Lead Program manifests the foundational principles of the VCCC by systematising and normalizing collaborative activities across the VCCC alliance. The program is a vehicle that allows the VCCC to address its strategic priorities to enable: - better integration of research, education and clinical care - sharing of ideas and knowledge to improve patient outcomes - shared education and training across member organizations Program/Policy process: Clinicians-scientists were appointed to each tumor stream as VCCC R & E Leads (approx. 0.2 EFT). Their role is to build networks of expertise and to drive change that is evidence-based, strategic and agreed across the VCCC alliance, with a focus on the end goal of better outcomes for cancer patients. The program provides the basis for a model of distributed leadership, wherein champions invested in the VCCC concept are embedded in partner organizations. Outcomes: Three R & E Leads were initially appointed as a pilot for 2 years, with a further three leads appointed during this period. Following the pilot, the program has been expanded to encompass 10 tumor streams as well as leads in primary care integration and cancer nursing. Achievements to date have included the development of a Massive Online Open Course in Cancer Survivorship, conduct of numerous symposia and events that upskill the cancer workforce in niche areas identified by the leads as needs, and consensus on the clinical challenges and research priorities to be tackled collectively within each tumor stream. Overarching program benefits included increased engagement and collaboration across partner organizations, more sharing of knowledge, and more participation in collaborative efforts including VCCC strategy development and advocacy. What was learned: A key finding of an interim program evaluation identified that the appointment of clinician-scientists as the leads was an important factor in their ability to cross the boundaries between research and clinical practice and between organizations, and to work closely and cohesively with clinical service leads for the tumor streams.