A comparison of physical performance during one- and two-person simulated casualty drags

The ability to drag a casualty to safety is critical for numerous physically demanding occupations. This study aimed to establish whether the pulling forces during a one-person 55 kg simulated casualty drag is representative of a two-person 110 kg drag. Twenty men completed up to 12 × 20m simulated casualty drags using a drag bag (55/110 kg) on a grassed sports pitch, with completion times and forces exerted measured. Completion time for the one-person 55 and 110 kg drags were 9.56 ± 1.18s and 27.08 ± 7.71s. Completion time for the 110 kg two-person drags for forwards and backwards iterations were 8.36 ± 1.23s and 11.04 ± 1.11s. The average individual force exerted during the one-person 55 kg drag was equivalent to the average individual contribution during the two-person 110 kg drag (t₍₁₆₎ = 3.3780, p < 0.001); suggesting a one-person 55 kg simulated casualty drag is representative of the individual contribution to a two-person 110 kg simulated casualty drag. Individual contributions can however vary during two-person simulated casualty drags.

Validation of a suite of ERP and QEEG biomarkers in a pre-competitive, industry-led study in subjects with schizophrenia and healthy volunteers

OBJECTIVE

Complexity and lack of standardization have mostly limited the use of event-related potentials (ERPs) and quantitative EEG (QEEG) biomarkers in drug development to small early phase trials. We present results from a clinical study on healthy volunteers (HV) and patients with schizophrenia (SZ) that assessed test-retest, group differences, variance, and correlation with functional assessments for ERP and QEEG measures collected at clinical and commercial trial sites with standardized instrumentation and methods, and analyzed through an automated data analysis pipeline.

METHODS

81 HV and 80 SZ were tested at one of four study sites. Subjects were administered two ERP/EEG testing sessions on separate visits. Sessions included a mismatch negativity paradigm, a 40 Hz auditory steady-state response paradigm, an eyes-closed resting state EEG, and an active auditory oddball paradigm. SZ subjects were also tested on the Brief Assessment of Cognition (BAC), Positive and Negative Syndrome Scale (PANSS), and Virtual Reality Functional Capacity Assessment Tool (VRFCAT).

RESULTS

Standardized ERP/EEG instrumentation and methods ensured few test failures. The automated data analysis pipeline allowed for near real-time analysis with no human intervention. Test-retest reliability was fair-to-excellent for most of the outcome measures. SZ subjects showed significant deficits in ERP and QEEG measures consistent with published academic literature. A subset of ERP and QEEG measures correlated with functional assessments administered to the SZ subjects.

CONCLUSIONS

With standardized instrumentation and methods, complex ERP/EEG testing sessions can be reliably performed at clinical and commercial trial sites to produce high-quality data in near real-time.

Changes in physical performance during British Army Junior Entry, British Army Standard Entry and Royal Air Force Basic Training

INTRODUCTION

The purpose was to quantify physical performance in men and women during British Army Junior Entry (Army-JE), British Army Standard Entry (Army-SE) and Royal Air Force (RAF) basic training (BT).

DESIGN

Prospective longitudinal study.

METHODS

381 participants ((339 men and 42 women) n=141 Army-JE, n=132 Army-SE, n=108 RAF) completed a 2 km run, medicine ball throw (MBT) and isometric mid-thigh pull (MTP), pre-BT and post-BT. To examine changes in pre-BT to post-BT physical test performance, for each course, paired Student t-test and Wilcoxon test were applied to normally and non-normally distributed data, respectively, with effect sizes reported as Cohen's D and with rank biserial correlations, respectively. A one-way between-subjects analysis of variance (ANOVA) (or Welch ANOVA for non-normally distributed data) compared performance between quartiles based on test performance pre-BT. Where the main tests statistic, p value and effect sizes identified likely effect of quartile, post hoc comparisons were made using Games-Howell tests with Tukey's p value. Data are presented as mean±SD, with statistical significance set at p<0.05.

RESULTS

During BT, 2 km run time improved by 13±46 s (-2.1%±8.1%), 30±64 s (-4.8%±12.3%) and 24±27 s (-4.5%±5.1%) for Army-JE, Army-SE and RAF, respectively (all p<0.005). MBT distance increased by 0.27±0.28 m (6.8%±7.0%) for Army-JE (p<0.001) and 0.07±0.46 m (2.3%±10.9%) for Army-SE (p=0.040), but decreased by 0.08±0.27 m (-1.4%±6.0%) for RAF (p=0.002). MTP force increased by 80±281 n (10.8%±27.6%) for Army-JE (p<0.001) and did not change for Army-SE (-36±295 n, -0.7%±20.6%, p=0.144) or RAF (-9±208 n, 1.0±17.0, p=0.603). For all tests and cohorts, participants in the lowest quartile of pre-BT performance scores demonstrated greater improvements, compared with participants in the highest quartile (except Army-JE MBT, ∆% change similar between all quartiles).

CONCLUSIONS

Changes in physical performance were observed for the three fitness tests following the different BT courses, and recruits with the lowest strength and aerobic fitness experienced greatest improvements.

65 POLYPHARMACY BURDEN IN THE RAPID-ACCESS FRAILTY ASSESSMENT UNIT (RAFAU)

Background

The adverse outcomes associated with polypharmacy (regular use of five or more medications) are well described. One in three over 65 report polypharmacy in Ireland (The Irish Longitudinal Study on Ageing, 2012). A review of the burden of polypharmacy was carried out in a Rapid Access Frailty Assessment Unit (RAFAU) in a regional Irish hospital.

Methods

Data was collected on each patient presenting to the RAFAU from May 2021 to March 2022. Each patient was categorised based on number of medications taken. It was recorded whether each patient had a change made to their medications during their review. The inclusion criterion was any patient over 65 presenting to the RAFAU with clear documentation of their medications. Excluded were those without medication lists available.

Results

Polypharmacy data was collected in 496 of the total 587 patients attending RAFAU since May 2021. A higher proportion of 59% (n=496) were female. The mean clinical frailty score was four. 100% of the group were reviewed by a doctor.

78.6% of patients were prescribed over five medications. 49.3% of patients were prescribed between 5-10 medications. 22.9% were prescribed 10-15 medications and 6.4% prescribed over 15 medications. 60.8% had a change made to their medication. The incidence of medication changes initiated rose with the increasing number of prescribed medications. 71% of those with more than 15 medications had changes made.

Conclusion

The incidence of polypharmacy in those attending RAFAU is extremely high. The frailty unit is an ideal location to review and reduce medication burden as patients have access to a specialist clinician and multidisciplinary team. Although 60% of our patients had medication changes made, we do not use a standard tool in RAFAU to guide medication reduction in frail patients with polypharmacy. It is planned to introduce routine assessment of polypharmacy utilising the STOPP/START tool and re-audit one year after implementation.

Comparative effectiveness of sacubitril/valsartan versus angiotensin converting enzyme inhibitors/angiotensin receptor blockers in de novo heart failure patients

Introduction

Effective use of pharmacological therapy in de novo heart failure (HF) patients is key for slowing down the progression of HF. Randomised clinical trials have shown sacubitril/valsartan (sac/val), providing superior benefit over renin angiotensin system (RAS) blockade with angiotensin converting enzyme inhibitors (ACEi) in patients with HF with reduced ejection fraction (HFrEF) including de novo HF patients. However, real world evidence is scarce.

Purpose

To compare the rate of all-cause hospitalisations in a real world de novo HFrEF US patient population after initiating sac/val or initiating or continuing RAS blockade with ACEi or angiotensin receptor blockers (ARB) within one year of index date.

Methods

This retrospective, non-interventional cohort study included adult de novo HFrEF patients (left ventricular ejection fraction ≤40%), from the Optum Electronic Health Records, from Jan 2016 to Mar 2020 (study period: Dec 2013–Mar 2021) who were prescribed sac/val or ACEi/ARB within 30 days of a new HF diagnosis. Patients either with any history of HF in the prior two years or with prior sac/val treatment were excluded. Index date was defined as the first prescription of sac/val or ACEi/ARB after a new HF diagnosis (≤30 days prior to index). One-to-two greedy propensity score matching was used to balance the study arms on demographics and clinical covariates (medications, LVEF, selected comorbidities). Negative binomial models were used to compare the primary endpoint between treatment groups and across subgroups of interest. The primary endpoint was the rate of all-cause hospitalisations within one year from index. Treatment groups were stratified by age, sex, race, ethnicity, history of myocardial infarction, comorbidities and prior ACEi/ARB treatment. Statistical analyses were conducted using R and SAS software.

Results

Prior to matching, 3,290 patients were initiated on sac/val, 47,678 on ACEi/ARB and post-matching there were 3,290 patients on sac/val and 6,580 patients on ACEi/ARB. Patients with prior ACEi/ARB treatment in both the groups were 1,597 and 2,806, respectively. Mean age was 63.5 in sac/val and 63.7 years in ACEi/ARB groups. After propensity-score matching, the annual rate (per person-year) of all-cause hospitalisation was lower in sac/val compared with ACEi/ARB group, with incidence rate ratio (IRR) of 0.81 (95% confidence interval [CI]: 0.74–0.90) ≤1 year from index. Similarly, in the ACEi/ARB treatment naïve subgroup, sac/val treatment led to 20% reduction in the primary endpoint (IRR: 0.80, 95% CI: 0.69–0.92) compared with ACEi/ARB. Amongst subgroups, results were consistent for most, with significant reduction seen in all-cause hospitalisation rates with sac/val treatment vs. ACEi/ARB.

Conclusion

Treatment with sac/val vs. ACEi or ARB significantly reduced the risk of all-cause hospitalisations in this real-world study supporting the first-line use of sac/val in treating de novo HFrEF patients.

Funding Acknowledgement

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

822 The Use of Prophylactic Antibiotics Pre-Orchidectomy – a Retrospective Cohort Study

Aim

NICE guidance recommends the use of antibiotic prophylaxis in clean-contaminated procedures and when a prosthetic is placed. However, the use in orchidectomies is not specified under the treatment summary heading of ‘Urological Procedures, Antibacterial Prophylaxis’. The use of prophylactic antibiotics pre-orchidectomy varied amongst senior urologists within a District General Hospital, where no specific protocol was in use. This retrospective cohort study aimed to decipher if the use of prophylactic antibiotics reduced post-operative infection incidence following radical orchidectomies.

Method

50 consecutive orchidectomies, performed between February 2019 and July 2021, were analysed. It was identified whether the patient had antibiotics administered pre-operatively and if they developed a subsequent wound infection through post-operative ward rounds, clinic letters and presentations to the Emergency Department. Orchidectomies performed by general surgeons were excluded from analysis.

Results

Of the 50 orchidectomies analysed, 30 patients received pre-operative antibiotics, four of whom subsequently developed a post-operative infection. Of the 20 patients that did not receive prophylactic antibiotics, nine developed a post-operative infection. The relative risk was calculated at 0.2963 with a 70.4% relative risk reduction if prophylactic antibiotics were administered. Chi squared tests calculated a p-value of 0.012 highlighting statistical significance. Eight patients had primary prosthesis placed at the time of orchidectomy, all of whom received prophylactic antibiotics.

Conclusion

Prophylactic antibiotics were effective in preventing post-orchiectomy wound infections and routine local protocols should advise the use in orchidectomies, which classify as clean-contaminated procedures as per NICE guidance.

Clinical Efficacy of a 2-Week Treatment Course of Zuranolone for the Treatment of Major Depressive Disorder and Postpartum Depression: Outcomes From the Clinical Development Program

Introduction

Antidepressants that offer a rapid onset of action without requiring chronic use are greatly needed in both major depressive disorder (MDD) and postpartum depression (PPD). Zuranolone is an investigational, oral, neuroactive steroid and GABA_A receptor positive allosteric modulator in clinical development as a 2-week treatment course for MDD and PPD.

Objectives

To present the efficacy and safety of zuranolone vs placebo in Phase 2 and 3 trials.

Methods

In the studies presented (Table 1), improvements in depressive symptoms were assessed by least-squares mean (LSM) using a mixed-effects model for repeated measures on the change from baseline (CFB) at Day 15 in the 17-item Hamilton Rating Scale for Depression total score (HAMD-17; primary endpoint for all trials) and the Montgomery–Åsberg Depression Rating Scale (MADRS; secondary endpoint) following a 14-day treatment course of once-daily zuranolone.

Results

Compared with placebo, zuranolone treatment led to rapid improvements in depressive symptoms across clinical trials, with significant improvements (LSM treatment difference [SE] in CFB) in HAMD-17 and MADRS scores at Day 15 in 3 of the 4 trials (Table 2). Common treatment-emergent adverse events (≥5% in zuranolone treatment arms) were headache, somnolence, dizziness, nausea, sedation, diarrhea, upper respiratory tract infection, and fatigue (Table 3). No incidences of loss of consciousness or excessive sedation were observed.

Conclusions

Across the completed studies in the zuranolone clinical trial program, patients receiving zuranolone consistently experienced improvement in depressive symptoms following a 2-week treatment course. Treatment with zuranolone was generally well tolerated with a consistent safety and tolerability profile.

Disclosure

The MDD-201B, MOUNTAIN, and ROBIN studies were sponsored by Sage Therapeutics, Inc; the WATERFALL study was sponsored by Sage Therapeutics, Inc, and Biogen. Medical writing and editorial support were provided by MediTech Media, Ltd, and funded by Biogen.

Employing the theory of planned behaviour to design an e-cigarette education resource for use in secondary schools

Background

An extended version of the theory of planned behaviour (TPB) was used to inform the design of a framework for an educational resource around e-cigarette use in young people.

Methods

A sequential exploratory design was employed. In Phase 1, elicited behavioural, normative and control beliefs, via 7 focus groups with 51 participants, aged 11–16 years, identified salient beliefs around e-cigarette use. These were used to construct a questionnaire administered to 1511 young people aged 11–16 years, which determined predictors of e-cigarette use and ever use. In Phase 2, sociodemographic variables, e-cigarette knowledge, access, use, marketing and purchasing of e-cigarettes and smoking behaviour were also gathered. The composite findings from Phase 1 and 2 informed the design of a post primary educational resource in Phase 3 around e-cigarette use.

Results

Current e-cigarette use was 4%, with almost 23% reporting ever use, suggesting current use is stable but experimentation may be increasing in this cohort. Sociodemographic variables, knowledge of e-cigarettes, smoking behaviour and TPB variables (direct and indirect measures of attitudes, subjective norm, and perceived behavioural control) accounted for 17% of the variance in current e-cigarette use, with higher intentions to use e-cigarettes within the next month, having the strongest impact on use (p < 0.001), followed by self-efficacy (p = 0.016). Sociodemographic and TPB variables accounted for 65% of the variance in intentions to use e-cigarettes in the next month; current e-cigarette use (p < 0.001), more positive attitudes (p < 0.001), stronger social influence (p < 0.001), higher self-efficacy (p < 0.001), higher control beliefs (p < 0.001) and greater motivation to use e-cigarettes (p < 0.001) were the main predictors of intentions. Phases 1 and 2 informed the mapping of key predictors of intentions and use of e-cigarettes onto the Theoretical Domains Framework, which identified appropriate intervention functions and behaviour change techniques.

Conclusions

This paper is the first to bridge the theoretical-practice gap in an area of significant public health importance through the development of a framework for a novel theory driven school-based educational resource aimed at reducing experimentation and uptake of e-cigarette use in young people.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12674-3.

What we may learn - and need - from pandemic fiction

N/A.

Achievements and challenges in developing health leadership in South Africa: the experience of the Oliver Tambo Fellowship Programme 2008-2014

The Oliver Tambo Fellowship Programme is convened by the School of Public Health and Family Medicine, University of Cape Town, South Africa. It is a health leadership training programme with a post-graduate Diploma at its core, supplemented by management seminars, mentorship and alumni networking. An external evaluation was conducted in 2015 for the period since 2008. This rapid, descriptive study made use of mixed methods-including a document review of existing Programme material (management reports, anonymized alumni's implementation project reports, exit interviews, field interviews and e-mailed questionnaires), a brief e-mailed questionnaire, and 18 semi-structured telephonic interviews conducted by the evaluator with Programme alumni, convenors and senior government line managers. Data were analysed according to indicators and associated criteria developed by the evaluator on the basis of the Programme's objectives, international experience, the nature of the South African health system and the particular philosophy of the Programme. The evaluation found that the Diploma offered a unique contribution. This is because it sought less to convey new technical knowledge, than to empower and galvanize students to become change agents in the complex settings of their workplaces. Reflective practice was an important part of this process. Alumni were able to point to a number of positive changes in their management practice and motivation, translating these into improved performance by their teams and more effective health services. Alumni also helped to build the capacity of their own and other staff, sharing the knowledge and skills they had gained through the Programme, and leading by example. However, the Programme found it difficult to arrange adequate mentorship or peer support for alumni once they returned to their workplaces, pointing to the need for human resource development units in government to become more active in supporting alumni and holding them accountable for improving practice.

Does expanding fiscal space lead to improved funding of the health sector in developing countries?: lessons from Kenya, Lagos State (Nigeria) and South Africa

Background: The global focus on promoting Universal Health Coverage has drawn attention to the need to increase public domestic funding for health care in low- and middle-income countries.

Objectives: This article examines whether increased tax revenue in the three territories of Kenya, Lagos State (Nigeria) and South Africa was accompanied by improved resource allocation to their public health sectors, and explores the reasons underlying the observed trends.

Methods: Three case studies were conducted by different research teams using a common mixed methods approach. Quantitative data were extracted from official government financial reports and used to describe trends in general tax revenue, total government expenditure and government spending on the health sector and other sectors in the first decade of this century. Twenty-seven key informant interviews with officials in Ministries of Health and Finance were used to explore the contextual factors, actors and processes accounting for the observed trends. A thematic content analysis allowed this qualitative information to be compared and contrasted between territories.

Findings: Increased tax revenue led to absolute increases in public health spending in all three territories, but not necessarily in real per capita terms. However, in each of the territories, the percentage of the government budget allocated to health declined for much of the period under review. Factors contributing to this trend include: inter-sectoral competition in priority setting; the extent of fiscal federalism; the Ministry of Finance’s perception of the health sector’s absorptive capacity; weak investment cases made by the Ministry of Health; and weak parliamentary and civil society involvement.

Conclusion: Despite dramatic improvements in tax revenue collection, fiscal space for health in the three territories did not improve. Ministries of Health must strengthen their ability to motivate for larger allocations from government revenue through demonstrating improved performance and the relative benefits of health investments.

Chemotherapeutic response to cisplatin-like drugs in human breast cancer cells probed by vibrational microspectroscopy

Studies of drug-cell interactions in cancer model systems are essential in the preclinical stage of rational drug design, which relies on a thorough understanding of the mechanisms underlying cytotoxic activity and biological effects, at a molecular level. This study aimed at applying complementary vibrational spectroscopy methods to evaluate the cellular impact of two Pt(ii) and Pd(ii) dinuclear chelates with spermine (Pt2Spm and Pd2Spm), using cisplatin (cis-Pt(NH3)2Cl2) as a reference compound. Their effects on cellular metabolism were monitored in a human triple-negative metastatic breast cancer cell line (MDA-MB-231) by Raman and synchrotron-radiation infrared microspectroscopies, for different drug concentrations (2-8 μM) at 48 h exposure. Multivariate data analysis was applied (unsupervised PCA), unveiling drug- and concentration-dependent effects: apart from discrimination between control and drug-treated cells, a clear separation was obtained for the different agents studied - mononuclear vs. polynuclear, and Pt(ii) vs. Pd(ii). Spectral biomarkers of drug action were identified, as well as the cellular response to the chemotherapeutic insult. The main effect of the tested compounds was found to be on DNA, lipids and proteins, the Pd(ii) agent having a more significant impact on proteins while its Pt(ii) homologue affected the cellular lipid content at lower concentrations, which suggests the occurrence of distinct and unconventional pathways of cytotoxicity for these dinuclear polyamine complexes. Raman and FTIR microspectroscopies were confirmed as powerful non-invasive techniques to obtain unique spectral signatures of the biochemical impact and physiological reaction of cells to anticancer agents.

Investigation and diagnostic formulation in patients admitted with transient loss of consciousness

Several commonly completed tests have low diagnostic yield in the setting of transient loss of consciousness (T-LOC). We estimated the use and cost of inappropriate investigations in patients admitted with T-LOC and assessed if these patients were given a definitive diagnosis for their presentation. We identified 80 consecutive patients admitted with T-LOC to a university teaching hospital. Eighty-eight percent (70/80) had a computerized topography (CT) brain scan and 49% (34/70) of these scans were inappropriate based on standard guidelines. Almost half (17/80) of electroencephalograms (EEG) and 82% (9/11) of carotid doppler ultrasound performed were not based on clinical evidence of seizure or stroke respectively. Forty-four percent (35/80) of patients had no formal diagnosis documented for their presentation. Inappropriate investigation in T-LOC is very prevalent in the acute hospital, increasing cost of patient care. In addition, there is poor diagnostic formulation for T-LOC making recurrent events more likely in the absence of definitive diagnoses.

Audit of provincial IVIG Request Forms and efficacy documentation in four Ontario tertiary care centres

OBJECTIVE

Retrospective audit of IVIG Request Forms in four Ontario tertiary care centres: to determine the case mix of new IVIG requests, to authenticate information provided, and to determine documentation of clinical efficacy.

AIMS

To understand contributors to increases in IVIG utilisation and to determine whether IVIG is being used and monitored appropriately.

INTRODUCTION

Intravenous immunoglobulin (IVIG) use in Canada is high compared with other developed countries. We performed a retrospective audit of new IVIG Request Forms across four tertiary care centres in Ontario, one with an active surveillance programme, to determine the case mix, authenticate information provided and assess documentation of efficacy.

METHODS

Consecutive adult patients with a first-time IVIG request in 2014 were included. The ordering physician specialty, form completeness, documentation of diagnostic criteria for the medical condition and indication for IVIG use and documentation of efficacy were assessed by form and chart review.

RESULTS

Of 178 patients, the most common indications for IVIG were immune thrombocytopenia (24.2%) and secondary immune deficiency (20.2%). The most frequent prescribers were haematologists (37.6%) and neurologists (10.7%). Other conditions not listed on the form represented 24.2% of cases, with most not indicated in current guidelines. A total of 32.6% of cases overall lacked verification of diagnostic criteria and 51.7% lacked verification for IVIG utilisation criteria, with the number of cases meeting criteria based on documentation being higher at the active surveillance site (P = 0.005). A total of 19.1% of cases had a discrepancy between the indication written on the form and the documented clinical diagnosis. A total of 18.7% of clinic notes following IVIG had no mention of efficacy.

CONCLUSION

Our audit demonstrates a lack of compliance with IVIG Request Form requirements, a lack of documentation of diagnostic criteria and efficacy, and suggests inappropriate use of IVIG. Current implementation of the form may not be sufficient as a strategy for improving appropriate IVIG use.

Dementia in the acute hospital: the prevalence and clinical outcomes of acutely unwell patients with dementia

BACKGROUND

Studies have demonstrated that a significant minority of older persons presenting to acute hospital services are cognitively impaired; however, the impact of dementia on long-term outcomes is less clear.

AIM

To evaluate the prevalence of dementia, both formally diagnosed and hitherto unrecognised in a cohort of acutely unwell older adults, as well as its impact on both immediate outcomes (length of stay and in-hospital mortality) and 12-month outcomes including readmission, institutionalisation and death.

DESIGN

Prospective observational study.

METHODS

190 patients aged 70 years and over, presenting to acute hospital services underwent a detailed health assessment including cognitive assessment (standardised Mini Mental State Examination, AD8 and Confusion Assessment Method for the Intensive Care Unit). Patients or informants were contacted directly 12 months later to compile 1-year outcome data. Dementia was defined as a score of 2 or more on the AD8 screening test.

RESULTS

Dementia was present in over one-third of patients (73/190). Of these patients, 36% (26/73) had a prior documented diagnosis of dementia with the remaining undiagnosed before presentation. The composite outcome of death or readmission to hospital within the following 12 months was more likely to occur in patients with dementia (73% (53/73) vs. 58% (68/117), P = 0.043). This finding persisted after controlling for age, gender, frailty status and medical comorbidities, including stroke and heart disease.

CONCLUSION

A diagnosis of dementia confers an increased risk of either death or further admission within the following 12 months, highlighting the need for better cognitive screening in the acute setting, as well as targeted intervention such as comprehensive geriatric assessment.

Epigastric pain…it's not always alcohol! An unusual presentation of caecal intussusception

Our patient is a 19-year-old man who presented to the emergency department after consuming 50-60 units of alcohol over a weekend. He presented with a 2-day history of right-upper quadrant (RUQ) and epigastric pain radiating to the back. On examination he was haemodynamically stable. His abdomen was soft with minimal tenderness in the RUQ, epigastric and right-iliac fossa areas. Laboratory results showed a slightly raised erythrocyte sedimentation rate. Amylase and white cell count were normal. Ultrasound was performed raising the suspicion of intussusception. A CT scan was recommended and confirmed the presence of an intussusception. Once diagnosis was established, the patient had an emergency laparotomy and right hemicoloectomy, with per-operative findings consistent with the CT findings. This case illustrates the importance of keeping an open approach to all differentials while considering a diagnosis along with the importance of recognising intussusception when it occurs as complications can each represent a cause of mortality on their own.

Comparison of prescribing and adherence patterns of anti-osteoporotic medications post-admission for fragility type fracture in an urban teaching hospital and a rural teaching hospital in Ireland between 2005 and 2008

INTRODUCTION

Poor adherence reduces the potential benefits of osteoporosis therapy, lowering gains in bone mineral density resulting in increased risk of fractures.

AIM

To compare prescribing and adherence patterns of anti-osteoporotic medications in patients admitted to an urban teaching hospital in Ireland with a fragility type fracture to patients admitted to a rural hospital in the North Western region.

METHODOLOGY

We identified all patients >55 years admitted to Sligo General Hospital between 2005 and 2008 with a fragility fracture (N = 744) using the hospital in-patient enquiry system (HIPE). The medical card number of those patients eligible for the primary care reimbursement services scheme (PCRS) facilitated the linkage of the HSE-PCRS scheme database to the HIPE database which enabled a study to identify persistence rates of patients prescribed osteoporosis therapy after discharge. The results were compared to the findings of a similar study carried out in St. James's Hospital, Dublin.

RESULTS

The 12 months post-fracture prescribing increased from 11.0 % (95 % CI 9.6, 12.4) in 2005 to 47 % (95 % CI 43.6, 50.3) in 2008 in the urban setting and from 25 % (95 % CI 21.5, 28.9) to 39 % (95 % CI 34.5, 42.7) in the rural setting. Adherence levels to osteoporosis medications at 12 months post-initiation of therapy was <50 % in both study groups. Patients on less frequent dosing regimes were better adherers.

CONCLUSION

The proportion of patients being discharged on anti-osteoporosis medications post-fragility fracture increased between 2005 and 2008 in both patient groups. Sub-optimal adherence levels to osteoporosis medications continue to be a major concern.

Developing a new mid-level health worker: lessons from South Africa's experience with clinical associates

Background

Mid-level medical workers play an important role in health systems and hold great potential for addressing the human resource shortage, especially in low- and middle-income countries. South Africa began the production of its first mid-level medical workers – known as clinical associates – in small numbers in 2008.

Objective

We describe the way in which scopes of practice and course design were negotiated and assess progress during the early years. We derive lessons for other countries wishing to introduce new types of mid-level worker.

Methods

We conducted a rapid assessment in 2010 consisting of a review of 19 documents and 11 semi-structured interviews with a variety of stakeholders. A thematic analysis was performed.

Results

Central to the success of the clinical associate training programme was a clear definition and understanding of the interests of various stakeholders. Stakeholder sensitivities were taken into account in the conceptualisation of the role and scope of practice of the clinical associate. This was achieved by dealing with quality of care concerns through service-based training and doctor supervision, and using a national curriculum framework to set uniform standards.

Conclusions

This new mid-level medical worker can contribute to the quality of district hospital care and address human resource shortages. However, a number of significant challenges lie ahead. To sustain and expand on early achievements, clinical associates must be produced in greater numbers and the required funding, training capacity, public sector posts, and supervision must be made available. Retaining the new cadre will depend on the public system becoming an employer of choice. Nonetheless, the South African experience yields positive lessons that could be of use to other countries contemplating similar initiatives.

Abstract LB-308: Combination of CTx-0294945 a highly selective inhibitor of focal adhesion kinase with bevacizumab in pre-clinical models of breast cancer

Background: Focal adhesion kinase (FAK) is a non-receptor tyrosine kinase that provides a critical hub for signalling from at least four different classes of cellular sensing mechanisms including growth factor receptors, GPCRs, integrins and mechanical stress forces. By temporal and spatial integration of signals from these sources, FAK plays a central role in cell migration, invasion and proliferation; processes vital for tumorigenesis. The significance of FAK to the function of signal transduction pathways provides a strong rationale for the combination of FAK inhibitors with other targeted agents to achieve improved efficacy against a range of cancers. Others have demonstrated the importance of FAK in angiogenesis and therefore combining a FAKi with anti-VEGF agents is attractive as it employs two complementary mechanisms of suppressing the formation of tumor vasculature. Here we present results from the co-administration of CTx-0294945, a highly selective FAKi, and bevacizumab (bev) in an orthotopic model of human breast cancer. Methods and Results: CTx-0294945 is an orally bioavailable small molecule ATP competitive inhibitor of focal adhesion kinase (FAK KD=0.21 nM). It exhibits high selectivity against a diverse panel of 125 kinases including the closely related Pyk2. CTx-0294945 inhibits autophosphorylation of 397Y-FAK in MDA-MB-231 cells with an IC50 = 7 nM and exhibits low general cellular toxicity (IC50 = 2.7 µM, MDA-MB-231 cells). CTx-0294945 is suitable for oral administration (%F=58 and t1/2=5.1 h at 20 mg/Kg in rat) and does not inhibit (IC50 &gt;20 µM) any of the cytochrome p450 isoforms tested to date. To assess the co-administration of CTx-0294945 with bev, mice were injected orthotopically with MDA-MB-231 cells (106). After 14 days, when tumors were palpable, mice were randomized into 4 groups and dosing commenced. The groups were treated with CTx-0294945 (80 mg/kg QD, PO), bev (12.5 mg/Kg IP, x2/week), CTx-0294945 (80 mg/Kg QD, PO) and bev (12.5 mg/Kg IP, x2/week) or vehicle. Tumor growth was monitored and on day 28 animals in the vehicle and CTx-0294945 arms were culled when the size of the tumors reached ethical end point (1000 mm3). Tumor growth in the bev only and the CTx-0294945 + bev arms was significantly inhibited (75% and 88% TGI respectively). At this time the treatment regimes for both cohorts were stopped and tumor growth allowed to progress. After an additional 14 days the experiment was terminated when the bev treatment group reached ethical end point; however the average size of the tumors in the CTx-0294945 + bev cohort was still was only 562 mm3. Conclusions: Our data suggest the potential utility of combining a selective FAK inhibitor with bevacizumab to prevent tumour progression and enhance the durability of response.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr LB-308. doi:1538-7445.AM2012-LB-308

Approaches to developing the capacity of health policy analysis institutes: a comparative case study

Objectives

To review and assess (i) the factors that facilitate the development of sustainable health policy analysis institutes in low and middle income countries and (ii) the nature of external support for capacity development provided to such institutes.

Methods

Comparative case studies of six health policy analysis institutes (3 from Asia and 3 from Africa) were conducted. In each region an NGO institute, an institute linked to government and a university based institute were included. Data collection comprised document review, semi-structured interviews with stakeholders and discussion of preliminary findings with institute staff.

Findings

The findings are organized around four key themes: (i) Financial resources: three of the institutes had received substantial external grants at start-up, however two of these institutes subsequently collapsed. At all but one institute, reliance upon short term, donor funding, created high administrative costs and unpredictability. (ii) Human resources: the retention of skilled human resources was perceived to be key to institute success but was problematic at all but one institute. In particular staff often moved to better paid positions elsewhere once having acquired necessary skills and experience, leaving remaining senior staff with heavy workloads. (iii) Governance and management: board structures and roles varied according to the nature of institute ownership. Boards made important contributions to organizational capacity through promoting continuity, independence and fund raising. Routine management systems were typically perceived to be strong. (iv) Networks: linkages to policy makers helped promote policy influences. External networks with other research organizations, particularly where these were longer term institutional collaborations helped promote capacity.

Conclusions

The development of strong in-country analytical and research capacity to guide health policy development is critical, yet many health policy analysis institutes remain very fragile. A combination of more strategic planning, active recruitment and retention strategies, and longer term, flexible funding, for example through endowments, needs to be promoted. Specific recommendations to funders and institutes are provided.

Influencing policy change: the experience of health think tanks in low- and middle-income countries

In recent years there has been a growth in the number of independent health policy analysis institutes in low- and middle-income countries which has occurred in response to the limitation of government analytical capacity and pressures associated with democratization. This study aimed to: (i) investigate the contribution made by health policy analysis institutes in low- and middle-income countries to health policy agenda setting, formulation, implementation and monitoring and evaluation; and (ii) assess which factors, including organizational form and structure, support the role of health policy analysis institutes in low- and middle-income countries in terms of positively contributing to health policy. Six case studies of health policy analysis institutes in Bangladesh, Ghana, India, South Africa, Uganda and Vietnam were conducted including two NGOs, two university and two government-owned policy analysis institutes. Case studies drew on document review, analysis of financial information, semi-structured interviews with staff and other stakeholders, and iterative feedback of draft findings. Some of the institutes had made major contributions to policy development in their respective countries. All of the institutes were actively engaged in providing policy advice and most undertook policy-relevant research. Relatively few were engaged in conducting policy dialogues, or systematic reviews, or commissioning research. Much of the work undertaken by institutes was driven by requests from government or donors, and the primary outputs for most institutes were research reports, frequently combined with verbal briefings. Several factors were critical in supporting effective policy engagement. These included a supportive policy environment, some degree of independence in governance and financing, and strong links to policy makers that facilitate trust and influence. While the formal relationship of the institute to government was not found to be critical, units within government faced considerable difficulties.

Differences in 5-year survival after a 'homeless' or 'housed' drugs-related hospital admission: a study of 15--30-year olds in Scotland

BACKGROUND

Young drug misusers and the homeless both have a greater risk of death than their peers. This study sought to estimate the additional impact of homelessness on the risk of death for young drugs misusers.

METHODS

From all admissions to NHS hospitals in Scotland between 1986 and 2001, those that were: drug misuse related, for people born between 1970 and 1986 and aged over 15 years (n=13 303), were selected. All subsequent admissions and registrations of death were linked to this dataset. Each admission was coded as homeless if the health board of residence was coded as 'no fixed abode'. 5-year survival after an admission was modelled using (1) life table and (2) proportional hazard models and then (3) differences in causes of deaths were explored.

RESULTS

Immediately after a drugs-related hospital admission there was no difference in survival between the homeless and those with a 'fixed address'. However, over a 3-year period the risk for those who were homeless was 3.5 times greater (CI 95% 1.2 to 12.8). This elevated risk seemed to be particularly focused on the second year after an admission. The causes of death were similar for the two groups.

CONCLUSION

Although a homeless hospital admission is associated with a greater risk of death for young drug users, it is also a point in time when a young person is in contact with public services. An attempt to link their discharge with housing services would seem a potentially productive policy.

Alpha- and gamma-synuclein proteins are present in cerebrospinal fluid and are increased in aged subjects with neurodegenerative and vascular changes

BACKGROUND

Disease-specific biomarkers should reflect a fundamental feature of neuropathology and be validated in neuropathologically confirmed cases. Several synaptic proteins have been described in cerebrospinal fluid (CSF) of patients with dementia. In Lewy body disease alpha-synuclein is incorporated within Lewy bodies and alpha-, beta- and gamma-synucleins in dystrophic neuritis. These pathological changes are expected to be seen in CSF.

METHODS

A total of 25 CSF post-mortem samples (8 control and 17 subjects with dementia) were used to quantify alpha- and gamma-synucleins and IgG.

RESULTS

We describe for the first time the presence of gamma-synuclein in CSF. There is an elevation of both alpha- and gamma-synucleins in CSF from elderly individuals with Alzheimer's disease, Lewy body disease (LBD) and vascular dementia (CVD), compared to normal controls. gamma-Synuclein showed a greater elevation in LBD, IgG in CVD. The elevation of alpha- and gamma-synucleins was seen from Braak stage III onwards and remained stable until Braak stage VI. These results were not influenced by age at death or post-mortem delay.

CONCLUSIONS

The reported increases in alpha- and gamma-synucleins and IgG in the ventricular CSF of individuals with dementia are novel findings. They now need to be explored further using a greater number of cases in each subgroup, using lumbar CSF samples to determine their applicability and relevance to a clinical diagnostic setting. It needs to be established whether using these markers may help to discriminate LBD from other types of neurodegenerative and vascular dementias.

Developing health systems research capacities through north-south partnership: an evaluation of collaboration with South Africa and Thailand

BACKGROUND

Over the past ten years, calls to strengthen health systems research capacities in low and middle income countries have increased. One mechanism for capacity development is the partnering of northern and southern institutions. However, detailed case-studies of north-south partnerships, at least in the domain of health systems research, remain limited.This study aims to evaluate the partnerships developed between the Health Economics and Financing Programme of the London School of Hygiene and Tropical Medicine and three research partners in South Africa and Thailand to strengthen health economics-related research capacity.

METHODS

Data from programme documents were collected over five years to measure quantitative indicators of capacity development. Qualitative data were obtained from 25 in-depth interviews with programme staff from South Africa, Thailand and London.

RESULTS AND DISCUSSION

Five years of formal partnership resulted in substantial strengthening of individual research skills and moderate instituonalised strengthening in southern partner institutions. Activities included joint proposals, research and articles, staff exchange and post-graduate training. In Thailand, individual capacities were built through post-graduate training and the partner institution developed this as part of a package aimed at retaining young researchers at the institution. In South Africa, local post-graduate teaching programs were strengthened, regular staff visits/exchanges initiated and maintained and funding secured for several large-scale, multi-partner projects. These activities could not have been achieved without good personal relationships between members of the partner institutions, built on trust developed over twenty years. In South Africa, a critical factor was the joint appointment of a London staff member on long-term secondment to one of the partner institutions.

CONCLUSION

As partnerships mature the needs of partners change and new challenges emerge. Partners' differing research priorities (national v international; policy-led v academic-led) need to be balanced and equitable funding mechanisms developed recognising the needs and constraints faced by both southern and northern partners. Institutionalising partnerships (through long-term development of trust, engagement of a broad range of staff in joint activities and joint appointment of staff), and developing responsive mechanisms for governing these partnerships (through regular joint negotiation of research priorities and funding issues), can address these challenges in mutually acceptable ways. Indeed, by late 2005 the partnership under scrutiny in this paper had evolved into a wider consortium involving additional partners, more explicit mechanisms for managing institutional relationships and some core funding for partners. Most importantly, this study has shown that it is possible for long-term north-south partnership commitments to yield fruit and to strengthen the capacities of public health research and training institutions in less developed countries.

Implications for anaesthesia in a patient established on clozapine treatment

Clozapine is an atypical antipsychotic agent with a novel pharmacological profile and multiple clinical properties. Because of its side effects, it is recommended in treatment of severe resistant schizophrenia for which purpose it is remarkably effective. Little is known about the safety profile of clozapine during pregnancy and labour and because it is now used more commonly to manage schizophrenia, it is important that we as anaesthetists are aware of its many interactions and potential side effects. We present a case of a successful emergency caesarean section in a schizophrenic patient on clozapine treatment.

Central line-related bacteraemia due to Tsukamurella tyrosinosolvens in a haematology patient

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[A guideline for guidelines--methodological report and use of the guideline women's information]

Information and education is needed to empower autonomy and self-determination of patients (informed consent). Furthermore reliable and accurate medical information is necessary for patients who want to take an active part in medical decision-making. The aim of this work is to define the requirements helping to assure the development of good qualified information material relevant for women and female patients as "a guideline on women information". An example of its use is given by embeding this guideline in the guideline for early detection of breast cancer in Germany by defining the specific elements required for developing qualified information on this issue for women.

METHODS

A systematic, stepwise methodological process according to a level two guideline of the German Association of the Scientific Medical Societies (AWMF) and the Agency for Quality in Medicine (AZQ) was performed with the following elements: 1. Establishing an expert panel, 2. Generating the guideline statements by a formal, consensus based nominal group process, 3. External review process and finding supportive partners for the guideline on women information, 4. Using the guideline for guidelines: implementing the concept in the guideline of early detection of breast cancer in Germany.

RESULTS

The "guideline women information" comprises nine elements of quality assuring requirements for the development of gender-specific information material and eleven specific elements which directly relate to the guideline statements on early detection of breast cancer. After external review 30 organisations gave their written support for future implementation of the guideline. The "guideline women information" was integrated as a tool for quality assurance of lay information into the "guideline for early detection of breast cancer in Germany".

CONCLUSION

The "guideline women information" is a systematically developed, consensus-based recommendation to improve the development of qualified lay information at the point of its process by defining gender-specific aspects required for good lay information and its evaluation. As a guideline for guidelines its use is demonstrated by integrating this guideline into the "guideline for early detection of breast cancer in Germany" to ensure the development of qualified guideline compliant information.