Could nudges reduce health literacy disparities in CVD prevention? An experiment using alternative messages for CVD risk assessment screening

OBJECTIVE

To explore the effect of SMS nudge messages amongst people with varying health literacy on their intention to get a Heart Health Check.

METHODS

A 3 (Initial SMS: scarcity, regret, or control nudge) x 2 (Reminder SMS: social norm or control nudge) factorial design was used in a hypothetical online experiment. 705 participants eligible for Heart Health Checks were recruited. Outcomes included intention to attend a Heart Health Check and psychological responses.

RESULTS

In the control condition, people with lower health literacy had lower behavioural intentions compared to those with higher health literacy (p = .011). Scarcity and regret nudges closed this gap, resulting in similar intention levels for lower and higher health literacy. There was no interactive effect of the reminder nudge and health literacy (p = .724).

CONCLUSION

Scarcity and regret nudge messages closed the health literacy gap in behavioural intentions compared to a control message, while a reminder nudge had limited additional benefit. Health literacy should be considered in behavioural intervention evaluations to ensure health equity is addressed.

PRACTICE IMPLICATIONS

Results informed a national screening program using a universal precautions approach, where messages with higher engagement for lower health literacy groups were used in clinical practice.

Providing environmentally sustainable nephrology care: focus in low- and middle-income countries

Health care on a global scale significantly contributes to carbon emissions, with high-income countries being the primary culprits. Within health care, dialysis plays a significant role as a major source of emissions. Low- and middle-income countries have a high burden of kidney disease and are facing an increasing demand for dialysis. This reality presents multiple opportunities to plan for environmentally sustainable and quality kidney care. By placing a stronger emphasis on primary and secondary prevention of kidney disease and its progression, within the framework of universal health coverage, as well as empowering patients to enhance self-care, we can significantly reduce the need for costly and environmentally detrimental kidney replacement therapy. Mandating the adoption of lean and innovative low-carbon dialysis practices while also promoting the growth of kidney transplantation would enable low- and middle-income countries to take the lead in implementing environmentally friendly nephrology practices and reducing costs, thus optimizing sustainability and the well-being of individuals living with kidney disease.

REMAP Periop: a randomised, embedded, multifactorial adaptive platform trial protocol for perioperative medicine to determine the optimal enhanced recovery pathway components in complex abdominal surgery patients within a US healthcare system

INTRODUCTION

Implementation of enhanced recovery pathways (ERPs) has resulted in improved patient-centred outcomes and decreased costs. However, there is a lack of high-level evidence for many ERP elements. We have designed a randomised, embedded, multifactorial, adaptive platform perioperative medicine (REMAP Periop) trial to evaluate the effectiveness of several perioperative therapies for patients undergoing complex abdominal surgery as part of an ERP. This trial will begin with two domains: postoperative nausea/vomiting (PONV) prophylaxis and regional/neuraxial analgesia. Patients enrolled in the trial will be randomised to arms within both domains, with the possibility of adding additional domains in the future.

METHODS AND ANALYSIS

In the PONV domain, patients are randomised to optimal versus supraoptimal prophylactic regimens. In the regional/neuraxial domain, patients are randomised to one of five different single-injection techniques/combination of techniques. The primary study endpoint is hospital-free days at 30 days, with additional domain-specific secondary endpoints of PONV incidence and postoperative opioid consumption. The efficacy of an intervention arm within a given domain will be evaluated at regular interim analyses using Bayesian statistical analysis. At the beginning of the trial, participants will have an equal probability of being allocated to any given intervention within a domain (ie, simple 1:1 randomisation), with response adaptive randomisation guiding changes to allocation ratios after interim analyses when applicable based on prespecified statistical triggers. Triggers met at interim analysis may also result in intervention dropping.

ETHICS AND DISSEMINATION

The core protocol and domain-specific appendices were approved by the University of Pittsburgh Institutional Review Board. A waiver of informed consent was obtained for this trial. Trial results will be announced to the public and healthcare providers once prespecified statistical triggers of interest are reached as described in the core protocol, and the most favourable interventions will then be implemented as a standardised institutional protocol.

TRIAL REGISTRATION NUMBER

NCT04606264.

Cell-autonomous effects of APOE4 in restricting microglial response in brain homeostasis and Alzheimer's disease

Microglial involvement in Alzheimer's disease (AD) pathology has emerged as a risk-determining pathogenic event. While apolipoprotein E (APOE) is known to modify AD risk, it remains unclear how microglial apoE impacts brain cognition and AD pathology. Here, using conditional mouse models expressing apoE isoforms in microglia and central nervous system-associated macrophages (CAMs), we demonstrate a cell-autonomous effect of apoE3-mediated microglial activation and function, which are negated by apoE4. Expression of apoE3 in microglia/CAMs improves cognitive function, increases microglia surrounding amyloid plaque and reduces amyloid pathology and associated toxicity, whereas apoE4 expression either compromises or has no effects on these outcomes by impairing lipid metabolism. Single-cell transcriptomic profiling reveals increased antigen presentation and interferon pathways upon apoE3 expression. In contrast, apoE4 expression downregulates complement and lysosomal pathways, and promotes stress-related responses. Moreover, in the presence of mouse endogenous apoE, microglial apoE4 exacerbates amyloid pathology. Finally, we observed a reduction in Lgals3-positive responsive microglia surrounding amyloid plaque and an increased accumulation of lipid droplets in APOE4 human brains and induced pluripotent stem cell-derived microglia. Our findings establish critical isoform-dependent effects of microglia/CAM-expressed apoE in brain function and the development of amyloid pathology, providing new insight into how apoE4 vastly increases AD risk.

The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2021 Part II: Cardiac Transplantation

This article spotlights the research highlights of this year that specifically pertain to the specialty of anesthesia for heart transplantation. This includes the research on recent developments in the selection and optimization of donors and recipients, including the use of donation after cardiorespiratory death and extended criteria donors, the use of mechanical circulatory support and nonmechanical circulatory support as bridges to transplantation, the effect of COVID-19 on heart transplantation candidates and recipients, and new advances in the perioperative management of these patients, including the use of echocardiography and postoperative outcomes, focusing on renal and cerebral outcomes.

Trem2 H157Y increases soluble TREM2 production and reduces amyloid pathology

BACKGROUND

The rare p.H157Y variant of TREM2 (Triggering Receptor Expressed on Myeloid Cells 2) was found to increase Alzheimer's disease (AD) risk. This mutation is located at the cleavage site of TREM2 extracellular domain. Ectopic expression of TREM2-H157Y in HEK293 cells resulted in increased TREM2 shedding. However, the physiological outcomes of the TREM2 H157Y mutation remain unknown in the absence and presence of AD related pathologies.

METHODS

We generated a novel Trem2 H157Y knock-in mouse model through CRISPR/Cas9 technology and investigated the effects of Trem2 H157Y on TREM2 proteolytic processing, synaptic function, and AD-related amyloid pathologies by conducting biochemical assays, targeted mass spectrometry analysis of TREM2, hippocampal electrophysiology, immunofluorescent staining, in vivo micro-dialysis, and cortical bulk RNA sequencing.

RESULTS

Consistent with previous in vitro findings, Trem2 H157Y increases TREM2 shedding with elevated soluble TREM2 levels in the brain and serum. Moreover, Trem2 H157Y enhances synaptic plasticity without affecting microglial density and morphology, or TREM2 signaling. In the presence of amyloid pathology, Trem2 H157Y accelerates amyloid-β (Aβ) clearance and reduces amyloid burden, dystrophic neurites, and gliosis in two independent founder lines. Targeted mass spectrometry analysis of TREM2 revealed higher ratios of soluble to full-length TREM2-H157Y compared to wild-type TREM2, indicating that the H157Y mutation promotes TREM2 shedding in the presence of Aβ. TREM2 signaling was further found reduced in Trem2 H157Y homozygous mice. Transcriptomic profiling revealed that Trem2 H157Y downregulates neuroinflammation-related genes and an immune module correlated with the amyloid pathology.

CONCLUSION

Taken together, our findings suggest beneficial effects of the Trem2 H157Y mutation in synaptic function and in mitigating amyloid pathology. Considering the genetic association of TREM2 p.H157Y with AD risk, we speculate TREM2 H157Y in humans might increase AD risk through an amyloid-independent pathway, such as its effects on tauopathy and neurodegeneration which merit further investigation.

Pre-Habilitation of Cardiac Surgical Patients, Part 2: Frailty, Malnutrition, Respiratory disease, Alcohol/Smoking cessation and Depression

The concept of "pre-habilitation" comprises screening for and identification of pre-existing disorders followed by medical optimization. This is performed for many types of surgeries, but may have profound impacts on outcomes, particularly in cardiac surgery given the multiple comorbidities typically carried by these patients. Components of pre-habilitation include direct medical intervention by preoperative specialists as well as significant care coordination and shared decision-making. In this second part of a two-part review, the authors describe existing evidence to support the optimization of various preoperative problems and present a few institutional protocols utilized at out center for cardiac presurgical care. This second installment will focus on alcohol and smoking cessation and the management of frailty, malnutrition, respiratory disease, and depression.

Peripheral apoE4 enhances Alzheimer's pathology and impairs cognition by compromising cerebrovascular function

The ε4 allele of the apolipoprotein E (APOE) gene, a genetic risk factor for Alzheimer's disease, is abundantly expressed in both the brain and periphery. Here, we present evidence that peripheral apoE isoforms, separated from those in the brain by the blood-brain barrier, differentially impact Alzheimer's disease pathogenesis and cognition. To evaluate the function of peripheral apoE, we developed conditional mouse models expressing human APOE3 or APOE4 in the liver with no detectable apoE in the brain. Liver-expressed apoE4 compromised synaptic plasticity and cognition by impairing cerebrovascular functions. Plasma proteome profiling revealed apoE isoform-dependent functional pathways highlighting cell adhesion, lipoprotein metabolism and complement activation. ApoE3 plasma from young mice improved cognition and reduced vessel-associated gliosis when transfused into aged mice, whereas apoE4 compromised the beneficial effects of young plasma. A human induced pluripotent stem cell-derived endothelial cell model recapitulated the plasma apoE isoform-specific effect on endothelial integrity, further supporting a vascular-related mechanism. Upon breeding with amyloid model mice, liver-expressed apoE4 exacerbated brain amyloid pathology, whereas apoE3 reduced it. Our findings demonstrate pathogenic effects of peripheral apoE4, providing a strong rationale for targeting peripheral apoE to treat Alzheimer's disease.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Patient factors associated with the offering of telehealth appointments from primary care physicians among Medicare Beneficiaries: Results from a national survey

INTRODUCTION

This study assessed patient factors associated with self-reported telehealth offerings from their primary care physicians (PCPs) among Medicare beneficiaries during the COVID-19 pandemic, and compared potential telehealth accessibility of telehealth appointments from PCP by US census region before and during the COVID-19 pandemic.

METHODS

Data were from the Medicare Current Beneficiary Survey (MCBS) 2021 Winter COVID-19 Supplement. We conducted a multivariable logistic regression to examine patient-level factors associated with telehealth offerings.

RESULTS

Overall, 78% Medicare beneficiaries reported that they had access to telehealth appointments from their PCPs during the COVID-19 pandemic. Majority beneficiary respondents reported to have Internet access (82.1%) and own at least one type of computer device (81.5%). Respondents with Internet access (Adjusted Odds Ratio (AOR) = 1.66, 95% Confidence Interval (CI): 1.38, 2.00; p < 0.0001) and owning a device (AOR = 1.43, 95 %CI: 1.19, 1.72; p < 0.0001) were more likely to report PCP telehealth offerings controlling for patient characteristic variables in the model. Respondents who were female (AOR = 1.16, 95 %CI: 1.02, 1.31; p = 0.020), age group of 65-74 years (AOR = 1.29, 95 %CI: 1.07, 1.56; p = 0.008), income ≥$25,000 (AOR = 1.36, 95 %CI: 1.18 1.56; p < 0.0001), metropolitan residence (AOR = 1.96, 95 %CI: 1.72, 2.24; p < 0.0001), and with a history of weakened immune system (AOR = 1.46, 95 %CI: 1.18, 1.80; p < 0.0001) or diabetes (AOR = 1.20, 95 %CI: 1.06, 1.37; p = 0.005) were more likely to report PCP telehealth offerings compared to their counterparts. Non-Hispanic Black (AOR = 0.70, 95 %CI: 0.58, 0.85; p < 0.0001) (compared to Non-Hispanic-White) and beneficiaries living in the South (compared to those living in the Northwest, Midwest, and West) were less likely to report PCP telehealth offerings.

DISCUSSION

Key findings suggested health disparities existed in telehealth offerings from PCPs in terms of Internet access, device owning, age, race/ethnicity, income, residential locations, and census regions. Policy makers should consider these health disparities and provide targeted incentives and/or interventions when expanding and encouraging utilization of telehealth among Medicare beneficiaries.

POS0462 HYDROXYCHLOROQUINE REDUCES THE TITERS OF ANTI-DOMAIN 1 ANTIBODIES OVER TIME IN PATIENTS WITH PERSISTENTLY POSITIVE ANTIPHOSPHOLIPID ANTIBODIES: RESULTS FROM THE APS ACTION CLINICAL DATABASE AND REPOSITORY (“REGISTRY”)

Background

Data on fluctuation of antibodies directed against domain 1 (anti-D1) of β2-glycoprotein I (β2GPI) are scarce. Patients with antiphospholipid syndrome (APS) and all three criteria tests for antiphospholipid antibodies (aPL) display higher titers of anti-D1, which correlate with anti-β2GPI levels.

Objectives

This project aims at evaluating predictors of the variation of anti-D1 titers over time in a large international cohort of persistently aPL positive patients.

Methods

AntiPhospholipid Syndrome Alliance For Clinical Trials and InternatiOnal Networking (APS ACTION) Registry was created to study the course of persistently aPL-positive patients with or without autoimmune disorders over at least 10 years. Inclusion criteria are positive aPL by Updated Sapporo Criteria tested within one year prior to enrolment. Patients are followed every 12±3 months with clinical data and blood collection. Patients with available blood samples from at least three time points were included in this analysis. Anti-β2GPI and anti-D1 IgG were tested by chemiluminescence (BioFlash, Werfen) at APS ACTION core laboratories. Positive results were defined as >20 CU, according to the manufacturer. Clinical data were retrieved from APS ACTION online database. Anti-D1 titers within the same subject were compared by Friedman’s test. A mixed linear model was built to identify predictors of the fluctuation of anti-D1 antibody titers over time.

Results

In this longitudinal study, 230 patients with anti-D1 tested at 4 time points were included (Table 1). Patients with thrombotic APS had anti-D1 titers significantly higher than those without thrombosis (p=0.022). Among 135 patients with at least one anti-D1 positive result, anti-D1 titers varied significantly over time (Friedman statistics: 508.5, p<0.0001; anti-D1 geometric mean at baseline 189.0; T1 132.3 [-15%]; T2 113.8 [-17%]; T3 109.2 [-6% versus T2, -38% versus T1]). Anti-D1 titers were significantly higher at baseline compared to T3 (p=0.029). In the 4 years of follow-up, 18 new thrombotic events occurred. Patients with double/triple aPL positivity displayed 12.5 fold increase [95%CI 7.4-20.0] in baseline anti-D1 titers. After adjustment for age, gender and number of positive aPL tests, the fluctuation of anti-D1 titers was associated with treatment with hydroxychloroquine (HCQ) at each time-point. In particular, treatment with HCQ, but not those with conventional immunosuppressors, was associated with a 1.3-fold decrease in anti-D1 titers [95%CI 1.1-1.5]. In the same multivariable model, incident vascular events were associated with a 1.5 fold increase of anti-D1 titers. A concomitant diagnosis of systemic lupus erythematosus did not affect the fluctuation of anti-D1 titers.

Table 1.

Demographic and Clinical Characteristics of 230 APS ACTION Registry Patients with anti-D1 tested ≥3 time points during the follow-up

Anti-D1 pos samplesAnti-D1 neg samplesp-valueOverall sample(n=135)(n=95)(n=230)Age [years] mean (SD)42.3 (11.8)48.8 (13.0)0.000145.0 (12.7)%Female (n)71.9 (97)65.3 (62)0.35869.1 (159)Associated systemic autoimmune disease39.3 (53)44.2 (42)0.53941.3 (95)aPL without APS19.3 (26)34.7 (33)0.01025.7 (59)Thrombotic APS54.1 (73)53.7 (51)53.9 (124)Obstetric APS11.9 (16)5.3 (5)9.1 (21)Thrombotic/+obstetric APS14.8 (20)6.3 (6)11.3 (26)aCL IgG89.5 (119/133)25.5 (24/94)<0.000163.0 (143/227)aCL, IgM36.1 (48/133)27.7 (26/94)0.23432.6 (74/227)Anti-2GPI, IgG93.2 (124/133)39.4 (37/94)<0.000170.9 (161/227)Anti-2GPI, IgM34.6 (46/133)21.3 (20/94)0.04329.1 (66/227)LA82.8 (82/99)59.5 (44/74)0.00172.8 (126/173)

Conclusion

Treatment with HCQ and vascular events during follow-up were identified as significant predictors of the fluctuation of anti-D1 antibody titers over time.

Disclosure of Interests

None declared.

Intraoperative Hypoxia Independently Associated With the Development of Acute Kidney Injury Following Bilateral Orthotopic Lung Transplantation

BACKGROUND

Acute kidney injury (AKI) is a common postoperative complication in bilateral orthotopic lung transplant (BOLTx) recipients, but the contribution of intraoperative variables is not well defined. The authors hypothesized that intraoperative hypotension as well as hypoxia and vasopressor use would be associated with the development of postoperative AKI after BOLTx in patients without pre-existing renal dysfunction.

METHODS

The authors performed a retrospective analysis of patients undergoing BOLTx at a single center between 2013 and 2017. Intraoperative variables of hemodynamics included duration of mean arterial pressure <55, <60, and <65 mm Hg; duration of oxygen saturation <90%; and vasoactive-inotropic score (VIS). Associations between the occurrence of AKI and intraoperative hypotension, hypoxemia, and VIS were evaluated while controlling for significant confounding variables.

RESULTS

AKI occurred in 177 (72%) of 245 patients in postoperative days 1-7. Notable significant differences in univariate analyses included cumulative mechanical support time, maximum VIS, peripheral oxygen saturation <90% for >15 min, total minutes oxygen saturation <90%, and surgery duration in minutes. There was no significant difference in intraoperative hypotension measured as a duration >15 min for mean arterial pressure <55, <60, or <65 mm Hg. Multivariate logistic regression revealed preoperative creatinine (Odds ratio [OR], 7.77; confidence interval [CI], 1.96-30.83; P = 0.004), surgery duration (OR, 1.004; CI, 1.002-1.007; P = 0.002), and oxygen saturation (OR, 2.06; CI, 1.01-4.24; P = 0.049) <90% for >15 min to be independently associated with AKI.

CONCLUSIONS

This study revealed that >15 min of intraoperative hypoxia was independently associated with postoperative AKI after BOLTx.

Robust but weak winter atmospheric circulation response to future Arctic sea ice loss

The possibility that Arctic sea ice loss weakens mid-latitude westerlies, promoting more severe cold winters, has sparked more than a decade of scientific debate, with apparent support from observations but inconclusive modelling evidence. Here we show that sixteen models contributing to the Polar Amplification Model Intercomparison Project simulate a weakening of mid-latitude westerlies in response to projected Arctic sea ice loss. We develop an emergent constraint based on eddy feedback, which is 1.2 to 3 times too weak in the models, suggesting that the real-world weakening lies towards the higher end of the model simulations. Still, the modelled response to Arctic sea ice loss is weak: the North Atlantic Oscillation response is similar in magnitude and offsets the projected response to increased greenhouse gases, but would only account for around 10% of variations in individual years. We further find that relationships between Arctic sea ice and atmospheric circulation have weakened recently in observations and are no longer inconsistent with those in models.

Ultrasound-guided percutaneous needle tenotomy using Tenex system for refractory lateral epicondylitis; short and long-term effectiveness and contributing factors

BACKGROUND

Ultrasound-guided percutaneous needle tenotomy (USPNT) has been proposed as an alternative treatment to surgical intervention for lateral epicondylitis (LE). The Tenex system (Tenex Health Inc., Lake Forest, CA, USA) for USPNT is an ultrasonic device involving a needle which oscillates at high frequency to debride and aspirate diseased tendon under ultrasound image guidance. This investigation evaluates the efficacy of USPNT using the Tenex system for LE refractory to conservative management. We also seek to evaluate patient-specific factors which may correlate with treatment response.

MATERIALS AND METHODS

PRTEE (Patient-Rated Tennis Elbow Evaluation) and DASH (Disabilities of the Arm, Shoulder, and Hand) questionnaires were completed before performing the Tenex USPNT for all consecutive patients over a course of 38 months (Feb 2015-Mar 2018). Patients were contacted for follow-up evaluations. Paired t test was used to evaluate significant changes in treatment response (p < 0.05). The univariate Tobit regression model was applied followed by multivariate Tobit model with forward selection algorithm. All models were adjusted by preoperative score and follow-up duration.

RESULTS

A total of 37 patients (average age 51± 9 years, M/F:15/22) with refractory LE were included (mean follow-up, 531 days; range, 65-1148 days). Tenex USPNT significantly improved PRTEE and DASH scores (p < 0.001). In some patients, this decrease persisted for up to 3 years after intervention. A significant association between treatment response and post-procedure physical therapy (PT) was present. Post-procedure PT contributes to 60, 68, 59, and 50% of reduction in PRTEE pain, function, total scores, and DASH score, respectively (p < 0.001). No tendon ruptures, post-procedural infections, or other complications were noted.

CONCLUSION

USPNT with Tenex significantly improves symptoms and function in individuals with LE even with long-term follow-up for 3 years. Post-procedure PT is associated with improved treatment response and should be considered after USPNT.

APOE3-Jacksonville (V236E) variant reduces self-aggregation and risk of dementia

Apolipoprotein E (APOE) genetic variants have been shown to modify Alzheimer’s disease (AD) risk. We previously identified an APOE3 variant (APOE3-V236E), named APOE3-Jacksonville (APOE3-Jac), associated with healthy brain aging and reduced risk for AD and dementia with Lewy bodies (DLB). Herein, we resolved the functional mechanism by which APOE3-Jac reduces APOE aggregation and enhances its lipidation in human brains, as well as in cellular and biochemical assays. Compared to APOE3, expression of APOE3-Jac in astrocytes increases several classes of lipids in the brain including phosphatidylserine, phosphatidylethanolamine, phosphatidic acid, and sulfatide, critical for synaptic functions. Mice expressing APOE3-Jac have reduced amyloid pathology, plaque-associated immune responses, and neuritic dystrophy. The V236E substitution is also sufficient to reduce the aggregation of APOE4, whose gene allele is a major genetic risk factor for AD and DLB. These findings suggest that targeting APOE aggregation might be an effective strategy for treating a subgroup of individuals with AD and DLB.

An Approach to Standard Perioperative Transthoracic Echocardiography Practice for Anesthesiologists-Perioperative Transthoracic Echocardiography Protocols

The use of intraoperative transesophageal echocardiography (TEE) has become the standard of care for most cardiac surgical procedures. There are guidelines established for training, practice, and quality improvement in perioperative TEE by the joint efforts of the American Society of Echocardiography and Society of Cardiovascular Anesthesiologists. Cardiac point-of-care ultrasound (POCUS) increasingly is being incorporated into anesthesiologists' training and practice. While a special "certification in Critical Care Echocardiography" was created by the National Board of Echocardiography in 2019, there currently exist no guidelines for training, certification, and practice of perioperative TTE by anesthesiologists. In this review, the authors describe the categories, indications and applications of perioperative TTE and provide a recommended sequence for performing an examination tailored to the evaluation of perioperative patients. Although the authors describe a protocol utilized at their institution, there are no standards described in the literature for PTTE. Cardiac anesthesiologists and cardiac anesthesia societies (Society of Cardiovascular Anesthesiologists, European Association of Cardiothoracic Anesthesiologists) must come forward to establish standards working in collaboration with echocardiography societies (American Society of Echocardiography, European Society of Cardiology).

Core surgical field camps: a new deanery-based model for enhancing advanced skills in core surgical trainees through simulation

Hands-on wet lab simulation training is a vital part of modern surgical training. Since 2010, surgical 'boot camps' have been run by many UK deaneries to teach core surgical trainees basic entry level skills. Training in advanced skills often requires attendance at national fee-paying courses. In the Wessex Deanery, multiple, free of charge, core surgical 'field camps' were developed to provide more advanced level teaching in the particular specialty preference of each core surgical trainee. After the COVID-19 pandemic, national hands-on courses will be challenging to provide and deanery-based advanced skills training may be the way forward for craft-based specialties. The experiences over 2 years of delivering the Wessex core surgical field camps are shared, giving a guide and advice for other trainers on how to run a field camp.

The Year in Cardiothoracic Transplantation Anesthesia: Selected Highlights from 2019

The highlights in cardiothoracic transplantation focus on the recent research pertaining to heart and lung transplantation, including expansion of the donor pool, the optimization of donors and recipients, the use of mechanical support, the perioperative and long-term outcomes in these patient populations, and the use of transthoracic echocardiography to diagnose rejection.

Developing a comprehensive database with sensitive health information: A profile of people living with HIV in Newfoundland and Labrador, Canada

Introduction

Developing a comprehensive cohort of people living with HIV (PLHIV) to help improve healthcare has long been the vision of researchers, clinicians and decision makers. The development of this kind of database is challenging and requires strict adherence to privacy and confidentiality policies. We explored procedures, activities and events in database development.

Objectives

To understand processes of developing a database with sensitive health information in Newfoundland and Labrador (NL), and to investigate procedures and activities to develop the database within its environmental context.

Methods

A narrative case study was used to explain the challenges and procedures involved in developing a database for our population. The development of the PLHIV cohort in NL is provided as an example to demonstrate the complexity of the process. We linked three datasets that included patient-level data for PLHIV: 1. laboratory data; 2. HIV clinic data; 3. health administrative data, which allowed for the creation of a large database containing many variables describing the PLHIV cohort in the province.

Results

We developed a de-identified cohort of 251 PLHIV that contained 178 variables. Our case study showed database development is an iterative process. The main challenges were ensuring patient privacy and data confidentiality are not compromised and working with multi-custodian data. These challenges were addressed by establishing a data governance team.

Conclusions

It is important that policy be implemented to merge siloed data sources in order to provide researchers with accurate and complete data that is required to conduct sound and precise research with maximum benefits for treatment and policy-making to improve health outcomes.

41 Using Patient Centred Care to Redesign Integrated Discharge Services in Derby

Background

Discharge to Assess as outlined by the Department of Health was adopted in Derby in 2016. Previously the discharge pathways to community settings from the acute trust were complex. Challenges included: Operating from a traditional residential care home.No integration of community health staff and social care teams leading to delays in treatment and decision making as well as multiple referrals and hand-overs and no joint communication which was confusing for patients.Stakeholder anticipation of 6 weeks length of stay.Limited responsiveness to capacity demand within planned and unplanned community physiotherapy.Changing the culture and mind-set of staff.Different health and social care processes and procedures, IT systems, working patterns, contracts and pay scales.

Methods

A new service model, joint processes and standard operating procedures was developed with the patient at the centre of the design. Trusted assessment and information sharing reduce multiple assessments and hand overs, ensuring a smoother and improved patient experience.

Outcomes

Triage of patients from the Integrated Discharge Hub to the appropriate pathway, early discharge planning, board rounds and MDT's and timely assessments combined with an enablement ethos have increased the flow of patients through the service, decreased care package hours and increased capacity through reducing both length of stay and delayed transfers of care. The health and social care teams are now delivering fully integrated care and undertaking joint training. This has led to a reduction in treatment times from 20 days to 12 days, reductions in DTOC to average of 8 days per month and improved access to community based routine therapy from 85% of referrals being seen by 6 weeks 2017-18 to 99% in 2018-19.

Conclusions

The integrated service delivers more for less resulting in significant savings in the healthcare and social care system while maintaining quality standards and outcomes.

B-66 The Effect of Bilingualism on Boston Naming Test Performance in Traumatic Brain Injury Survivors and Healthy Adults

Objective

The Boston Naming Test (BNT) is a lexical-retrieval task. It has been documented that those with a history of traumatic brain injury (TBI) have reduced performance on the BNT. Bilingualism is also known to impact BNT performances. We examined the relationship of TBI and bilingualism/monolingualism on BNT performances.

Method

The sample (N = 95) consisted of 36 healthy controls (19 bilingual; 17 monolingual), 32 acute TBI participants (12 bilingual; 20 monolingual), and 27 chronic TBI participants (16 bilingual; 11 monolingual). Acute TBI participants were tested 6 months post-injury and chronic TBI participants were tested 12 months or more post-injury. All participants passed performance validity testing. A 3X2 ANOVA was conducted to determine the effect of TBI and bilingualism/monolingualism on BNT performance.

Results

A main effect was found for group (i.e., control, 6 month TBI, and 12 month TBI), p < .001, ηp² = .21. Pairwise comparisons revealed that acute TBI participants performed worse than the control and chronic TBI groups. A main effect for bilingualism/ monolingualism was found, p < .001, ηp² = .14; monolinguals performed better on the BNT. No interactions were found between TBI and bilingualism/monolingualism.

Conclusions

BNT performance improves overtime in TBI and the pattern of improvement post-TBI is not statistically different between bilingual/monolingual groups. Relative to monolinguals, bilingual participants demonstrated worse BNT performance.

B-71 The Effect of Bilingualism on Verbal and Design Fluency Performance in Traumatic Brain Injury Survivors and Healthy Adults

Objective

Traumatic brain injury (TBI) impacts neurocognitive function. Language is also known to influence test performances. We examined the relationship between TBI and monolingualism/bilingualism on verbal and design fluency tests.

Method

The sample (N = 74) consisted of 33 healthy controls (18 bilingual; 15 monolingual), 15 acute TBI participants (6 bilingual; 9 monolingual), and 26 chronic TBI participants (15 bilingual; 11 monolingual). Acute TBI participants were tested 6 months post-injury and chronic TBI participants were tested 12 months or more post-injury. The Delis-Kaplan Executive Function System Letter Fluency (DKEFS-LF), Category Fluency (DKEFS-CF), Category Switching Fluency (DKEFS-CSF), and global verbal fluency composite (DKEFS-GVF) scores assessed verbal fluency; DKEFS fill-dots (DKEFS-FD), empty dots (DFEFS-ED), dot switching (DKEFS-DS), and global design fluency composite (DKEFS-GDF) scores assessed design fluency; and global verbal and non-verbal fluency composite (DKEFS-GF) assessed overall fluency. 3X2 ANOVAs were conducted to evaluate the effect of monolingualism/bilingualism on fluency performance in TBI and controls.

Results

The groups (control and TBI groups) differed for DKEFS-LF, p = .048, ηp² = .09, DKEFS-CF, p = .000, ηp² = .21, DKEFS-GVF, p = .004, ηp² = .15, DKEFS-ED, p = .008, ηp² = .13, DKEFS-GF, p = .001, ηp² = .20, with controls outperforming TBI groups on the DKEFS-CF, DKEFS-GVF, and DKEFS-GF. Furthermore, controls outperformed acute TBI participants on the DKEFS-LF and DKEFS-ED. Main effects were found for bilingualism/monolingualism on DKEFS-CF, p = .035, ηp² = .06, with bilinguals outperforming monolinguals. No interactions were found.

Conclusion

The TBI group had poor verbal and design fluency in contrast controls. Unexpectedly, bilinguals outperformed monolinguals on a task of verbal category fluency. Revealing that in the present study bilinguals have better semantic verbal fluency abilities.

A-01 Age of Immigration and Test Performance for Immigrant Spanish-speakers on Córdoba Naming Test

Objective

This study examines the correlation between age of immigration for Spanish speakers in the USA and their performance on the Córdoba Naming Test (CNT), a confrontation naming test designed to be multicultural. We predicted that those who immigrated at a later age, whom we expect to have more years of education in their native language, will perform better on the CNT.

Method

The study used the CNT with a sample of 44 Spanish-speakers from the United States. We worked with participants with no prior history of medical complications, such as damage to the central nervous system, drug use, or excessive alcohol use. 21 male and 23 female participants were recruited. The age of participants ranged from 20 to 89 years old and education ranged from 0 to 22 years of schooling (either in the United States or in their native country). The variables of focus are the age of immigration into the United States (when participants migrated into the US) and their test performance on the CNT (total score of correct responses).

Results

Our results indicate a statistically significant positive correlation between age of immigration and performance on the CNT, (r(44)) = .357, p = .019). Conclusions: The overall trend of the data suggested that older age at immigration was indeed associated with better performance on the CNT, thus highlighting the importance of language and acculturation issues when being assessed with neuropsychological or cognitive testing.

Conclusions

The overall trend of the data suggested that older age at immigration was indeed associated with better performance on the CNT, thus highlighting the importance of language and acculturation issues when being assessed with neuropsychological or cognitive testing.

B-69 The Effect of Bilingualism on Symbol Digit Modalities Test Performance in Traumatic Brain Injury Survivors and Healthy Adults

Objective

Traumatic brain injury (TBI) survivors exhibit cognitive deficits. Language factors can also influence neurocognitive performance. We examined the effects of TBI and bilingualism/monolingualism on a test of attention and cognitive speed (i.e., Symbol Digit Modalities Test; SDMT).

Method

The sample (N = 98) consisted of 37 controls (19 bilingual; 18 monolingual), 34 acute TBI participants (12 bilingual; 22 monolingual), and 27 chronic TBI participants (16 bilingual; 11 monolingual). Acute TBI participants were tested 6 months post-injury; chronic TBI participants were tested 12 months or more post-injury. All participants passed performance validity testing. 3X2 ANOVAs were conducted to determine the effect of TBI and language on SDMT written and oral performance.

Results

A main effect was found between groups (control and TBI groups) on SDMT written, p < .001, ηp² = .19 and SDMT oral p < .001, ηp² = .16. Pairwise comparisons revealed a difference between the control group and TBI groups, with TBI groups performing worse. A main effect for bilingualism/monolingualism was not found; interaction effects emerged between TBI and bilingualism/monolingualism on SDMT written, p < .05, ηp² = .07 and SDMT oral p < .05, ηp² = .07.

Conclusion

TBI groups performed worse than controls on the SDMT. Relative to monolinguals with TBI, our findings suggest better cognitive recovery of verbal attention and cognitive speed in bilingual TBI participants.

B-68 The Effect of Bilingualism on Stroop Performance in Traumatic Brain Injury Survivors and Healthy Adults

Objective

Traumatic brain injury (TBI) affects neurocognition. Speaking multiple languages can also influence cognitive test performances. We examined the relationship between TBI and monolingualism/bilingualism on a task of attention and response inhibition (Stroop Color Word Test; SCWT).

Method

The sample (N = 96) consisted of 37 healthy controls (19 bilingual; 18 monolingual), 32 acute TBI participants (12 bilingual; 20 monolingual), and 27 chronic TBI participants (16 bilingual; 11 monolingual). Acute TBI participants were tested 6 months post-injury and chronic TBI participants were tested 12 months or more post-injury. The SCWT included the word (SCWT-W), color (SCWT-C), and color-word interference (SCWT-I) conditions. All participants passed performance validity testing. 3X2 ANOVAs were conducted to examine the relationship between TBI and monolingualism/bilingualism on SCWT performances.

Results

Group effects (control and TBI groups) were found for all Stroop measures. We found main effects of TBI on SCWT-W, p = .013, ηp² = .09, SCWT-C, p = .001, ηp² = .14, and SCWT-I, p = .022, ηp² = .08, with the controls outperforming acute TBI survivors on SCWT-I, chronic TBI survivors on SCWT-W, and both TBI groups on SCWT-C. We also observed main effects of language for SCWT-C, p = .012, ηp² = .07, and SCWT-I, p = .003, ηp² = .09, with the monolinguals outperforming bilinguals on SCWT-C and SCWT-I. However, no significant interactions between TBI and language were found.

Conclusion

As expected, the control group outperformed TBI survivors on the SCWT. Monolinguals outperformed bilinguals on all Stroop measures except SCWT-W condition. Our findings seem to suggest that monolingual speakers may have better attention and response inhibition abilities that resulted in better SCWT performance.

B-67 The Effect of Bilingualism on Executive Functioning Performance in Traumatic Brain Injury Survivors and Healthy Adults

Objective

Traumatic brain injury (TBI) survivors often exhibit problems with executive function (EF). Language use can also impact EF test performances. We examined the effects of TBI and bilingualism/monolingualism on several EF tests.

Method

The sample (N = 94) consisted of 37 healthy controls (19 bilingual; 18 monolingual), 30 acute TBI participants (10 bilingual; 20 monolingual), and 27 chronic TBI participants (16 bilingual; 11 monolingual). Acute TBI participants were tested 6 months post-injury and chronic TBI participants were tested 12 months or more post-injury. Stroop Color-Word (SCW), Delis-Kaplan Executive Function System Letter Fluency (DKEFS-LF), Trail Making Test part B (TMT-B) and a EF global composite (EF-GC) were used to assess EF. All participants passed performance validity testing. 3X2 ANOVAs were conducted to determine the effect of TBI and bilingualism/monolingualism on EF performances.

Results

Main effects were found between groups (control and TBI groups) on SCW, p = .046, ηp² = .07, TMT-B, p = .042, ηp² = .07, and EF-GC, p = .005, ηp² = .13; the 6-month TBI group performed worse than controls on TMT-B and EF-GC. Main effects were found for bilingualism/ monolingualism on SCW, p = .012, ηp² = .07, and TMT-B, p = .034, ηp² = .05; monolingual participants performed better than bilingual participants. No significant interactions between TBI and language were found.

Conclusion

The TBI group underperformed on SCW, TMT-B, and EF-GC compared to controls; relative to monolinguals, bilinguals underperformed on the SCW and TMT-B only. In conclusion, our findings seem to suggest that monolinguals have better cognitive flexibility compared to bilinguals that result in better EF performances.

B-70 The Effect of Bilingualism on Trail Making Test Performance in Traumatic Brain Injury Survivors and Healthy Adults

Objective

Traumatic brain injury (TBI) is associated with a number of cognitive deficits. Language factors also impact neurocognitive performance. We examined the effects of TBI and bilingualism/monolingualism on a test of attention and executive functioning (Trail Making Test; TMT).

Method

The sample (N = 96) consisted of 36 healthy controls (19 bilingual; 17 monolingual), 34 acute TBI participants (12 bilingual; 21 monolingual), and 27 chronic TBI participants (16 bilingual; 11 monolingual). Acute TBI participants were tested 6 months post-injury and chronic TBI participants were tested 12 months or more post-injury. 3X2 ANOVAs were conducted to determine the effect of TBI and bilingualism/monolingualism on TMT part A and B.

Results

Main effects were found between groups (i.e., control and TBI groups) on TMT A, p < .001, ηp² = .17 and TMT B, p < .05, ηp² = .09. Pairwise comparisons revealed a difference only between the control group and the 6-month TBI group, with the latter performing worse. Main effects were found for bilingualism/monolingualism on TMT A, p < .05, ηp² = .04 and TMT B, p < .05, ηp² = .05; monolingual participants performed better than bilingual participants. No interactions emerged.

Conclusion

Relative to monolinguals, bilingual participants demonstrated worse attention and executive functioning performances 6 months post-TBI; however, 12 months post-TBI, the difference was negligible.

Observation of two types of charge-density-wave orders in superconducting La2-xSrxCuO4

The discovery of charge- and spin-density-wave (CDW/SDW) orders in superconducting cuprates has altered our perspective on the nature of high-temperature superconductivity (SC). However, it has proven difficult to fully elucidate the relationship between the density wave orders and SC. Here, using resonant soft X-ray scattering, we study the archetypal cuprate La_2-xSr_xCuO₄ (LSCO) over a broad doping range. We reveal the existence of two types of CDW orders in LSCO, namely CDW stripe order and CDW short-range order (SRO). While the CDW-SRO is suppressed by SC, it is partially transformed into the CDW stripe order with developing SDW stripe order near the superconducting T_c. These findings indicate that the stripe orders and SC are inhomogeneously distributed in the superconducting CuO₂ planes of LSCO. This further suggests a new perspective on the putative pair-density-wave order that coexists with SC, SDW, and CDW orders.

To fully elucidate the relationship between density wave orders and superconductivity in high-T_c cuprates remains difficult. Here, the authors reveal two types of charge-density-wave orders and their intertwined relationship with spin-density-wave order and superconductivity in La_2-xSr_xCuO_4.

Impact of a co-curricular, e-learning activity on pharmacy student knowledge of laboratory values

BACKGROUND AND PURPOSE

Pharmacists are increasingly taking on roles that require interpretation of laboratory values. We sought to assess the impact of a co-curricular, e-learning activity on pharmacy student knowledge of laboratory values.

EDUCATIONAL ACTIVITY AND SETTING

We implemented a co-curricular, e-learning activity during the 2015-2016 academic year at the South Carolina College of Pharmacy. While students in all professional years could participate, the activity was required for those in their third professional year (P3). The activity consisted of a two-hour recorded lesson and accompanying handout. We administered a pre-assessment consisting of 10 multiple-choice questions, followed by a post-assessment comprised of 20 questions, including the 10 questions from the pre-assessment. Mean scores on these 10 questions were compared before and after the activity.

FINDINGS

Two hundred and thirty-five students completed the activity. Mean pre-assessment scores numerically increased as year of study increased; ranging from 65.0% to 93.4%. Compared to mean pre-assessment scores for all students, mean post-assessment scores were higher (82.2% vs. 94.3%, p < 0.001). When pre- and post-assessment scores were evaluated by year of study, significant improvements in post-assessment scores were observed for all groups (p ≤ 0.009).

SUMMARY

Following the completion of a co-curricular, e-learning activity designed to provide instruction on laboratory values for pharmacy students, increases in mean post-assessment scores were observed. Applicability of our results is reduced for students outside of the P3 year.

Abstract LB-189: Blockade of stearoyl CoA desaturase 1 promotes immunogenic clearance of tumors

Metabolic reprogramming plays a critical role in carcinogenesis, in part due its ability to promote immune suppressive properties within tumors. Agents that specifically target crucial metabolic enzymes utilized by cancer are been actively investigated. However, it is unclear whether inhibition of fatty acid metabolism in tumors affects their immunogenicity. Here, we show for the first time that inhibition of stearoyl-CoA desaturase 1 (SCD1), a key enzyme involved in fatty-acid synthesis and a potential prognostic marker for human cancers, increases the immunogenicity of poorly immunogenic tumors. The enhanced immune activation is accompanied by upregulated endoplasmic reticulum (ER) stress and is dependent on the translocation of ER protein calreticulin to the tumor cell surface. Inhibition of SCD1 increased both recruitment and activation of immune cells in vivo, which when combined with PD-1 blockade resulted in potent and durable anti-tumor T cell responses. Together, our results indicate that inhibition of tumorigenic de novo lipogenesis represents a novel approach to enhance T cell based cancer immunotherapy.

Citation Format: Christina Anna Elizabeth Von Roemeling, Thomas Caulfield, Yaqing Qie, Derek C. Radisky, Xiujie Liu, Yuanxin Chen, Joshua Knight, John Copland, Betty Kim. Blockade of stearoyl CoA desaturase 1 promotes immunogenic clearance of tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr LB-189. doi:10.1158/1538-7445.AM2017-LB-189