EADV Task Force Pruritus White Paper on chronic pruritus and chronic prurigo: Current challenges and future solutions

Chronic pruritus (CP) is frequent in general medicine and the most common complaint in general dermatology. The prevalence of CP is expected to rise in the future due to the ageing population. The clinical presentation, underlying aetiology and treatment strategy of CP are heterogeneous. Also, individual treatment aims and physical, psychic and economic burdens of patients might vary. Chronic prurigo (CPG) is the most severe disease in the chronic pruritus spectrum, being associated with long-standing scratch-induced skin lesions and a therapy refractory itch-scratch-cycle. It is thus important to raise disease awareness for CP and CPG in the general public and among decision-makers in the health system. Further, there is a need to support a rational clinical framework to optimize both diagnostics and therapeutics. Currently, there is still a shortcoming regarding approved therapies and understanding CP/CPG as severe medical conditions. Therefore, the EADV Task Force Pruritus decided to publish this white paper based on several consensus meetings. The group consented on the following goals: (a) ensure that CP is recognized as a serious condition, (b) increase public awareness and understanding of CP and CPG as chronic and burdensome diseases that can greatly affect a person's quality of life, (c) clarify that in most cases CP and CPG are non-communicable and not caused by a psychiatric disease, (d) improve the support and treatment given to patients with CP to help them manage their disease and (e) publicize existing therapies including current guidelines. We aim to point to necessary improvements in access and quality of care directed to decision-makers in health policy, among payers and administrations as well as in practical care.

Sentiment Analysis of Patient- and Family-Related Sepsis Events: Exploratory Study

BACKGROUND

Despite the life-threatening nature of sepsis, little is known about the emotional experiences of patients and their families during sepsis events. We conducted a sentiment analysis pertaining to sepsis incidents involving patients and families, leveraging textual data retrieved from a publicly available blog post disseminated by the Centers for Disease Control and Prevention (CDC).

OBJECTIVE

This investigation involved a sentiment analysis of patient- and family-related sepsis events, leveraging text responses sourced from a publicly accessible blog post disseminated by the CDC. Driven by the imperative to elucidate the emotional dynamics encountered by patients and their families throughout sepsis incidents, the overarching aims centered on elucidating the emotional ramifications of sepsis on both patients and their families and discerning potential avenues for enhancing the quality of sepsis care.

METHODS

The research used a cross-sectional data mining methodology to investigate the sentiments and emotional aspects linked to sepsis, using a data set sourced from the CDC, which encompasses 170 responses from both patients and caregivers, spanning the period between September 2014 and September 2020. This investigation used the National Research Council Canada Emotion Lexicon for sentiment analysis, coupled with a combination of manual and automated techniques to extract salient features from textual responses. The study used negative binomial least absolute shrinkage and selection operator regressions to ascertain significant textual features that correlated with specific emotional states. Moreover, the visualization of Plutchik's Wheel of Emotions facilitated the discernment of prevailing emotions within the data set.

RESULTS

The results showed that patients and their families experienced a range of emotions during sepsis events, including fear, anxiety, sadness, and gratitude. Our analyses revealed an estimated incidence rate ratio (IRR) of 1.35 for fear-related words and a 1.51 IRR for sadness-related words when mentioning "hospital" in sepsis-related experiences. Similarly, mentions of "intensive care unit" were associated with an average occurrence of 12.3 fear-related words and 10.8 sadness-related words. Surviving patients' experiences had an estimated 1.15 IRR for joy-related words, contrasting with discussions around organ failure, which were associated with multiple negative emotions including disgust, anger, fear, and sadness. Furthermore, mentions of "death" were linked to more fear and anger words but fewer joy-related words. Conversely, longer timelines in sepsis events were associated with more joy-related words and fewer fear-related words, potentially indicating improved emotional adaptation over time.

CONCLUSIONS

The study's outcomes underscore the imperative for health care providers to integrate emotional support alongside medical interventions for patients and families affected by sepsis, emphasizing the emotional toll incurred and highlighting the necessity of acknowledgment and resolution, advocating for the use of sentiment analysis as a means to tailor personalized emotional aid, and thereby potentially augmenting both patient and family welfare and overall outcomes.

Screening for problematic opioid use in the emergency department: Comparison of two screening measures

Study objective

Earlier intervention for opioid use disorder (OUD) may reduce long-term health implications. Emergency departments (EDs) in the United States treat millions with OUD annually who may not seek care elsewhere. Our objectives were (1) to compare two screening measures for OUD characterization in the ED and (2) to determine the proportion of ED patients screening positive for OUD and those who endorse other substance use to guide future screening programs.

Methods

A cross-sectional study of randomly selected adult patients presenting to three Midwestern US EDs were enrolled, with duplicate patients excluded. Surveys were administered via research assistant and documented on tablet devices. Demographics were self-reported, and OUD positivity was assessed by the DSM 5 checklist and the WHO ASSIST 3.1. The primary outcome was the concordance between two screening measures for OUD. Our secondary outcome was the proportion of ED patients meeting OUD criteria and endorsed co-occurring substance use disorder (SUD) criteria.

Results

We enrolled 1305 participants; median age of participants was 46 years (range 18-84), with 639 (49.0%) Non-Hispanic, White, and 693 (53.1%) female. Current OUD positivity was identified in 17% (222 out of 1305) of the participants via either DSM-5 (two or more criteria) or ASSIST (score of 4 or greater). We found moderate agreement between the measures (kappa = 0.56; Phi coefficient = 0.57). Of individuals screening positive for OUD, 182 (82%) endorsed criteria for co-occurring SUD.

Conclusions

OUD is remarkably prevalent in ED populations, with one in six ED patients screening positive. We found a high prevalence of persons identified with OUD and co-occurring SUD, with moderate agreement between measures. Developing and implementing clinically feasible OUD screening in the ED is essential to enable intervention.

Distinct Inflammatory Phenotypes are associated with subclinical and clinical Cardiovascular disease in People living with HIV

Despite inflammation being implicated in cardiovascular disease (CVD) in people with HIV (PWH), considerable heterogeneity within populations of PWH exists. Stratifying CVD risk based on inflammatory phenotype could play an important role. Using principal component analyses and unsupervised hierarchical clustering, we examined 38 biomarkers to identify inflammatory phenotypes in two independent cohorts of PWH. We identified three distinct inflammatory clusters present in both cohorts that associated with altered risk of both subclinical CVD (cohort 1) and prevalent clinical CVD (cohort 2) after adjusting for CVD risk factors. These data support precision medicine approaches to enhance CVD risk assessment in PWH.

Shared Risk Factors Among Women for Intimate Partner Violence in the United States: A Secondary Analysis

Multilevel risk factors may increase the risk of experiencing intimate partner violence among women. The overall goal of this study was to provide a comprehensive view of factors that may be associated with three forms of intimate partner violence. The primary aim was to explore associations between understudied factors and women's experiences of physical and sexual violence and stalking by an intimate partner. Secondary analysis of existing health registry data was conducted. Our evidence-driven strategy was based on a multipronged analytical approach informed by existing literature and the social-ecological model. We created an evidence-based hierarchical list comprised of three tiers. Three separate multiple logistic regression analyses were performed. Several shared risk factors were retained across all three forms including low levels of formal education, past experiences of non- partner sexual violence, residential instability, presence of children, experiences of a traumatic event and panic attacks, status of receiving US government benefits, and barriers to healthcare access. Results contribute to future research on intimate partner violence prevention by providing preliminary evidence of emerging factors associated with experiencing three forms of intimate partner violence.

Development and Validation of the Lewy Body Disease Caregiver Activities Scale

Background and Purpose: Caring for someone with Lewy body disease (LBD) is difficult. This study describes the development and validity testing of the LBD Caregiver Activities Scale (LBD-CAS). Methods: Caregiver interviews informed the development of the LBD-CAS. Experts estimated the content validity of items (I-CVI) and provided feedback about the scale. Family caregivers evaluated items for face validity. Results: Expert I-CVI ratings yielded 49 items with scores of 0.83 or higher. Four items with I-CVI scores <.83 were retained due to conceptual significance. The overall scale CVI was 0.86. Items evaluated by caregivers for face validity showed excellent variability in responses, with no major ceiling or floor effects. Conclusions: LBD-CAS showed evidence of content and face validity for the assessment of activities performed by LBD caregivers. Further psychometric testing is recommended.

The influences of sociocultural norms on women's decision to disclose intimate partner violence: Integrative review

Sociocultural norms against women can contribute to promoting intimate partner violence (IPV) and shape women's decision to disclose IPV. A cross-cultural analysis of the existing literature is needed to present an overview of the influences of sociocultural norms on women's decisions regarding the disclosure of IPV across different cultural contexts. The purpose of the review was to synthesize published quantitative, qualitative, and mixed methods (MMs) studies to identify known sociocultural norms across different cultures that may influence women's decision to disclose IPV. The Whittemore and Knafl framework, Rayyan software, and PRISMA flow diagram were used. Databases included APA PsycInfo, CINAHL, PubMed, SocINDEX, and Women's Studies International. The quality of studies was assessed by the MMs appraisal tool. A total of 15 research articles written in English and published in peer-reviewed journals were included. Main categories emerged: (1) stigma surrounding IPV disclosure, victimization, and divorce; (2) gender roles; (3) preserving family honor; and (4) Children's well-being and future. A one-size-fits-all approach is not adequate for women who are considering disclosing IPV. Findings underscore that regardless of residing in individualistic countries, those sociocultural norms related to traditional gender roles and gender inequality are still important barriers to the disclosure of IPV among women with collectivist roots.

Artificial light at night (ALAN) disrupts behavioural patterns of reef corals

Increasing levels of Artificial Light At Night (ALAN) alter the natural diel cycles of organisms at global scale. ALAN constitutes a potential threat to the light-dependent functioning of symbiotic scleractinian corals, the habit-founders of warm, shallow water reefs. Here, we show that ALAN disrupts the natural diel tentacle expansion and contraction behaviour, a key mechanism for prey capture and nutrient acquisition in corals. We exposed four symbiotic scleractinian coral species to different ALAN treatments (0.4-2.5 μmol quanta m-2 s-1). Exposure to ALAN levels of 1.2 μmol quanta m-2 s-1 and above altered the normal tentacle expansion response in diurnal species (Stylophora pistillata and Duncanopsammia axifuga). The tentacle expansion pattern of nocturnal species (Montastraea cavernosa and Lobophyllia hemprichii) was less affected, which may indicate a greater capacity to tolerate ALAN exposure. The results of this work suggest that ALAN has the potential to affect nutrient acquisition mechanisms of symbiotic corals which may in turn result in changes in the coral community structure in shallow water reefs in ALAN-exposed areas.

Statins and psoriasis: Position statement by the Psoriasis Task Force of the European Academy of Dermatology and Venerology

BACKGROUND

Psoriasis is associated with an increased mortality risk, with cardiovascular disease being the leading excess cause (in a dose-response manner with psoriasis severity). Statins have demonstrated a reduction in all-cause mortality with no excess of adverse events among the general population. The underuse of interventions in cardiovascular prevention, such as statins, for patients with psoriasis may be the result of an insufficient evaluation.

OBJECTIVES

To provide the dermatologist with a tool for systematizing the treatment of dyslipidemia in psoriasis, which generally escapes the scope of dermatological practice, and to facilitate decision-making about the referral and treatment of patients.

METHODS

The Psoriasis Task Force of the European Academy of Dermatology and Venereology performed this two-phase study to achieve a consensus and create recommendations on the use of statin therapy in patients with psoriasis. The first phase included a systematic review to identify a list of outline concepts and recommendations according to guidelines. The second phase consisted in a two-round Delphi study to evaluate those recommendations not literally taken from guidelines.

RESULTS

A list of 47 concepts and recommendations to be followed by dermatologists involved in the treatment of patients with moderate-severe psoriasis was created. It included six main concepts about cardiovascular risk and psoriasis, six items related with the role of low-density lipoprotein cholesterol (LDL-c) and the benefits of statin treatment in psoriasis patients, eight recommendations about how cardiovascular risk should be assessed, three on the role of non-invasive cardiovascular imaging, three on LDL-c thresholds, eight key points related to statin prescription, 10 on statin treatment follow-up and three on patient referral to another specialist.

CONCLUSIONS

The application of this position statement (close final list of concepts and recommendations) will help dermatologists to manage dyslipidemia and help psoriasis patients to reduce their cardiovascular risk.

Prognosis and molecular characteristics of IBD-associated colorectal cancer: Experience from a French tertiary-care center

BACKGROUND

Little is known about the prognosis of colorectal cancer associated with inflammatory bowel disease (CRC-IBD) in a real-world cohort in France.

METHODS

We conducted a retrospective observational study including all patients presenting CRC-IBD in a French tertiary center.

RESULTS

Among 6510 patients, the rate of CRC was 0.8% with a median delay of 19.5 years after IBD diagnosis (median age 46 years, ulcerative colitis 59%, initially localized tumor 69%). There was a previous exposure to immunosuppressants (IS) in 57% and anti-TNF in 29% of the cases. A RAS mutation was observed in only 13% of metastatic patients. OS of the whole cohort was 45 months. OS and PFS of synchronous metastatic patients was 20.4 months and 8.5 months respectively. Among the patients with localized tumor those previously exposed to IS had a better PFS (39 months vs 23 months; p = 0.05) and OS (74 vs 44 months; p = 0.03). The IBD relapse rate was 4%. No unexpected chemotherapy side-effect was observed CONCLUSIONS: OS of CRC-IBD is poor in metastatic patients although IBD is not associated with under-exposure or increased toxicity to chemotherapy. Previous IS exposure may be associated with a better prognosis.

Pinprick-induced gamma-band oscillations are not a useful electrophysiological marker of pinprick hypersensitivity in humans

OBJECTIVE

This study aimed to investigate scalp gamma-band oscillations (GBOs) induced by mechanical stimuli activating skin nociceptors before and after the induction of mechanical hypersensitivity using high-frequency electrical stimulation (HFS) of the skin.

METHODS

In twenty healthy volunteers, we recorded the electroencephalogram during robot-controlled mechanical pinprick stimulation (512 mN) applied at the right ventral forearm before and after HFS.

RESULTS

HFS induced a significant increase in mechanical pinprick sensitivity, but this increased pinprick sensitivity was, at the group level, not accompanied by a significant increase in GBOs. Visual inspection of the individual data revealed that possible GBOs were present in eight out of twenty participants (40%) and the frequency of these GBOs varied substantially across participants.

CONCLUSIONS

Based on the low number of participants showing GBOs we question the (clinical) utility of mechanically-induced GBOs as an electrophysiological marker of pinprick hypersensitivity in humans.

SIGNIFICANCE

Mechanical pinprick-induced scalp GBOs are not useful for evaluating mechanical pinprick hypersensitivity in humans.

A portable primary-standard level graphite calorimeter for absolute dosimetry in clinical pencil beam scanning proton beams

Objective. To report the use of a portable primary standard level graphite calorimeter for direct dose determination in clinical pencil beam scanning proton beams, which forms part of the recommendations of the proposed Institute of Physics and Engineering in Medicine (IPEM) Code of Practice (CoP) for proton therapy dosimetry.Approach. The primary standard proton calorimeter (PSPC) was developed at the National Physical Laboratory (NPL) and measurements were performed at four clinical proton therapy facilities that use pencil beam scanning for beam delivery. Correction factors for the presence of impurities and vacuum gaps were calculated and applied, as well as dose conversion factors to obtain dose to water. Measurements were performed in the middle of 10 × 10 × 10 cm3homogeneous dose volumes, centred at 10.0, 15.0 and 25.0 g·cm-2depth in water. The absorbed dose to water determined with the calorimeter was compared to the dose obtained using PTW Roos-type ionisation chambers calibrated in terms of absorbed dose to water in60Co applying the recommendations in the IAEA TRS-398 CoP.Main results.The relative dose difference between the two protocols varied between 0.4% and 2.1% depending on the facility. The reported overall uncertainty in the determination of absorbed dose to water using the calorimeter is 0.9% (k= 1), which corresponds to a significant reduction of uncertainty in comparison with the TRS-398 CoP (currently with an uncertainty equal or larger than 2.0% (k= 1) for proton beams).Significance. The establishment of a purpose-built primary standard and associated CoP will considerably reduce the uncertainty of the absorbed dose to water determination and ensure improved accuracy and consistency in the dose delivered to patients treated with proton therapy and bring proton reference dosimetry uncertainty in line with megavoltage photon radiotherapy.

Analgesic efficacy of selective tibial nerve block versus partial local infiltration analgesia for posterior pain after total knee arthroplasty: a randomized, controlled, triple-blinded trial

BACKGROUND

The adductor canal block provides pain relief on the anterior aspect of the knee after arthroplasty. Pain on the posterior aspect may be treated either by partial local infiltration analgesia of the posterior capsule or by a tibial nerve block. This randomized, controlled, triple-blinded trial tests the hypothesis that a tibial nerve block would provide superior analgesia compared to posterior capsule infiltration in patients scheduled for total knee arthroplasty under spinal anesthesia with an adductor canal block.

METHODS

Sixty patients were randomized to receive either infiltration of the posterior capsule by the surgeon with ropivacaine 0.2%, 25 mL, or a tibial nerve block with 10 mL of ropivacaine 0.5%. Sham injections were performed to guarantee proper blinding. The primary outcome was intravenous morphine consumption at 24 h. Secondary outcomes included intravenous morphine consumption, pain scores at rest and on movement, and different functional outcomes, measured at up to 48 h. When necessary, longitudinal analyses were performed with a mixed-effects linear model.

RESULTS

The median (interquartile range) of cumulative intravenous morphine consumption at 24 h was 12 mg (4-16) and 8 mg (2-14) in patients having the infiltration or the tibial nerve block respectively (p = 0.20). Our longitudinal model showed a significant interaction between group and time in favor of the tibial nerve block (p = 0.015). No significant differences were present between groups in the other above-mentioned secondary outcomes.

CONCLUSION

A tibial nerve block does not provide superior analgesia when compared to infiltration. However, a tibial nerve block might be associated with a slower increase in morphine consumption over time.

Performance of Automated ASPECTS Software and Value as a Computer-Aided Detection Tool

BACKGROUND AND PURPOSE

ASPECTS quantifies early ischemic changes in anterior circulation stroke on NCCT but has interrater variability. We examined the agreement of conventional and automated ASPECTS and studied the value of computer-aided detection.

MATERIALS AND METHODS

We retrospectively collected imaging data from consecutive patients with acute ischemic stroke with large-vessel occlusion undergoing thrombectomy. Five raters scored conventional ASPECTS on baseline NCCTs, which were also processed by RAPID software. Conventional and automated ASPECTS were compared with a consensus criterion standard. We determined the agreement over the full ASPECTS range as well as dichotomized, reflecting thrombectomy eligibility according to the guidelines (ASPECTS 0-5 versus 6-10). Raters subsequently scored ASPECTS on the same NCCTs with assistance of the automated ASPECTS outputs, and agreement was obtained.

RESULTS

For the total of 175 cases, agreement among raters individually and the criterion standard varied from fair to good (weighted κ = between 0.38 and 0.76) and was moderate (weighted κ = 0.59) for the automated ASPECTS. The agreement of all raters individually versus the criterion standard improved with software assistance, as did the interrater agreement (overall Fleiss κ = 0.15-0.23; P < .001 and .39 to .55; P = .01 for the dichotomized ASPECTS).

CONCLUSIONS

Automated ASPECTS had agreement with the criterion standard similar to that of conventional ASPECTS. However, including automated ASPECTS during the evaluation of NCCT in acute stroke improved the agreement with the criterion standard and improved interrater agreement, which could, therefore, result in more uniform scoring in clinical practice.

A Cross-Sectional Study of the Social Work Environment and Black Registered Nurses' Sleep

INTRODUCTION

Workplace experiences may place Black nurses at higher risk for poor sleep and adverse health outcomes. This study aimed to identify poor sleep prevalence and associations of workplace discrimination and workplace social capital with sleep.

METHODOLOGY

Descriptive statistics and multiple linear regression with exploratory analyses were conducted of cross sectional survey data from US Black nurses.

RESULTS

On average, 63 respondents reported sleeping 6.15 h, 45 min less daily than 6.9 h reported nationally for nurses. Ninety-percent of respondents reported poor sleep quality. While no direct significance was found, respondents reporting sleep quality changes had lower workplace social capital and higher workplace discrimination.

CONCLUSION

Black nurses may have higher prevalence of poor sleep than the larger nursing workforce. A potential relationship between decreased sleep quality and negative perceptions of the work environment may exist. Organizations should examine sleep and potential occupational health inequities among Black nurses when considering worker health.

Epidemiology and Outcomes of AKI Treated With Continuous Kidney Replacement Therapy: The Multicenter CRRTnet Study

Rationale & Objective

Continuous kidney replacement therapy (CKRT) is the predominant form of acute kidney replacement therapy used for critically ill adult patients with acute kidney injury (AKI). Given the variability in CKRT practice, a contemporary understanding of its epidemiology is necessary to improve care delivery.

Study Design

Multicenter, prospective living registry.

Setting & Population

1,106 critically ill adults with AKI requiring CKRT from December 2013 to January 2021 across 5 academic centers and 6 intensive care units. Patients with pre-existing kidney failure and those with coronavirus 2 infection were excluded.

Exposure

CKRT for more than 24 hours.

Outcomes

Hospital mortality, kidney recovery, and health care resource utilization.

Analytical Approach

Data were collected according to preselected timepoints at intensive care unit admission and CKRT initiation and analyzed descriptively.

Results

Patients' characteristics, contributors to AKI, and CKRT indications differed among centers. Mean (standard deviation) age was 59.3 (13.9) years, 39.7% of patients were women, and median [IQR] APACHE-II (acute physiologic assessment and chronic health evaluation) score was 30 [25-34]. Overall, 41.1% of patients survived to hospital discharge. Patients that died were older (mean age 61 vs. 56.8, P < 0.001), had greater comorbidity (median Charlson score 3 [1-4] vs. 2 [1-3], P < 0.001), and higher acuity of illness (median APACHE-II score 30 [25-35] vs. 29 [24-33], P = 0.003). The most common condition predisposing to AKI was sepsis (42.6%), and the most common CKRT indications were oliguria/anuria (56.2%) and fluid overload (53.9%). Standardized mortality ratios were similar among centers.

Limitations

The generalizability of these results to CKRT practices in nonacademic centers or low-and middle-income countries is limited.

Conclusions

In this registry, sepsis was the major contributor to AKI and fluid management was collectively the most common CKRT indication. Significant heterogeneity in patient- and CKRT-specific characteristics was found in current practice. These data highlight the need for establishing benchmarks of CKRT delivery, performance, and patient outcomes. Data from this registry could assist with the design of such studies.

Early-life exposure to methylmercury induces reversible behavioral impairments and gene expression modifications in one isogenic lineage of mangrove rivulus fish Kryptolebias marmoratus

Methylmercury (MeHg) is a ubiquitous bioaccumulative neurotoxicant present in aquatic ecosystems. It is known to alter behaviors, sensory functions and learning abilities in fish and other vertebrates. Developmental and early-life stages exposure to MeHg can lead to brain damage with immediate consequences on larvae behavior, but may also induce long term effects in adults after a detoxification period. However, very little is known about developmental origin of behavioral impairment in adults due to early exposure to MeHg. The aim of this study is to assess whether early-life MeHg exposure induces immediate and/or delayed effects on behaviors, related genes expression and DNA methylation (one of epigenetic mechanisms). To reach this goal, newly hatched larvae of mangrove rivulus fish, Kryptolebias marmoratus, were exposed to two sub-lethal concentrations of MeHg (90 μg/L and 135 µg/L) for 7 days, and immediate and delayed effects were assessed respectively in 7 dph (days post-hatching) and 90 dph fish. This species naturally produces isogenic lineages due to its self-fertilizing reproduction system, which is unique among vertebrates. It allows to study how environment stressors can influence organism's phenotype while minimizing genetic variability. As results, both MeHg exposures are associated with a decreased foraging efficiency and thigmotaxis, and a dose-dependent reduction in larvae locomotor activity. Regarding molecular analysis in larvae whole bodies, both MeHg exposures induced significant decreased expression of DNMT3a, MAOA, MeCP2 and NIPBL, and significant increase of GSS, but none of those genes underwent methylation changes in targeted CpGs. None of significant behavioral and molecular impairments observed in 7-dph larvae were found in 90-dph adults, which highlight a distinction between immediate and delayed effects of developmental MeHg exposure. Our results suggest implications of aminergic system and its neurotransmitters, redox/methylation trade-off and possibly other epigenetic mechanisms in MeHg neurotoxicity underlying behavioral alterations in rivulus.

Genetic Variants Associated with Opioid Use Disorder

Genetics are presumed to contribute 30-40% to opioid use disorder (OUD), allowing for the possibility that genetic markers could be used to identify personal risk for developing OUD. We aimed to test the potential association among 180 candidate single nucleotide polymorphisms (SNPs), 120 of which were related to the dopamine reward pathway and 60 related to pharmacokinetics. Participants were randomly recruited in 2020-2021 in a cross-sectional genetic association study. Self-reported health history including Diagnostic and Statistical Manual of Mental Disorders (DSM-5) OUD criteria and buccal swabs were collected. A total of 1,301 participants were included in the analyses for this study. Of included participants, 250 met the DSM-5 criteria for ever having OUD. Logistic regression, adjusting for age and biologic sex, was used to characterize the association between each SNP and DSM-5 criteria consistent with OUD. Six SNPs found in 4 genes were associated with OUD: increased odds with CYP3A5 (rs15524 and rs776746) and DRD3 (rs324029 and rs2654754), and decreased odds with CYP3A4 (rs2740574) and CYP1A2 (rs2069514). Homozygotic CYP3A5 (rs15524 and rs776746) had the highest adjusted odds ratio of 2.812 (95% confidence interval (CI) 1.737, 4.798) and 2.495 (95% CI 1.670, 3.835), respectively. Variants within the dopamine reward and opioid metabolism pathways have significant positive (DRD3 and CYP3A5) and negative (CYP3A4 and CYP1A2) associations with OUD. Identification of these variants provides promising possibilities for genetic prognostic and therapeutic targets for future investigation.

A longitudinal study of creatine kinase and creatinine levels in Duchenne muscular dystrophy

INTRODUCTION/AIMS

Management of Duchenne muscular dystrophy (DMD) has entered an era featuring novel treatments. Trackable noninvasive biomarkers could improve disease progression monitoring and drug effect detection. Our aim in this study was to measure changes in selected noninvasive biomarkers and assess their relationship to age and motor function.

METHODS

We retrospectively studied 555 patients with DMD who had at least 12 months of treatment of glucocorticoids and were not enrolled in trials of potential disease-modifying therapies. We extracted biomarker data of serum creatine kinase (CK), serum creatinine (Cr), urine Cr, and urine Cr/urine osmolality (osm), as well as functional data for age at loss of ambulation and Functional Motor Scale (FMS) values from patients' clinical records. Data were analyzed using linear mixed-model analyses.

RESULTS

CK, serum Cr, urine Cr, and urine Cr/urine osm all decreased with declining motor function. CK consistently decreased and FMS score consistently worsened with age without clear inflection points. There was an increased odds ratio for LOA with lower values of CK, serum Cr, urine Cr, and urine Cr/urine osm, most notably for urine Cr.

DISCUSSION

Although individual biomarker values are challenging to directly apply clinically, our study has demonstrated that trends over time may complement functional measures in the assessment of individuals with DMD. Future studies could elucidate predictive utility of these biomarkers in assessing motor function changes in DMD.

Outpatient medications associated with protection from COVID-19 hospitalization

The COVID-19 pandemic remains the pre-eminent global health problem, and yet after more than three years there is still no prophylactic agent against the disease aside from vaccines. The objective of this study was to evaluate whether pre-existing, outpatient medications approved by the US Food and Drug Administration (FDA) reduce the risk of hospitalization due to COVID-19. This was a retrospective cohort study of patients from across the United States infected with COVID-19 in the year 2020. The main outcome was adjusted odds of hospitalization for COVID-19 amongst those positive for the infection. Outcomes were adjusted for known risk factors for severe disease. 3,974,272 patients aged 18 or older with a diagnosis of COVID-19 in 2020 met our inclusion criteria and were included in the analysis. Mean age was 50.7 (SD 18). Of this group, 290,348 patients (7.3%) were hospitalized due to COVID-19, similar to the CDC's reported estimate (7.5%). Four drugs showed protective effects against COVID-19 hospitalization: rosuvastatin (aOR 0.91, p = 0.00000024), empagliflozin-metformin (aOR 0.69, p = 0.003), metformin (aOR 0.97, p = 0.017), and enoxaparin (aOR 0.88, p = 0.0048). Several pre-existing medications for outpatient use may reduce severity of disease and protect against COVID-19 hospitalization. Well-designed clinical trials are needed to assess the efficacy of these agents in a therapeutic or prophylactic setting.

Use of supported standing in males with Duchenne muscular dystrophy: Individual and family perspectives

PURPOSE

This study aimed to explore stander use in individuals with Duchenne Muscular Dystrophy (DMD).

METHODS

This mixed method research study employed a survey with categorical and open-ended questions related to stander use. Categorical responses were analyzed quantitatively. Qualitative analysis of open-ended responses was linked to the International Classification of Function. Qualitative and quantitative results were merged to derive meta-inferences.

RESULTS

Of 147 respondents, 28.6% (n = 42) reported stander use. Equipment used included sit-to-stand stander (n = 27), power standing feature in a wheelchair (n = 13), and unspecified equipment (n = 2). Economic services were the most common barrier to stander obtainment. Age of loss of ambulation (LOA) and age of start of stander use were positively correlated (r = 0.61, p < 0.0001, n = 36), with 59.5% initiating stander use after LOA. Twenty-nine respondents reported standing less than the recommended dose of 60-90 minutes at least five days a week, with frequency directionally less than five days per week (p = 0.06) and time significantly less than 60-90 minutes (p = 0.002). Respondents' total dose was significantly lower than the recommended 300 minutes (p = 0.02). Lack of time and presence of contractures contributed to decreased duration of use.

CONCLUSION

This study provides a greater understanding of stander use among individuals with DMD and can assist with decision making about stander use prior to complications of disease progression to promote optimal health despite reported barriers.

A randomized feasibility trial of the Midlife Black Women's Stress and Wellness intervention (B-SWELL); a community participatory intervention to increase adoption of Life's Simple 7 healthy lifestyle behaviors

BACKGROUND

Black women have a disproportionately higher incidence of cardiovascular disease-related mortality than other groups, yet they are less likely to receive culturally proficient education and competent preventive care.

PURPOSE

The purpose of this study was to determine feasibility of the Midlife Black Women's Stress and Wellness intervention (B-SWELL); a culturally adapted, 8-week group intervention leveraging stress reduction and goal setting to increase awareness and adoption of Life's Simple 7 (LS7) healthy lifestyle behaviors.

METHODS

A randomized feasibility trial was conducted. Participants (N = 48, mean age = 55 years) were randomized to the B-SWELL or a group wellness (WE) intervention that lacked stress reduction and goal setting instruction. We hypothesized that B-SWELL participants would achieve a lower perceived stress, greater self-efficacy, improved LS7 scores, fewer symptoms (depression and unhealthy days), and greater perceived general health compared to WE participants. Survey data were collected at three timepoints: baseline, 8 weeks, and 12 weeks.

RESULTS

Both B-SWELL and WE groups had low attrition and navigated the online platform well. Further, both groups experienced lower perceived stress, improved LS7 scores, reduced depressive symptoms, and greater perceived general health from baseline to 8 weeks. Based on data trends, participants in the B-SWELL had more improvement in perceived stress, self-efficacy, and mental and physical unhealthy days compared to WE participants.

CONCLUSION

The B-SWELL is a feasible intervention for midlife Black women. Positive data trends were found for both B-SWELL and WE groups. Based on observations from the feasibility study, a larger outcomes-based study is planned.

Symptoms of Survivors of Pediatric Hematopoietic Stem Cell Transplant by Age, Sex, and Transplant Type

Purpose: The purpose of this study was to describe symptoms experienced by survivors of pediatric hematopoietic stem cell transplant (HSCT), and demographic and treatment-factors associated with ongoing symptomology. Methods: Fifty pediatric survivors completed a cross-sectional pilot study. Questionnaires were administered online via REDCap to assess symptoms experienced in the last week. Survivors also consented to a medical record chart review. Results: Survivors were on average 5.4 years post-HSCT (range 1.1 to 9 years), male (58%), and Caucasian (80%) who received an allogeneic HSCT (92%). The most commonly reported symptoms were difficulty concentrating (42.5%), pain (38%), worry (38%), nervousness (37.5%), and lack of energy/fatigue (34%). Survivors reported up to 14 symptoms, with 90% of the sample experiencing at least one symptom in the previous week. Average number of symptoms varied by age group between 2.1 (8-9 years) and 6.8 (18 and older). Age and female gender were associated with higher levels of fatigue. Conclusions: The majority of survivors experienced at least one symptom in the previous week. Neuropsychological symptoms and pain endure well into survivorship that can influence outcomes such as function and health-related quality of life (HRQOL). Research is needed on biological mechanisms of ongoing symptomology, effective interventions to prevent or mitigate symptoms, and the impact of symptoms on patient outcomes including daily functioning and HRQOL. Implications Survivors of pediatric HSCT continued to experience symptoms for up to nine years. Survivors should be frequently screened for symptoms, as symptoms may affect function, learning/employment outcomes, and HRQOL.

A strategy to identify event specific hospitalizations in large health claims databases

BACKGROUND

Health insurance claims data offer a unique opportunity to study disease distribution on a large scale. Challenges arise in the process of accurately analyzing these raw data. One important challenge to overcome is the accurate classification of study outcomes. For example, using claims data, there is no clear way of classifying hospitalizations due to a specific event. This is because of the inherent disjointedness and lack of context that typically come with raw claims data.

METHODS

In this paper, we propose a framework for classifying hospitalizations due to a specific event. We then tested this framework in a private health insurance claims database (Symphony) with approximately 4 million US adults who tested positive with COVID-19 between March and December 2020. Our claims specific COVID-19 related hospitalizations proportion is then compared to nationally reported rates from the Centers for Disease Control by age.

RESULTS

Across all ages (18 +) the total percentage of Symphony patients who met our definition of hospitalized due to COVID-19 was 7.3% which was similar to the CDC's estimate of 7.5%. By age group, defined by the CDC, our estimates vs. the CDC's estimates were 18-49: 2.7% vs. 3%, 50-64: 8.2% vs. 9.2%, and 65 + : 14.6% vs. 28.1%.

CONCLUSIONS

The proposed methodology is a rigorous way to define event specific hospitalizations in claims data. This methodology can be extended to many different types of events and used on a variety of different types of claims databases.

Acute kidney injury contributes to worse physical and quality of life outcomes in survivors of critical illness

Objectives

Survivors of critical illness and acute kidney injury (AKI) are at risk of increased morbidity. The purpose of this study was to compare physical, emotional, and cognitive health in survivors of critical illness with and without AKI.

Methods

Retrospective cohort study of adult (≥ 18 years old) survivors of critical illness due to sepsis and/or acute respiratory failure who attended follow-up in a specialized ICU Recovery Clinic. Outcomes were evaluated during 3-month visit and comprised validated tests for evaluation of physical function, muscle strength, cognitive and emotional health, and self-reported health-related quality of life (HRQOL). Descriptive statistics and group comparisons were performed.

Results

A total of 104 patients with median age of 55 [49-64] years, 54% male, and median SOFA score of 10 [8-12] were analyzed. Incidence of AKI during ICU admission was 61 and 19.2% of patients required renal replacement therapy (RRT). Patients with AKI stage 2 or 3 (vs. those with AKI stage 1 or no AKI) walked less on the 6-min walk test (223 ± 132 vs. 295 ± 153 m, p = 0.059) and achieved lower of the predicted walk distance (38% vs. 58%, p = 0.041). Similar patterns of worse physical function and more significant muscle weakness were observed in multiple tests, with overall worse metrics in patients that required RRT. Patients with AKI stage 2 or 3 also reported lower HRQOL scores when compared to their counterparts, including less ability to return to work or hobby, or reengage in driving. There were no significant differences in cognitive function or emotional health between groups.

Conclusions

Survivors of critical illness and AKI stage 2 or 3 have increased physical debility and overall lower quality of life, with more impairment in return to work, hobby, and driving when compared to their counterparts without AKI or AKI stage 1 at 3 months post-discharge.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02749-z.

Sentiment and emotion trends in nurses' tweets about the COVID-19 pandemic

PURPOSE

Twitter is being increasingly used by nursing professionals to share ideas, information, and opinions about the global pandemic, yet there continues to be a lack of research on how nurse sentiment is associated with major events happening on the frontline. The purpose of the study was to quantitatively identify sentiments, emotions, and trends in nurses' tweets and to explore the variations in sentiments and emotions over a period in 2020 with respect to the number of cases and deaths of COVID-19 worldwide.

DESIGN

A cross-sectional data mining study was held from March 3, 2020 through December 3, 2020. The tweets related to COVID-19 were downloaded using the tweet IDs available from a public website. Data were processed and filtered by searching for keywords related to nursing in the profile description field using the R software and JMP Pro Version 16 and the sentiment analysis of each tweet was done using AFINN, Bing, and NRC lexicon.

FINDINGS

A total of 13,868 tweets from the Twitter accounts of self-identified nurses were included in the final analysis. The sentiment scores of nurses' tweets fluctuated over time and some clear patterns emerged related to the number of COVID-19 cases and deaths. Joy decreased and sadness increased over time as the pandemic impacts increased.

CONCLUSIONS

Our study shows that Twitter data can be leveraged to study the emotions and sentiments of nurses, and the findings suggest that the emotional realm of nurses was affected during the COVID-19 pandemic according to the emotional trends observed in tweets.

CLINICAL RELEVANCE

The study provides insight into what nurses are feeling, and findings from this study highlight the importance of developing and implementing interventions targeted at nurses at the workplace to prevent mental health consequences.

Development of a heterogeneous phantom to measure range in clinical proton therapy beams

PURPOSE

In particle therapy, determination of range by measurement or calculation can be a significant source of uncertainty. This work investigates the development of a bespoke Range Length Phantom (RaLPh) to allow independent determination of proton range in tissue. This phantom is intended to be used as an audit device.

METHOD

RaLPh was designed to be compact and allows different configurations of tissue substitute slabs, to facilitate measurement of range using radiochromic film. Fourteen RaLPh configurations were tested, using two types of proton fluence optimised water substitutes, two types of bone substitute, and one lung substitute slabs. These were designed to mimic different complex tissue interfaces. Experiments were performed using a 115 MeV mono-energetic scanning proton beam to investigate the proton range for each configuration. Validation of the measured film ranges was performed via Monte Carlo simulations and ionisation chamber measurements. The phantom was then assessed as an audit device, by comparing film measurements with Treatment Planning System (TPS) predicted ranges.

RESULTS

Varying the phantom slab configurations allowed for measurable range differences, and the best combinations of heterogeneous material gave agreement between film and Monte Carlo on average within 0.2% and on average within 0.3% of ionisation chamber measurements. Results against the TPS suggest a material density override is currently required to enable the phantom to be an audit device.

CONCLUSION

This study found that a heterogeneous phantom with radiochromic film can provide range verification as part of a dedicated audit for clinical proton therapy beams.

Freedom from disease in psoriasis: a Delphi consensus definition by patients, nurses and physicians

Background

Physician‐reported clinical outcome and quality of life (QoL) measures are currently used to assess outcomes and direct treatment of plaque psoriasis. However, people with psoriasis may have different criteria for judging treatment success.

Objectives

To build a unified consensus on the definition of ‘freedom from disease’ from a European stakeholder group, including people with psoriasis, dermatologists and nurses.

Methods

The modified Delphi consensus methodology was used to define ‘freedom from disease’, with a consensus group consisting of people with psoriasis, nurses and dermatologists. This methodology involved people with psoriasis during the entire process and consisted of a 15‐member Facilitating Consensus Panel to drive the programme content and a larger Voting Consensus Panel to vote on defining ‘freedom from disease’. The Facilitating Panel agreed on disease domains, and aspects of each domain were put forward to the Voting Consensus Panel to establish relative importance. Following two voting rounds, a meeting was held to agree on a final consensus statement.

Results

The Facilitating Panel consisted of six patient advocacy group representatives, three specialist nurses and six dermatologists. Voting rounds 1 and 2 were completed by 166 and 130 respondents from the Voting Consensus Panel, respectively. The outputs from both rounds of voting were similar, focusing on normality of living, symptom control, and a relationship of mutual respect and trust between the individual with psoriasis and their healthcare professional. The consensus statement emphasizes that ‘freedom from disease’ is multifaceted and includes the following domains ‘management of clinical symptoms’, ‘psychosocial elements’, ‘QoL and well‐being’, ‘treatment’ and ‘healthcare team support’. ‘Freedom from disease’ means all aspects are addressed.

Conclusions

Freedom from disease in psoriasis is a multicomponent concept including five main domains. This diverse and multifaceted patient perspective will help us to improve understanding of the outcomes of treatment interventions in people with psoriasis.

Diagnoses during the First Three Years of Life for Children with Prenatal Opioid Exposure and Neonatal Abstinence Syndrome Using a Large Maternal Infant Data Hub

PURPOSE

The purpose of this study was to examine patterns of health and developmental outcomes in children with prenatal opioid exposure (POE) and neonatal abstinence syndrome (NAS) compared to children without exposure during the first three years of life.

DESIGN AND METHODS

This was a secondary data analysis of the Maternal and Infant Data Hub (MIDH), a de-identified dataset originating from the Midwest region of the United States, consisting of newborn billing records and corresponding maternal and child electronic medical records. For these analyses, the repository included data on more than 20,000 children born between 2013 and 2019. Diagnoses were identified with International Classification of Diseases, ninth and tenth Revision, Clinical Modification codes (ICD-9/10-CM). Firth logistic regression was used to assess whether incidence of each diagnosis code differed by exposure group.

RESULTS

Among 20,389 children in the dataset, 13,173 were unexposed; 455 were POE, and 199 were POE + NAS. There were significant differences in frequency of diagnoses between groups, specifically regarding growth and development, infection, mental health, musculoskeletal, neonatal, sensory, and social issues. When comparing exposed groups, children with POE + NAS experienced more negative health outcomes than children with only POE across all years.

CONCLUSIONS

This study implicates POE as a significant variable associated with many health and developmental outcomes of children during the first three years of life.

PRACTICE IMPLICATIONS

It is crucial to understand and identify health risks observed more frequently in exposed children during such a critical period of growth and brain development.

Validity of the 6-Minute Walk Test and YMCA Submaximal Cycle Test During Midpregnancy

Tinius, RA, Blankenship, M, Maples, JM, Pitts, BC, Furgal, K, Norris, ES, Hoover, DL, Olenick, A, Lambert, J, and Cade, WT. Validity of the 6-minute walk test and Young Men's Christian Association (YMCA) submaximal cycle test during midpregnancy. J Strength Cond Res 35(11): 3236-3242, 2021-Submaximal exercise testing can be a feasible alternative to maximal testing within special populations to safely predict fitness levels; however, submaximal exercise testing has not been well-validated for use during pregnancy. The purpose of this study was to determine the concurrent validity of the 6-minute walk test (6MWT) and the YMCA submaximal cycle test (YMCAT) to predict V̇o2max in physically active women during midpregnancy. Thirty-seven (n = 37) pregnant women (22.1 ± 1.4 weeks' gestation) and 10 (n = 10) nonpregnant women participated in the study. Subjects completed a graded maximal treadmill test at 1 visit to measure maximal oxygen consumption (V̇o2max), and then subjects completed the 6MWT and YMCAT in randomized order during a separate visit. The predicted V̇o2max from each submaximal test were compared with the measured V̇o2max from the treadmill test to assess the validity of these tests during pregnancy. Among pregnant women, predicted V̇o2max from the YMCAT was not correlated to the measured V̇o2max (r = 0.14, p = 0.42), and the predicted V̇o2max from the 6MWT was only moderately correlated (r = 0.40, p = 0.016) to the measured V̇o2max. Among nonpregnant women, the predicted V̇o2max values from both the YMCAT and the 6MWT had strong correlations with the measured V̇o2max values (YMCAT: r = 0.71, p = 0.02; 6MWT: r = 0.80, p = 0.006). Neither test demonstrated concurrent validity among the pregnant sample. The main finding is that the YMCAT is not a valid method to estimate V̇o2max during midpregnancy (likely due to physiological changes in heart rate [HR] during pregnancy). The 6MWT has potential to be used clinically for estimating fitness as actual and predicted values did positively correlate, and it is not dependent on HR responses to exercise. However, if a precise measure of fitness is needed, then neither test appears to have strong validity for use during midpregnancy.

Management of lung cancer patients' quality of life in clinical practice: a Delphi study

BACKGROUND

The assessment of health-related quality of life (HRQoL) has seen exponential growth in oncology clinical trials. However, the measurement of HRQoL has yet to be optimised in routine clinical practice. This study aimed at exploring the operationalisation of HRQoL in clinical practice with the goal of reaching a consensus from a panel of physicians.

MATERIALS AND METHODS

Physicians involved in the management of lung cancer patients in France were recruited to participate in a Delphi study. The study involved three rounds of iterated queries to gain consensus on management aspects of HRQoL, including timing of discussion on HRQoL, which specific domains of HRQoL should be discussed, and what was the most appropriate method of assessment. The threshold adopted for consensus was at least 70% agreement among physicians. A scientific committee reviewed results following each round of the Delphi study.

RESULTS

A representative panel of 60 physicians participated in this study. Consensus was obtained for HRQoL management at all time points in the patient care pathway. Panellists agreed that HRQoL discussions should occur during routine visits and hospitalisation. The involvement of patients' relatives was also recognised as important, except when discussing side-effects and involvement of a multidisciplinary team. There was a lack of consensus on a systematic assessment for all patients at each visit and no consensus on how HRQoL should be measured in clinical practice.

CONCLUSIONS

HRQoL discussions are considered an integral part in the management of lung cancer patients, and are deemed key to success in patient-physician interaction. Further research is required to harmonise how best to implement HRQoL assessment.

Risk-mitigating behaviours in people with inflammatory skin and joint disease during the COVID-19 pandemic differ by treatment type: a cross-sectional patient survey

BACKGROUND

Registry data suggest that people with immune-mediated inflammatory diseases (IMIDs) receiving targeted systemic therapies have fewer adverse coronavirus disease 2019 (COVID-19) outcomes compared with patients receiving no systemic treatments.

OBJECTIVES

We used international patient survey data to explore the hypothesis that greater risk-mitigating behaviour in those receiving targeted therapies may account, at least in part, for this observation.

METHODS

Online surveys were completed by individuals with psoriasis (globally) or rheumatic and musculoskeletal diseases (RMDs) (UK only) between 4 May and 7 September 2020. We used multiple logistic regression to assess the association between treatment type and risk-mitigating behaviour, adjusting for clinical and demographic characteristics. We characterized international variation in a mixed-effects model.

RESULTS

Of 3720 participants (2869 psoriasis, 851 RMDs) from 74 countries, 2262 (60·8%) reported the most stringent risk-mitigating behaviour (classified here under the umbrella term 'shielding'). A greater proportion of those receiving targeted therapies (biologics and Janus Kinase inhibitors) reported shielding compared with those receiving no systemic therapy [adjusted odds ratio (OR) 1·63, 95% confidence interval (CI) 1·35-1·97]. The association between targeted therapy and shielding was preserved when standard systemic therapy was used as the reference group (OR 1·39, 95% CI 1·23-1·56). Shielding was associated with established risk factors for severe COVID-19 [male sex (OR 1·14, 95% CI 1·05-1·24), obesity (OR 1·37, 95% CI 1·23-1·54), comorbidity burden (OR 1·43, 95% CI 1·15-1·78)], a primary indication of RMDs (OR 1·37, 95% CI 1·27-1·48) and a positive anxiety or depression screen (OR 1·57, 95% CI 1·36-1·80). Modest differences in the proportion shielding were observed across nations.

CONCLUSIONS

Greater risk-mitigating behaviour among people with IMIDs receiving targeted therapies may contribute to the reported lower risk of adverse COVID-19 outcomes. The behaviour variation across treatment groups, IMIDs and nations reinforces the need for clear evidence-based patient communication on risk-mitigation strategies and may help inform updated public health guidelines as the pandemic continues.

Optimal control pulses for subspectral editing in low field NMR

Low field NMR is an inexpensive and low footprint technique to obtain physical, chemical, electronic and structural information on small molecules, but suffers from poor spectral dispersion, especially when applied to the analysis of mixtures. Subspectral editing employing optimal control pulses is a suitable approach to cope with the severe signal superpositions in complex mixture spectra at low field. In this contribution, the use of optimal control pulses is demonstrated to be feasible at a field strength as low as 0.5 T. The optimal control pulse shapes were calculated using the Krotov algorithm. Downsizing the complexity of the algorithm from exponential to polynomial is shown to be possible by using a system approach with each system corresponding to a (small) molecule. In this way compound selective excitation pulses can be calculated. The signals of substructures of the cyclopentenone molecule were excited using optimal control pulses calculated by the Krotov algorithm demonstrating the feasibility of subspectral editing. Likewise, for a mixture of benzoic acid and alanine, editing of the signals of either benzoic acid or alanine employing optimal control pulses was shown to be possible. The obtained results are very promising and can be extended to the targeted analysis of complex mixtures such as biofluids or metabolic samples at low field strengths opening access for benchtop NMR to point of care settings.

484 CHANGING PRACTICES OF DECISION MAKING REGARDING DO-NOT-ATTEMPT-CARDIOPULMONARY-RESUSCITATION ORDERS AMID THE COVID-19 PANDEMIC

Introduction

The COVID-19 pandemic has brought the decision-making process regarding cardiopulmonary resuscitation into focus. This study aims to analyse Do-Not-Attempt CPR (DNACPR) documentation in older hospitalised patients before and during the COVID-19 pandemic.

Methods

This was a retrospective repeated cross-sectional study. Data including co-morbidities and resuscitation status was collected on 300 patients with COVID-19 hospitalised from March 1st to May 31 s t 2020. DNACPR documentation rates in patients aged ≥65 years with a diagnosis of COVID-19 were compared to those without COVID-19 admitted during the same period. Pre-COVID-19 pandemic DNACPR documentation rates were also examined. Factors associated with DNACPR order instatement during the first wave of the COVID-19 pandemic were identified.

Results

Of 300 COVID-19-positive patients, 28% had a DNACPR order documented during their admission. 50% of DNAR orders were recorded within 24 hours of a positive swab result for SARS-CoV-2. Of 131 patients aged 65 years or over within the cohort admitted with COVID-19, 60.3% had a DNACPR order compared to 25.4% of 130 patients ≥65 without COVID-19 (p &lt; 0.0001). During a comparable time period pre-pandemic, 15.4% of 130 older patients had a DNACPR order in place (p &lt; 0.0001). Independent associations with DNACPR order documentation included increasing age (Odds Ratio [O.R.] 1.12; 95% CI 1.05-1.21); nursing home resident status (O.R. 3.57; 95% CI 1.02-12.50); frailty (O.R. 3.34; 95% CI 1.16-9.61) and chronic renal impairment (O.R. 5.49; 1.34-22.47). The case-fatality-rate of older patients with COVID-19 was 29.8% versus 5.4% without COVID-19. Of older COVID-19-positive patients, 39.2% were referred to palliative care services and 70.2% survived.

Conclusion

The COVID-19 pandemic has prompted more widespread and earlier decision-making regarding resuscitation status. Although case-fatality-rates were higher for older hospitalised patients with COVID-19, many older patients survived the illness. Advance care planning should be prioritised in all patients and should remain clinical practice despite the pandemic.