Use of Telemedicine for Children in Foster Care

Introduction: Telemedicine studies specific to children in foster care are needed, given unique health care needs and barriers. It is important to utilize lessons learned from telemedicine programs deployed by necessity during the COVID-19 emergency. Objectives: Describe telemedicine health assessments for children in foster care performed during the COVID-19 pandemic. Compare medical recommendations resulting from telemedicine and in-person assessments. Methods: After navigating barriers specific to children in foster care including consent issues, we implemented a telemedicine program at our specialty clinic for children in foster care when in-person visits were restricted. Outcomes of telemedicine referrals were tracked. After each visit, physicians were asked to rate ability to express themselves, hear and see patients from 1 (strongly disagree) to 5 (strongly agree) using items from the validated Telehealth Usability Questionnaire. Recommendations for laboratory work, medication, and health services referrals were recorded and compared with 205 patients seen in-person the year prior. Results: From 91 referrals, 83 (91%) children with a mean age of 9 years completed telemedicine visits. Physicians rated receptive and expressive communications more favorably than visual quality. Most telemedicine patients (77%) received a referral for health care services but had significantly lower rates of laboratory work completion, vision referrals, and prescriptions for new medications compared with 205 patients seen in-person. Conclusions: Results suggest that telemedicine was accessible to most patients and highlighted essential in-person components of comprehensive health assessments. Findings could inform ongoing telemedicine applications and advocacy for underserved populations.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

POS0003 DEVELOPMENT AND VALIDATION OF A DISEASE SPECIFIC PATIENT REPORTED OUTCOME FOR GIANT CELL ARTERITIS

Background

Giant cell arteritis (GCA) is caused by inflammation of the blood vessels of the head and neck; patients can present with cranial, ocular or large vessel vasculitis involvement. Treatment is with glucocorticoids, steroid sparing agents and biologics to control inflammation and protect sight.

Objectives

The aim of this study was to produce a validated disease specific PROM for patients with GCA, to capture the impact of GCA and its treatment on health-related quality of life.

Methods

Patients with clinician- confirmed GCA from the UK, either diagnosed in the last three years or with a flare in the last year, were included in the survey. A longlist of 40 candidate questionnaire items, each with a 5-point Likert scale, had previously been developed, based on a qualitative study with patients from the UK and Australia [1]. In this cross-sectional survey, patients completed the 40-item draft GCA-PROM alongside EQ5D-5L, CAT-PRO5 and self-report of GCA disease activity. Rasch and factor analysis were used in an iterative manner to determine the underlying construct validity of the new PROM. Items were fitted to the Rasch model to determine its construct validity, reliability, unidimensionality and statistical sufficiency of the total score from the scale. Factor analysis was used to establishing factor structure. Item reduction decisions were be based on clinical importance, lack of fit to the Rasch model, and redundancy detected during principal component analysis. External validity was tested by comparing the scores of the newly validated GCA-PROM (i) in participants who self-identify as having ‘active disease’ versus patients ‘in remission’ (known groups validity) (ii) with scores derived from EQ5D-5L and CAT-PRO5 (convergent validity).

Results

The survey included 428 patients; 327 (76%) cranial GCA, 114 (26.6%) large vessel vasculitis and 142 (33.2%) ocular involvement. 285 (67%) of participants were female with a mean age (SD) of 74.2 (7.2). 167 (39%) temporal artery biopsies and 177 (41.4%) temporal artery ultrasounds, and 51 (11.9%) Positron Emission Tomography and Computed Tomography (PET-CT)s were reported as positive. 108 (25%) received second-line immunosuppressants, and 34 (7.9%) anti-IL6 therapy. Active disease was reported in 197 (46%). Four factors (domains) were identified after deletion of 10 redundant items: Acute symptoms (8 items), Activities of daily living (7 items), Psychological (7 items) and Participation (8 items). The four domains were analysed as ‘super-items’ and shown to fit the Rasch model. The overall scale had an adequate fit to the Rasch model: X2 = 25.219, DF=24, p=0.394 including reliability PSI=0.828. The raw-to-linear transformation scale was calibrated to enable parametric analyses if desired. Each domain was shown to have known-groups validity (p<0.001 patients reporting active versus inactive disease) and correlation with EQ5D-5L and CAT-PRO5 (Rs) ranging between 0.4.42 and 0.778.

Conclusion

The GCA-PROM is a new patient reported outcome measure for patients with GCA which demonstrates good internal and external validity.

References

[1]Robson JC, Almeida C, Dawson J, Bromhead A, Dures E, Guly C, Hoon E, Mackie S, Ndosi M, Pauling J, Hill C. Patient perceptions of health-related quality of life in giant cell arteritis; international development of a disease-specific Patient-Reported Outcome Measure. Rheumatology (Oxford). 2021:keab076. http://dx.doi.org/10.1093/rheumatology/keab076

Disclosure of Interests

Joanna Robson Speakers bureau: Vifor Pharma EULAR 2021 Symposium, Consultant of: Vifor Pharma Advisory board 2021, Grant/research support from: Vifor Pharma Steroid PRO grant, Celia Almeida: None declared, Jill Dawson: None declared, Emma Dures: None declared, Rosemary Greenwood: None declared, Catherine Guly: None declared, Sarah Mackie Speakers bureau: Roche/Chugai Educational talk on GCA., Consultant of: Roche/Chugai

Sanofi

Abbvie (2021-)

AstraZeneca (2021-), Grant/research support from: Vifor Pharma Steroid PRO 2020

Vifor Pharma GTI Validation 2020

Roche GCA Tocilizumab Registry 2019

, Alison Bromhead: None declared, Steve Stern: None declared, Mwidimi Ndosi: None declared

POS0040-HPR PATIENT PERCEPTIONS OF IMPACT OF GLUCOCORTICOID THERAPY IN THE RHEUMATIC DISEASES: INTERNATIONAL DEVELOPMENT OF A TREATMENT-SPECIFIC PATIENT REPORTED OUTCOME MEASURE

Background

Glucocorticoids (GCs) are a key treatment for inflammatory rheumatic diseases, but they cause a wide range of adverse side-effects which are of concern both to patients and clinicians.

Objectives

The objective of this study was to explore the impact of GC therapy on health-related quality of life (HRQoL) during treatment for rheumatic diseases, as a basis for development of a Patient-Reported Outcome Measure (PROM) to be used in clinical trials and practice.

Methods

Patients from the UK, USA and Australia who were treated with GCs in the last two years for a rheumatic condition were invited to take part in semi-structured qualitative interviews. Purposive sampling was used to include participants with a range of demographic and disease features. A steering committee of patient research partners, clinicians and methodologists devised an initial conceptual framework, which informed interview prompts and cues. Interviews were carried out by experienced qualitative researchers who encouraged participants to tell their stories and talk about the effects, both adverse and beneficial, of their experiences and perceptions of treatment with GCs, to identify salient physical and psychological symptoms and aspects of HRQoL. The interview data were organised using NVivo, and inductive analysis identified initial themes and domains. Candidate questionnaire items were developed and refined using cognitive interviewing, linguistic assessment, and input from patient research partners.

Results

Sixty semi-structured qualitative interviews were conducted (UK n=34, USA n=10, Australia n=16). Mean participant age was 58 years; 39 (66.1%) were female. Purposive sampling of participants provided a broad range of demographic features, GC dosages and inflammatory rheumatic conditions, with 27% having connective tissue disease, 25% inflammatory arthritis, 30% systemic vasculitis and 16% other rheumatic conditions.

Initial domains were developed to identify key themes relating to treatment using GCs and their impact on HRQoL; see Figure 1.

Figure 1.

Steroid PRO Initial Themes

A long-list of 134 initial candidate questionnaire items was developed from the individual themes. These items were reviewed by a qualitative working group of patient research partners, researchers and clinicians to reduce duplication and ambiguity of items. The resulting 62 items were tested and refined by piloting with patient research partners, iterative rounds of cognitive interviews with patients with a range of rheumatic conditions from the UK, USA and Australia, and a linguistic translatability assessment, to define a draft questionnaire of 40 items.

Conclusion

This international qualitative study underpins the development of candidate items for a treatment-specific PROM for patients with rheumatic diseases. The draft questionnaire is currently being tested in an online large-scale survey to determine the final scale structure and measurement properties using Rasch analysis, factor analysis, test-retest, comparison with EQ5D, and known groups analysis.

Disclosure of Interests

Susan Bridgewater Grant/research support from: Vifor Pharma, Michael A Shepherd Grant/research support from: Vifor Pharma, Jill Dawson: None declared, Pamela Richards: None declared, Christine Silverthorne: None declared, Mwidimi Ndosi: None declared, Celia Almeida: None declared, Rachel J Black: None declared, Jonathan T.L. Cheah: None declared, Emma Dures: None declared, Nilasha Ghosh: None declared, Elizabeth A Hoon: None declared, Suellen Lyne: None declared, Iris Navarro-Millan Consultant of: Honorarium on Swedish Orpham Biovitrum (SOBI) advisory board 2021, Diyu Pearce-Fisher: None declared, Carlee Ruediger: None declared, Joanna Tieu: None declared, Kevin Yip: None declared, Sarah Mackie: None declared, Susan Goodman: None declared, Catherine Hill: None declared, Joanna Robson Speakers bureau: EULAR Symposium 2021 for Vifor Pharma, Consultant of: Honorarium for Vifor Pharma advisory board 2021, Grant/research support from: Vifor Pharma 2020-2022

440 Training in Microbiological Sampling for Toe Amputations in Diabetic Foot Disease: A Survey of UK Vascular Trainees

Aim

To determine usual practice and extent of training received by United Kingdom (UK) vascular surgery trainees in microbiological sampling for toe amputations in diabetic patients.

Method

A prospective online survey was distributed via social media networks and trainee organisations. All vascular surgery trainees in the UK were invited to participate. A total of 29 responses were included in the analysis.

Results

86% of respondents have been trained in toe amputations during registrar training. 66% have not been taught which samples to send for microbiological analysis. 10% receive regular training reviews in toe amputations. There is significant variability in the types of samples sent by trainees for microbiological analysis and the majority of trainees did not know how their samples are processed in the laboratory.

Conclusions

Toe amputations appear to be a neglected aspect of training for UK vascular surgery registrars. Lack of consistency in microbiological sampling techniques may prevent optimum antimicrobial stewardship and therefore increase the risk of further complications including major amputation. Inclusion of diabetic foot sepsis as a critical condition in the new vascular surgery curriculum may help to address this issue. A national consensus needs to be reached on how microbiological samples should be taken and processed in order for trainees to be taught in a consistent manner.

AB0834 DEVELOPMENT OF A CONCEPTUAL FRAMEWORK FOR A PATIENT REPORTED OUTCOME MEASURE TO CAPTURE PATIENTS’ PERCEPTIONS OF GLUCOCORTICOID THERAPY DURING TREATMENT FOR RHEUMATIC DISEASES

Background:

Glucocorticoids (GCs) are a key treatment for the autoimmune rheumatic diseases; however, they produce numerous physical and psychological side effects.1 The Outcome Measures in Rheumatology (OMERACT) Glucocorticoid Working Group have identified that there are no Patient Reported Outcome Measures (PROMs) for assessing the impact of systemic GC therapy across multiple rheumatic diseases from the patient’s perspective.2,3

Objectives:

The aim is to explore the impact of GCs on the symptoms and health-related quality of life of adults with rheumatic inflammatory diseases, to inform items for inclusion in a PROM. Key considerations will include patient perceptions of GC therapy at diagnosis and over the course of treatment, for use in future randomised controlled trials or in clinical practice.

Methods:

An international steering committee comprising researchers, rheumatology clinicians, methodologists and patient partners in the UK, Australia and USA developed an initial conceptual framework informed by a review of the literature. Semi-structured interviews were conducted in each country with patients who had an autoimmune rheumatic disease and had received GC therapy. The interviews explored salient aspects of health-related quality of life associated with being treated with GCs.

Results:

Interviews have been completed in three continents with patients who had a range of demographic features, rheumatological conditions and duration and dosage of GC therapy. Figure 1 shows the initial conceptual framework for developing the GC PROM (Steroid PRO).

Figure 1.

Conclusion:

This conceptual framework will act as an evolving guide in the development of a PROM for assessing patients’ perspectives of systemic glucocorticoid therapy. Future work will include inductive analysis of qualitative transcripts to inform candidate questionnaire items, cognitive interviewing, linguistic translatability assessment, and an international validation survey to define the final PROM questionnaire and its measurement properties.

References:

[1]Cheah JTL, Robson JC, Black RJ, et al. The patient’s perspective of the adverse effects of glucocorticoid use: A systematic review of quantitative and qualitative studies. From an OMERACT working group. Semin Arthritis Rheum. 2020 Oct; 50(5):996-1005.

[2]Black RJ, Robson JC, Goodman SM, et al. A Patient-reported Outcome Measure for Effect of Glucocorticoid Therapy in Adults with Inflammatory Diseases Is Needed: Report from the OMERACT 2016 Special Interest Group. J Rheumatol. 2017; 44(11):1754-8.

[3]Cheah JTL, Black RJ, Robson JC, et al. Toward a Core Domain Set for Glucocorticoid Impact in Inflammatory Rheumatic Diseases: The OMERACT 2018 Glucocorticoid Impact Working Group. J Rheumatol. 2019; 46(9):1179-1182.

Disclosure of Interests:

Susan Bridgewater Grant/research support from: Grant from Vifor Pharma for an independent investigator-led study to develop a PRO for steroids, Jill Dawson: None declared, Mwidimi Ndosi: None declared, Rachel J Black: None declared, Jonathan T.L. Cheah: None declared, Emma Dures: None declared, Nilasha Ghosh: None declared, Elizabeth A Hoon: None declared, Iris Navarro-Millan Consultant of: Received consultant fees from SOBI, Diyu Pearce-Fisher: None declared, Pamela Richards: None declared, Carlee Ruediger: None declared, Christine Silverthorne: None declared, Joanna Tieu Grant/research support from: Vifor Pharma, Sarah Mackie Consultant of: Consultancy on behalf of institution for Roche/Chugai, Sanofi, AbbVie and AstraZeneca, Grant/research support from: Educational grant from Roche to attend EULAR2019, Susan Goodman: None declared, Catherine Hill: None declared, Joanna Robson Speakers bureau: Vifor Pharma for educational webinar, Grant/research support from: Grant from Vifor Pharma for an independent investigator-led study to develop a PRO for steroids

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

THU0542 THE IMPACT OF GLUCOCORTICOID INITIATION ON THE DIAGNOSTIC ACCURACY OF ULTRASOUND IN GIANT CELL ARTERITIS: EXPERIENCES FROM A DISTRICT GENERAL HOSPITAL IN THE UK

Background:

Temporal and axillary artery ultrasound (US) has been recommended by EULAR as the first-line investigation in patients with suspected giant cell arteritis (GCA).1US is reported as having a 77% sensitivity and 96% specificity for GCA.1However, these figures have largely been derived from studies carried out in specialist centres where US was performed rapidly following the onset of symptoms. When performed by highly experienced sonographers, halos can still be detected on US weeks after initiation of glucocorticoid treatment.2Little is known about the relationship between the dose and duration of glucocorticoid and diagnostic accuracy of US in real-world experience.

Objectives:

We evaluated the impact of glucocorticoid initiation on the diagnostic accuracy of US in patients with suspected GCA in routine clinical practice in a district general hospital.

Methods:

This is a single-centre retrospective study of all temporal and axillary artery US performed since its inception in November 2015 until October 2019. Patients who were aged ≥50 years and assessed by a rheumatologist were included in the study. US was performed by either a musculoskeletal consultant radiologist, musculoskeletal sonographer or vascular sonographer. US was considered positive for GCA when a halo, occlusion or stenosis was seen. Patients’ medical records and investigation results were reviewed in a systematic manner. The reference standard for GCA was the final clinical diagnosis after a minimum of 3-month rheumatology follow up.

Results:

311 US performed on 305 patients were included. 62% of the scans were requested by rheumatologists, the rest by ophthalmologists and general physicians. 57 of these episodes had a final clinical diagnosis of GCA. US had an overall sensitivity of 39% and specificity of 100% for GCA. Overall positive and negative predictive values were 100% and 88%, respectively. Sensitivity was 31% for US done in the first 2 years (n=160) which was lower than sensitivity of 45% in the latter 2 years (n=151) (p=0.2663). Specificity remained the same in the two periods. When performed on patients who were not on any glucocorticoids, US had a sensitivity of 89% which was significantly higher than sensitivity of 29% in those who had been treated with any dose or duration of steroids (p=0.0007).

Compared to US-negative GCA patients, US-positive GCA patients are older and more likely to have jaw claudication (Table 1).

Table.

Characteristics of patients with a final clinical diagnosis of GCA

All GCA (n=57)US positive (n=22)US negative (n=35)p-valueAge, mean years7478720.01Sex, no of females41 (72%)13 (59%)27 (77%)0.15Any head pain present, no of patients49 (86%)18 (82%)31 (89%)0.50Jaw claudication, no of patients26 (46%)15 (68%)14 (40%)0.04Ocular ischaemia, no of patients8 (14%)3 (14%)5 (14%)0.94ESR, mm/hour,* mean6766680.78CRP, mg/L,* mean8585840.96Days of high-dose glucocorticoid pre-US, mean5460.11

* ESR was determined in n=55 patients and CRP in n=53 patients. ESR and CRP were measured before initiation of high-dose steroid treatment.

Table 2.

Diagnostic accuracy of US stratified by duration of high dose glucocorticoid* pre-scan

Steroid durationnSensitivity, %Specificity, %PPV, %NPV, %0-1 day15471100100972-3 days34†22100100774-5 days32†33100100796-7 days181310010059>7 days413310010072

*>30mg of oral prednisone or equivalent

†included episodes when patients were treated with intravenous methylprednisone

Conclusion:

US has an 89% sensitivity and 100% specificity for GCA when performed before initiation of glucocorticoid. Its sensitivity rapidly decreases within a day of starting high dose steroid but up to one-third of GCA cases can still be detected after over 1 week of treatment.

References:

[1]Dejaco C, Ramiro S, Duftner C,et al. EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice.Ann Rheum Dis2018;77:636-43.

[2]De Miguel E, Roxo A, Castillo C,et al. The utility and sensitivity of colour Doppler ultrasound in monitoring changes in giant cell arteritis.Clin Exp Rheumatol2012;30:S34-8.

Disclosure of Interests

None declared

Tuberculosis serosurveillance and management practices of captive African elephants (Loxodonta africana) in the Kavango-Zambezi Transfrontier Conservation Area

Transfrontier conservation areas represent an international effort to encourage conservation and sustainable development. Their success faces a number of challenges, including disease management in wildlife, livestock and humans. Tuberculosis (TB) affects humans and a multitude of non-human animal species and is of particular concern in sub-Saharan Africa. The Kavango-Zambezi Transfrontier Conservation Area encompasses five countries, including Zimbabwe, and is home to the largest contiguous population of free-ranging elephants in Africa. Elephants are known to be susceptible to TB; thus, understanding TB status, exposure and transmission risks to and from elephants in this area is of interest for both conservation and human health. To assess risk factors for TB seroprevalence, a questionnaire was used to collect data regarding elephant management at four ecotourism facilities offering elephant-back tourist rides in the Victoria Falls area of Zimbabwe. Thirty-five working African elephants were screened for Mycobacterium tuberculosis complex antibodies using the ElephantTB Stat-Pak and the DPP VetTB Assay for elephants. Six of 35 elephants (17.1%) were seropositive. The risk factor most important for seropositive status was time in captivity. This is the first study to assess TB seroprevalence and risk factors in working African elephants in their home range. Our findings will provide a foundation to develop guidelines to protect the health of captive and free-ranging elephants in the southern African context, as well as elephant handlers through simple interventions. Minimizing exposure through shared feed with other wildlife, routine TB testing of elephant handlers and regular serological screening of elephants are recommended as preventive measures.

A Simple Composite Dynamic Digital Tool to Communicate Complex Physical and Mental Health needs and Measure Outcomes: The Cornwall Health Radar

Introduction

Clinician-patient communication is a major factor in influencing outcomes of healthcare. Complexity increases if an individual has multiple health needs requiring support of different clinicians or agencies.

Aim

To develop and evidence a simple dynamic computerised tool to capture and communicate outcomes of intervention or alteration in clinical need in patients with multiple chronic health needs.

Method

A MS Excel algorithm was designed for swift capture of clinical information discussed in an appointment using pre-designed set of evidenced based domains. An instant personalized single screen visual is produced to facilitate information sharing and decision-making. The display is responsive to compare changes across time. A prototype was conceptually tested in an epilepsy clinic for people with Intellectual disability (ID) due to the unique challenges posed in this population.

Results

Evidence across 300 patients with ID and epilepsy showed the tool works by enhancing reflective communication, compliance and therapeutic relationship. Medication and appointment compliance was 95% and patient satisfaction over 90%.

Conclusion

To discuss all influencing health factors in a consultation is a communication challenge esp. if the patient has multiple health needs. A picture equals 1000 words and helps address the cognitive complexity of verbal information. The radar offers an evidenced based common framework to host care plans of different health conditions. It provides individualised easy view person centred care plans to allow patients to gain insight on how the different conditions impact on their overall well being and be active participants. The tool will be practically demonstrated.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

GPR91 deficiency exacerbates allergic contact dermatitis while reducing arthritic disease in mice

Background

Succinate, in addition to its role as an intermediary of the citric acid cycle, acts as an alarmin, initiating and propagating danger signals resulting from tissue injury or inflammatory stimuli. The contribution of this immune sensing pathway to the development of allergic and inflammatory responses is unknown.

Methods

Ear thickness of wild‐type (wt) and Sucnr1‐deficient (Sucnr1^−/−) mice, sensitized and challenged with oxazolone, was used as a criterion to assess the relevance of SUCNR1/GPR91 expression mediating allergic contact dermatitis (ACD). Results obtained in this system were contrasted with data generated using passive cutaneous anaphylaxis, ovalbumin‐induced asthma and arthritis models.

Results

We found augmented ACD reactions in Sucnr1^−/− mice. This observation correlated with increased mast cell activation in vitro and in vivo. However, exacerbated mast cell activation in Sucnr1^−/− mice did not contribute to the enhancement of asthma or arthritis and seemed to be due to alterations during mast cell development as augmented mast cell responses could be recapitulated in wt mast cells differentiated in the absence of succinate.

Conclusions

A deficiency in succinate sensing during mast cell development confers these cells with a hyperactive phenotype. Such a phenomenon does not translate into exacerbation of asthma or mast cell‐dependent arthritis. On the contrary, the fact that Sucnr1^−/− mice developed reduced arthritic disease, using two different in vivo models, indicates that GPR91 antagonists may have therapeutic potential for the treatment of allergic and autoimmune diseases.

Effectiveness of open and arthroscopic rotator cuff repair (UKUFF): a randomised controlled trial

AIMS

The appropriate management for patients with a degenerative tear of the rotator cuff remains controversial, but operative treatment, particularly arthroscopic surgery, is increasingly being used. Our aim in this paper was to compare the effectiveness of arthroscopic with open repair of the rotator cuff.

PATIENTS AND METHODS

A total of 273 patients were recruited to a randomised comparison trial (136 to arthroscopic surgery and 137 to open surgery) from 19 teaching and general hospitals in the United Kingdom. The surgeons used their usual preferred method of repair. The Oxford Shoulder Score (OSS), two years post-operatively, was the primary outcome measure. Imaging of the shoulder was performed at one year after surgery. The trial is registered with Current Controlled Trials, ISRCTN97804283.

RESULTS

The mean OSS improved from 26.3 (standard deviation (sd) 8.2) at baseline, to 41.7 (sd 7.9) two years post-operatively for arthroscopic surgery and from 25.0 (sd 8.0) to 41.5 (sd 7.9) for open surgery. Intention-to-treat (ITT) analysis showed no statistical difference between the groups at two years (difference in OSS score -0.76; 95% confidence interval (CI) -2.75 to 1.22; p = 0.452). The confidence interval excluded the pre-determined clinically important difference in the OSS of three points. The rate of re-tear was not significantly different between the two groups (46.4% for arthroscopic and 38.6% for open surgery; 95% CI -6.9 to 25.8; p = 0.256). Healed repairs had the most improved OSS. These findings were the same when analysed per-protocol.

CONCLUSION

There is no evidence of difference in effectiveness between open and arthroscopic repair of rotator cuff tears. The rate of re-tear is high in both groups, for all sizes of tear and ages and this adversely affects the outcome. Cite this article: Bone Joint J 2017;99-B:107-15.

Non-invasive imaging demonstrates clinical features of ankylosing spondylitis in a rat adjuvant model: a case study

Main features of ankylosing spondylitis like inflammatory erosive osteopenia and bony overgrowth are recapitulated in rats challenged with complete Freund’s adjuvant. In vivo changes induced in the rat spine were followed longitudinally by magnetic resonance imaging (MRI) and assessed terminally by micro-computerized tomography (micro-CT) and histology. Signals reflecting inflammation were detected by MRI at levels L5-L6 throughout the experiment, peaking at day 27 after adjuvant. Bone erosion and formation occurred from this time point onward, as confirmed by micro-CT. Histology confirmed the inflammation and bone remodeling. The present study demonstrates the potential of imaging for longitudinal assessments of spinal changes in this animal model and the excellent correlation between in vivo images and histology underlines its fundamental role in the validation of non-invasive imaging.

HbA1c measurement and relationship to incident stroke

AIMS

To determine the proportion of people with diabetes who have HbA1c measured, what proportion achieve an HbA1c level of < 58 mmol/mol (7.5%), the frequency of testing and if there was any change in HbA1c level in the year before and the year after an incident stroke.

METHODS

This study used the Secure Anonymised Information Linkage (SAIL) databank, which stores hospital data for the whole of Wales and ~ 65% of Welsh general practice records, to identify cases of stroke in patients with diabetes between 2000 and 2010. These were matched against patients with diabetes but without stroke disease. We assessed the frequency of HbA1c testing and change in HbA1c in the first year after stroke. Estimation was made of the proportion of patients achieving an HbA1c measurement ≤ 58 mmol/mol (7.5%).

RESULTS

There were 1741 patients with diabetes and stroke. Of these, 1173 (67.4%) had their HbA1c checked before their stroke and 1137 (65.3%) after their stroke. In the control group of 16 838 patients with diabetes but no stroke, 8413 (49.9%) and 9288 (55.1%) had their HbA1c checked before and after the case-matched stroke date, respectively. In patients with diabetes and stroke, HbA1c fell from 61-56 mmol/mol (7.7-7.3%) after their stroke (P < 0.001). Before the study, 55.0% of patients with stroke had an HbA1c ≥ 58 mmol/mol compared with 65.2% of control patients, these figures were 62.5% and 65.3% after the stroke.

CONCLUSIONS

The frequency of diabetes testing was higher in patients who had experienced a stroke before and after their incident stroke compared with control patients but did not increase after their stroke. Glucose control improved significantly in the year after a stroke.

Cohort profile of the UK Biobank: diagnosis and characteristics of cerebrovascular disease

PURPOSE

The UK Biobank is a large-scale biomedical resource, containing sociodemographic and medical information, including data on a previous diagnosis of stroke or transient ischaemic attack (TIA). We described these participants and their medication usage.

PARTICIPANTS

We identified participants who either self-reported or were identified from a nurse-led interview, having suffered a stroke or a TIA and compared them against participants without stroke ort TIA. We assessed their risk factor burden (sex, age, deprivation, waist to hip ratio (WHR), hypertension, smoking, alcohol intake, diabetes, physical exercise and oral contraception use (oral contraceptive pill, OCP)) and medication usage.

FINDINGS TO DATE

We studied 502,650 people (54.41% women), 6669 (1.23%) participants self-reported a stroke. The nurse-led interview identified 7669 (1.53%) people with stroke and 1781 (0.35%) with TIA. Hypertension, smoking, higher WHR, lower alcohol consumption and diabetes were all more common in people with cerebrovascular disease (p<0.0001 for each). Women with cerebrovascular disease were less likely to have taken the OCP (p=0.0002). People with cerebrovascular disease did more exercise (p=0.03). Antithrombotic medication was taken by 81% of people with stroke (both self-report and nurse-led responders) and 89% with TIA. For self-reported stroke, 63% were taking antithrombotic and cholesterol medications, 54% taking antithrombotic and antihypertensive medications and 46% taking all 3. For the nurse-led interview and TIA, these figures were 65%, 54% and 46%, and 70%, 53% and 45%, respectively.

FUTURE PLANS

The UK Biobank provides a large, generalisable and contemporary data source in a young population. The characterisation of the UK Biobank cohort with cerebrovascular disease will form the basis for ongoing research using this data source.

Randomized controlled trial examining expectancy effects on the accuracy of weight measurement

BACKGROUND

Researchers and participants' expectations can influence treatment response. Less is known about the effects of researchers' expectations on the accuracy of data collection in the context of a weight loss trial.

METHODS

Student raters (N = 58; age = 20.1 ± 2.3 years) were recruited to weigh individuals who they thought were completing a 12-month weight loss trial, although these 'participants' were actually standardized patients (SPs) playing these roles. Prior to data collection, student raters were provided information suggesting that the tested treatment had been effective. Each student rater received a list of 9-10 'participants' to weigh. While the list identified each person as 'treatment' or 'control', this assignment was at random, which allowed us to examine the effects of non-blinding and expectancy manipulation on weight measurement accuracy. We hypothesized that raters would record the weights of 'treatment participants' as lower than those of 'control participants'.

RESULTS

Contrary to our hypothesis, raters recorded weights that were 0.293 kg heavier when weighing 'treatment' vs. 'control' SPs, although this difference was not significant (P = 0.175).

CONCLUSIONS

This pilot study found no evidence that manipulating expectancies about treatment efficacy or not blinding raters biased measurements. Future work should examine other biases which may be created by not blinding research staff who implement weight loss trials as well as the participants in those trials.

Can pain and function be distinguished in the Oxford Hip Score in a meaningful way? : an exploratory and confirmatory factor analysis

Objective

The objective of this study was to explore dimensionality of the Oxford Hip Score (OHS) and examine whether self-reported pain and functioning can be distinguished in the form of subscales.

Methods

This was a secondary data analysis of the UK NHS hospital episode statistics/patient-reported outcome measures dataset containing pre-operative OHS scores on 97 487 patients who were undergoing hip replacement surgery.

Results

The proposed number of factors to extract depended on the method of extraction employed. Velicer’s Minimum Average Partial test and the Parallel Analysis suggested one factor, the Cattell’s scree test and Kaiser-over-1 rule suggested two factors. Exploratory factor analysis demonstrated that the two-factor OHS had most of the items saliently loading either of the two factors. These factors were named ‘Pain’ and ‘Function’ and their respective subscales were created. There was some cross-loading of items: 8 (pain on standing up from a chair) and 11 (pain during work). These items were assigned to the ‘Pain’ subscale. The final ‘Pain’ subscale consisted of items 1, 8, 9, 10, 11 and 12. The ‘Function’ subscale consisted of items 2, 3, 4, 5, 6 and 7, with the recommended scoring of the subscales being from 0 (worst) to 100 (best). Cronbach’s alpha was 0.855 for the ‘Pain’ subscale and 0.861 for the ‘Function’ subscale. A confirmatory factor analysis demonstrated that the two-factor model of the OHS had a better fit. However, none of the one-factor or two-factor models was rejected.

Conclusion

Factor analyses demonstrated that, in addition to current usage as a single summary scale, separate information on pain and self-reported function can be extracted from the OHS in a meaningful way in the form of subscales.

Cite this article: Bone Joint Res 2014;3:305–9.

Protocol for the United Kingdom Rotator Cuff Study (UKUFF): a randomised controlled trial of open and arthroscopic rotator cuff repair

This protocol describes a pragmatic multicentre randomised controlled trial (RCT) to assess the clinical and cost effectiveness of arthroscopic and open surgery in the management of rotator cuff tears. This trial began in 2007 and was modified in 2010, with the removal of a non-operative arm due to high rates of early crossover to surgery. Cite this article: Bone Joint Res 2014;3:155-60.

Development of a patient-reported outcome measure of activity and participation (the OKS-APQ) to supplement the Oxford knee score

The primary aim of this study was to develop a patient-reported Activity & Participation Questionnaire (the OKS-APQ) to supplement the Oxford knee score, in order to assess higher levels of activity and participation. The generation of items for the questionnaire involved interviews with 26 patients. Psychometric analysis (exploratory and confirmatory factor analysis and Rasch analysis) guided the reduction of items and the generation of a scale within a prospective study of 122 relatively young patients (mean age 61.5 years (42 to 71)) prior to knee replacement. A total of 99, completed pre-operative and six month post-operative assessments (new items, OKS, Short-Form 36 and American Knee Society Score).

The eight-item OKS-APQ scale is unidimensional, reliable (Cronbach’s alpha 0.85; intraclass correlation coefficient (ICC) 0.79; or 0.92 when one outlier was excluded), valid (r >  0.5 with related scales) and responsive (effect size 4.16).

We recommend that it is used with the OKS with adults of all ages when further detail regarding the levels of activity and participation of a patient is required.

Cite this article: Bone Joint J 2014;96-B:332–8.

The Manchester-Oxford Foot Questionnaire (MOXFQ): Development and validation of a summary index score

Objectives

The Manchester–Oxford Foot Questionnaire (MOXFQ) is a validated 16-item, patient-reported outcome measure for evaluating outcomes of foot or ankle surgery. The original development of the instrument identified three domains. This present study examined whether the three domains could legitimately be summed to provide a single summary index score.

Methods

The MOXFQ and Short-Form (SF)-36 were administered to 671 patients before surgery of the foot or ankle. Data from the three domains of the MOXFQ (pain, walking/standing and social interaction) were subjected to higher order factor analysis. Reliability and validity of the summary index score was assessed.

Results

The mean age of the participants was 52.8 years (sd 15.68; 18 to 89). Higher order principle components factor analysis produced one factor, accounting for 74.7% of the variance. The newly derived single index score was found to be internally reliable (α = 0.93) and valid, achieving at least moderate correlations (r ≥ 0.5, p < 0.001) with related (pain/function) domains of the SF-36.

Conclusions

Analyses indicated that data from the MOXFQ can be presented in summary form. The MOXFQ summary index score (MOXFQ-Index) provides an overall indication of the outcomes of foot and ankle surgery. Furthermore, the single index reduces the number of statistical comparisons, and hence the role of chance, when exploring MOXFQ data.

Collagen remodeling by phagocytosis is determined by collagen substrate topology and calcium-dependent interactions of gelsolin with nonmuscle myosin IIA in cell adhesions

Cell adhesion to collagen presented on beads activates Ca²⁺ entry and promotes the formation of phagosomes enriched with NMMIIA and gelsolin. The Ca²⁺-dependent interaction of gelsolin and NMMIIA in turn enables actin remodeling and enhances collagen degradation by phagocytosis.

We examine how collagen substrate topography, free intracellular calcium ion concentration ([Ca²⁺]_i, and the association of gelsolin with nonmuscle myosin IIA (NMMIIA) at collagen adhesions are regulated to enable collagen phagocytosis. Fibroblasts plated on planar, collagen-coated substrates show minimal increase of [Ca²⁺]_i, minimal colocalization of gelsolin and NMMIIA in focal adhesions, and minimal intracellular collagen degradation. In fibroblasts plated on collagen-coated latex beads there are large increases of [Ca²⁺]_i, time- and Ca²⁺-dependent enrichment of NMMIIA and gelsolin at collagen adhesions, and abundant intracellular collagen degradation. NMMIIA knockdown retards gelsolin recruitment to adhesions and blocks collagen phagocytosis. Gelsolin exhibits tight, Ca²⁺-dependent binding to full-length NMMIIA. Gelsolin domains G4–G6 selectively require Ca²⁺ to interact with NMMIIA, which is restricted to residues 1339–1899 of NMMIIA. We conclude that cell adhesion to collagen presented on beads activates Ca²⁺ entry and promotes the formation of phagosomes enriched with NMMIIA and gelsolin. The Ca²⁺ -dependent interaction of gelsolin and NMMIIA in turn enables actin remodeling and enhances collagen degradation by phagocytosis.