Fostering equitable change in health services: Using critical reflexivity to challenge dominant discourses in low back pain care in Australia

OBJECTIVES

Justice and equity-focused practices in health services play a critical but overlooked role in low back pain (LBP) care. Critical reflexivity - the ability to examine and challenge power relations, and broader social issues embedded in everyday life - can be a useful tool to foster practices that are more socially just. No research has yet explored this approach in back pain health services. This study sought to understand how clinicians construct LBP in relation to broader socio-cultural-political aspects of care and explore if those constructions changed when clinicians engaged with critically reflexive dialogues with researchers.

METHODS

Using critical discourse analysis methods, this qualitative study explored institutionalised patterns of knowledge in the construction of LBP care. We conducted 22 critically reflexive dialogues with 29 clinicians from two health services in Australia - a private physiotherapy clinic and a public multidisciplinary pain clinic.

RESULTS

Our analyses suggested that clinicians and services often constructed LBP care at an individual level. This dominant individualistic discourse constrained consideration of justice-oriented practices in the care of people with LBP. Through dialogues, discursive constructions of LBP care expanded to incorporate systems and health service workplace practices. This expansion fostered more equitable clinical and service practices - such as assisting patients to navigate health care systems, considering patients' socioeconomic circumstances when developing treatment plans, encouraging staff discussion of possible systemic changes to enhance justice, and fostering a more inclusive workplace culture. Although such expansions faced challenges, incorporating broader discourses enabled recommendations to address LBP care inequities.

CONCLUSIONS

Critical reflexivity can be a tool to foster greater social justice within health services. By expanding constructions of LBP care beyond individuals, critical reflexive dialogues can foster discussion and actions towards more equitable workplace cultures, services and systems.

'Engaging on a slightly more human level': A qualitative study exploring the care of individuals with back pain in a multidisciplinary pain clinic

Chronic low back pain is characterised by multiple and overlapping biological, psychological, social and broader dimensions, affecting individuals' lives. Multidisciplinary pain services have been considered optimal settings to account for the multidimensionality of chronic low back pain but have largely focused on cognitive and behavioural aspects of individuals' pain. Social dimensions are usually underexplored, considered outside or beyond healthcare professionals' scope of practice. Employing Actor Network Theorist Mol's concept multiplicity, our aim in this paper is to explore how a pain service's practices bring to the fore the social dimensions of individuals living with low back pain. Drawing on 32 ethnographic observations and four group exchanges with the service's clinicians, findings suggest that practices produced multiple enactments of an individual with low back pain. Although individuals' social context was present and manifested during consultations at the pain service (first enactment: 'the person'), it was often disconnected from care and overlooked in 'treatment/management' (second enactment: 'the patient'). In contrast, certain practices at the pain service not only provided acknowledgement of, but actions towards enhancing, individuals' social contexts by adapting rules and habits, providing assistance outside the service and shifting power relations during consultations (third enactment: 'the patient-person'). We therefore argue that different practices enact different versions of an individual with low back pain in pain services, and that engagement with individuals' social contexts can be part of a service's agenda.

An Experimental and Computational Approach to Development of Mixing Processes for Miscible Liquids in Unbaffled Tanks

PURPOSE

Mixing of liquids is a critical unit operation in the biopharmaceutical drug product manufacturing. It commonly consists of mixing miscible liquids to dilute bulk drug substance (DS) or pool multiple lots of drug substance. In the past, at-scale mixing studies have been conducted to determine the mixing parameters, namely mixing speed, and mixing time. At-scale studies have historically been utilized to overcome the challenges associated with geometric dissimilarity of mixing systems found when scaling up. In addition, such studies are quite costly, as they often use actual DS to overcome a lack of representativeness associated with simple salt trace models often employed. As a result, there is a significant need for alternative cost-effective methods that can predict mixing parameters with close agreement to actual experiments and operations.

METHOD

At-scale mixing experiments were conducted using full-sized tanks and surrogate solutions. Several computational fluid dynamic (CFD) simulation methods were conducted and compared with the experiments to determine the most reliable computational techniques.

RESULTS

The experiments demonstrate that surrogate solutions can be used reliably to determine mixing parameters in at-scale studies instead of the valuable drug products. Studying different CFD methods also showed that transient simulations that use a large eddy simulation (LES) viscous model and a sliding mesh can correctly predict the mixing parameters.

CONCLUSION

Results of this study establish a practical and reliable methodology to perform mixing studies for miscible liquids with different kinematic viscosities. The methods discussed herein greatly reduce the routine mixing study costs in the biopharmaceutical industry and increase efficiency and accuracy of the results, allowing proactive scale-up of mixing operations.

Uncertainty in low back pain care - insights from an ethnographic study

PURPOSE

To explore how uncertainty plays out in low back pain (LBP) care and investigate how clinicians manage accompanying emotions/tensions.

MATERIALS AND METHODS

We conducted ethnographic observations of clinical encounters in a private physiotherapy practice and a public multidisciplinary pain clinic. Our qualitative reflexive thematic analysis involved abductive thematic principles informed by Fox and Katz (medical uncertainty) and Ahmed (emotions).

RESULTS

We identified three themes. (1) Sources of uncertainty: both patients and clinicians expressed uncertainty during clinical encounters (e.g., causes of LBP, mismatch between imaging findings and presentation). Such uncertainty was often accompanied by emotions - anger, tiredness, frustration. (2) Neglecting complexity: clinicians often attempted to decrease uncertainty and associated emotions by providing narrow answers to questions about LBP. At times, clinicians' denial of uncertainty also appeared to deny patients the right to make informed decisions about treatments. (3) Attending to uncertainty?: clinicians attended to uncertainty through logical reasoning, reassurance, acknowledgement, personalising care, shifting power, adjusting language and disclosing risks.

CONCLUSIONS

Uncertainty pervades LBP care and is often accompanied by emotions, emphasising the need for a healthcare culture that recognises the emotional dimensions of patient-clinician interactions and prepares clinicians and patients to be more accepting of, and clearly communicate about, uncertainty.IMPLICATIONS FOR REHABILITATIONUncertainty pervades LBP care and is often accompanied by emotions.Neglecting complexity in LBP care may compromise person-centred care.Acknowledging uncertainty can enhance communication, balance patient-clinician relationships and address human aspects of care.

294 INTEGRATION OF MUSIC THERAPY WITHIN A MULTIDISCIPLINARY TEAM FOR OLDER ADULTS IN AN ACUTE HOSPITAL

Background

Music Therapy (MT) is an evidence-based intervention in which a music therapist uses music within a therapeutic relationship to achieve targeted goals. Studies show that MT may improve patient communication, cognition and mood, and facilitate rehabilitation by improving motor skills, particularly in those with stroke and Parkinson’s disease. We aimed to integrate MT within our geriatric multidisciplinary team (MDT) by: (1) promoting knowledge of MT among MDT staff; and (2) developing and implementing a MT referral pathway for patients. Furthermore, we aimed to assess its overall impact.

Methods

Music therapists delivered oral presentations and experiential learning through creative workshops, collaboration and feedback to allied health therapists in our geriatric MDT. Criteria for referrals for MT and a referral pathway were developed. Data on patients who received MT was collated.

Results

There were 70 referrals for MT from our MDT. 61% were female, mean age 77 years. Referral sources were occupational therapists (45%), speech therapists (34%), medical social workers (13%), physiotherapists (8%). Patients included those with stroke (41%), general medical conditions (23%), dementia (16%), Parkinson's (11%) and mental health concerns (9%). There were 16 joint MDT sessions and a mean of 5 MT sessions per patient (about 40 minutes in duration). Interventions included: Melodic Intonation Therapy (MIT), singing and vocal exercises, Rhythmic Auditory Stimulation (RAS), Musical Neglect Training (MNT), Therapeutic Instrumental Musical Performance (TIMP), reminiscence and song-writing. Overall, we identified better engagement with rehabilitation and improvements in mood, speech (voice strength and verbal fluency) and upper and lower limb co-ordination.

Conclusion

MT was successfully integrated into a geriatric MDT and had beneficial effects on patient mood, speech, communication and motor function. Education of MDT members was crucial in achieving appropriate MT referrals. Joint MDT’s also facilitated individualised MT interventions. Findings strongly support our model that incorporates MT within an MDT.

301 BENEFITS OF ENVIRONMENTAL MUSIC THERAPY IN AN ACUTE HOSPITAL

Background

Environmental Music Therapy (EMT) uses live music played by a music therapist to enhance the surrounding environment and is increasingly used in clinical settings. Studies show that EMT may reduce anxiety, enhance wellbeing, promote better communication between patients and staff, and reduce patient perception of waiting times in hospital. We aimed to explore the benefit of EMT for older adults in a geriatric outpatient setting and on rehabilitation wards.

Methods

Harp music was played by a music therapist in the vicinity of ambulatory clinics and on rehabilitation wards for 4 hours per week (over a 2-day period) for 20 weeks. Music exposure on any given day was to an estimated 50 outpatients, as well as 50 people passing the vicinity or to about 30 patients on the rehabilitation ward. Music was selected and played in a dynamic process, responding to verbal and non-verbal reactions of patients, family, and staff. Voluntary responses were recorded and collated.

Results

There were 36 recorded responses and all reflected positively on EMT. Patients cited that the music created a welcoming space and stimulated interaction and conversation. Several patients waiting for their clinic appointment noted that it distracted from fearful expectation and was a source of comfort. Some commented that they felt more relaxed and that it reduced stress. On rehabilitation wards, patients found familiar music to be calming with nurses citing that it stimulated social interaction between patients, family and staff. Responses to EMT gave insights that resulted in patient referrals for music therapy.

Conclusion

Environmental music played by a music therapist was found to modify patient hospital experiences. In particular, it appeared to reduce self-perceived stress and stimulate positive social interaction and conversation. This supports the use of EMT to advance the integration of the arts for wellbeing in an acute hospital.

130 Surgical Repair of Cleft Lip: Comparison of Neonatal and Standard Time Repair

Aim

Cleft lip and palate (CLP) abnormalities are the most common congenital orofacial anomalies, affecting 1 in 700 live births per year in the United Kingdom. Cleft lip is present in approximately 55% of all CLP deformities. The aim of this study is to compare standard and neonatal cleft lip repair.

Method

Advanced literature searches were carried out using Medline ALL (1946 to date) and Embase (1974 to date), 11 articles were deemed relevant and included in this study.

Results

Aesthetic results showed excellent outcomes with neonatal repair with regards to the appearance of the scar, facial (lip and nasal) symmetry but those aesthetic results are no better than those achieved at standard time.

Conclusions

Early intervention can be beneficial as early repair takes place when the cleft is less severe and when the tissues are more malleable, making the surgery less challenging and when some aspects of foetal scar healing remain. Early repair has a positive impact on the development of the alveolar projections and can assist in reducing an alveolar cleft if present, improving the aesthetic outcome. Neonatal surgery carries with it no greater risk than surgery carried out at 6 months and will allow feeding to begin at an early stage promoting recovery. Early repair also brings with it a positive psychosocial impact where infants and mothers can build a normal relationship from an early stage. Later in life, children and adults will be less self-conscious following good aesthetic repair. In conclusion, neonatal repair may be recommended over standard time repair.

Efficient In Vitro Digestion of Lipids and Proteins in Bovine Milk Fat Globule Membrane (MFGM) Ingredient and Infant Formula Containing MFGM

Objectives

The relative immaturity of the infant digestive system after birth has the potential to affect the bioaccessibility of dietary lipids, proteins and their digested product. The in vitro digestion of lipids and protein in bovine milk fat globule membrane (MFGM) ingredient and infant formula without and with MFGM ingredient (bovine source), as well as the partitioning of non-digested and products of digestion in bioaccessible fraction of chyme were measured. Conditions that simulate those in the stomach and small intestine of infants were used.

Methods

MFGM ingredient and whey/casein-based infant formula with and without 6%MFGM ingredient were digested using static, two-phase in vitro digestion model with conditions simulating those in the infant gut. Digestion and bioaccessibility of lipids were monitored by measuring a wide lipid profile using direct infusion-mass spectrometry (DI-MS/MS). Digestion of proteins were determined by denaturing polyacrylamide gel electrophoresis, with quantitative imaging of all blue stained bands.

Results

Cholesterol esters, diacylglycerides, triacylglycerides, phosphatidylcholines, and phosphatidylethanolamines in the MFGM ingredients were readily hydrolyzed resulting in marked increases in the amounts of free fatty acids and lyso-phospholipids in the bioaccessible fraction of chyme. In contrast, sphingomyelins, ceramides and GM3 gangliosides were relatively resistant to digestion. Protein in MFGM ingredient and infant formula without and with added MFGM ingredient also were efficiently digested.

Conclusions

The results suggest proteins, neutral lipids and phospholipids in MFGM are efficiently digested using conditions that simulate those in the prandial lumen of the stomach and small intestine of infants. Also, the profile of lipid and protein digestion is similar for whey/casein-based infant formula without and with MFGM ingredient using conditions that simulate those in the infant gut.

Funding Sources

Ohio State Agriculture Research and Development Center, the JT Parker Endowment and Reckitt Nutrition Institute.

Physiotherapists Both Reproduce and Resist Biomedical Dominance when Working With People With Low Back Pain: A Qualitative Study Towards New Praxis

Despite recommendations to incorporate physical and psychosocial factors when providing care for people with back pain, research suggests that physiotherapists continue to focus on biological aspects. This study investigated how interpersonal and institutional norms influence this continued enactment of the biological aspects of management. We used theoretically-driven analysis, drawing from Foucauldian notions of power, to analyse 28 ethnographic observations of consultations and seven group discussions with physiotherapists. Analysis suggested that physiotherapy training established expectations of what a physiotherapist 'should' focus on, and institutional circumstances strongly drew the attention of physiotherapists towards biological aspects. Resistance to these forces was possible when, for example, physiotherapists reflected upon their practice, used silences and pauses during consultations, and actively collaborated with patients. These circumstances facilitated use of non-biomedical management approaches. Findings may assist physiotherapists to rework the enduring normative focus on biomedical aspects of care when providing care for patients with back pain.

Beyond Forensic Evidence: Examining Sexual Assault Medical Forensic Exam Mechanisms that Influence Sexual Assault Case Outcomes

Despite the widespread use of sexual assault medical forensic exams (SAMFEs), practitioners and researchers continue to debate the role of SAMFEs and the evidence they provide in the investigation and prosecution of sexual assault cases. Using data from a review of sexual assault cases reported to police between 2015 and 2017 in two jurisdictions (n = 534), we use logistic regression examine whether the presence of a SAMFE predicts the likelihood of achieving criminal case processing outcomes and whether the relationship of the SAMFE with criminal case processing outcomes is moderated by other legal and extralegal case characteristics. We did not find evidence that the presence of a SAMFE in a case significantly predicts whether a suspect will be identified, arrested, or convicted overall, but we did find evidence of the SAMFE's injury documentation value for arrest. Researchers and practitioners should account for the multiple ways SAMFEs can influence decision-making in future research and policymaking.

Acceptance of oclacitinib maleate (Apoquel®) chewable tablets in client-owned dogs with allergic and atopic dermatitis

Background

The oral acceptance of oclacitinib maleate (Apoquel®) chewable tablets administered twice daily for 7 days at the labeled dose range of 0.4–0.6 mg/kg was evaluated in 121 dogs treated at ten general practice veterinary clinics in the United States.

Results

Dogs that were enrolled in the study were client-owned, ranged from 1 to 14 years of age, weighed 3.7 to 60.7 kg, and required twice daily treatment with Apoquel for allergic or atopic dermatitis for 7 days. One hundred and twenty-one (121) dogs with 1673 total dose administrations successfully completed the study and were included in the data summary. Out of a total number of 1673 administrations, 1533 (91.6%) were accepted voluntarily within 5 min, 134 (8%) were consumed with assistance (with food treats or by pilling) outside of the 5 min offering time and 6 (0.4%) doses were not consumed. The per dose percent acceptance rate for the 14 offered doses showed minimal variation ranging from 89.9 to 93.3%.

Conclusions

Client-owned dogs from the general veterinary patient population that required treatment with oclacitinib found the chewable tablets to be very palatable and no aversion occurred with repeated dosing. Oclacitinib chewable tablets were well tolerated and are a palatable alternative to the film-coated tablet.

257 POSITIVE HEALTH AND AGING FOR OLDER IRISH TRAVELLERS AND OLDER PEOPLE WHO HAVE EXPERIENCED HOMELESSNESS: LIFE-COURSE MEANINGS AND DETERMINANTS

Background

The position of marginalized groups of older people remains neglected in positive health and aging (PHA) agendas, whether they concern healthy, active or positive aging. Questions exist around the meaning of such constructs, and the factors that enable disadvantaged populations to achieve equitable later-life experiences. In focusing on two such groups, this study investigates the constituent dimensions of PHA for older Irish Travellers and older people who have experienced homelessness, and the role of life-course and structural determinants in constructing PHA trajectories for these groups.

Methods

The study involves a multi-method qualitative, participatory voice-led methodology, but the analysis draws primarily on 49 in-depth life-course interviews with the populations.

Results

In addition to five interconnected dimensions of PHA, four determinants related to life-course experiences and structural factors are identified: social relations; material and accommodation circumstances; formal supports and systems; and critical transitions and resilience.

Conclusion

While illustrating the validity of PHA agendas for these groups when understood through their lived experiences, the findings highlight the significant deprivations and risks to rights that must be accounted for to secure meaningful gains in PHA for the groups.

187 A QUALITATIVE EXPLORATION OF PLACE AND PERSONHOOD IN DEMENTIA

Background

In dementia research, supporting personhood is seen as a corner stone of person-centred care. However, little is understood about how personhood is conceptualised in the context of the home and communities that people living with dementia reside within, and how place may constitute a key dimension of, or a determining factor of someone’s sense of self. This study seeks to explore these relationships by examining the intersection between place and personhood through the lens of Rowles (1983) work on place and personal identity in old age.

Methods

Qualitative secondary analysis of datasets from two separate studies was conducted. The first study examined the perspectives of people living with dementia on place across the life course, while the second study examined the perspectives of people living with dementia on personhood in formal care. In total, 15 interviews with people with dementia were analysed using theoretical framework analysis.

Results

Participants reflected on the meaning of place, and its iterative relationship with personhood across the life course. They used the residential life course, to convey and narrate their life story, locating themselves and major events in time and place. Participants also spoke about the impact of the physical environment on their sense of personhood, conceptualising personhood in relation to attachment to the physical landscape, location and their own homes. Finally, participants referred to the close link between place, relationships, and community. In particular, how important feelings of community and belonging to place are to their sense of personhood.

Conclusion

This research shows the role of place in interpreting understandings of personhood from the perspectives of people living with dementia. This is critical for understanding the nature and orientation of community-based interventions, and designing supports and services which appropriately harness place-based relationships of people living with dementia.

Effectiveness of Aquatic OT for Children With Autism Spectrum Disorder

Date Presented 04/23/21

Children with autism often experience difficulty with gross motor skills, leading to decreased activity engagement. A 10-week therapeutic adaptive swimming pilot study was conducted with individualized instruction from an OT or physical therapy student. Goal Attainment Scaling was used to form individualized goals and track each child's motor control and swim skills. Quantitative data show increased skill attainment and supports the use of OT in the aquatic setting.

Primary Author and Speaker: Kelly Walsh

Community Approaches to Sexual Assault: VAWA's Role and Survivors' Experiences

This article reviews two types of community-based approaches to addressing sexual assault that survivors may encounter-sexual assault nurse examiners and victim advocates from nonprofit community agencies-and highlights ways that the Violence Against Women Act (VAWA) and its reauthorizations have influenced this work. We also review information on the intersections of the work of these providers with police and prosecutors and include how these relate to survivors' experiences. We conclude with thoughts that look forward to future research on these issues emphasizing authentic engagement of practitioners and survivors in the research process.

The role of clonal haematopoiesis in cardiovascular diseases: epidemiology and experimental studies

Clonal haematopoiesis results from acquired mutations in haematopoietic stem and progenitor cells (HSPCs). These mutations can confer the HSPC with a competitive advantage, leading to their clonal expansion within the limiting bone marrow niche. This process is often insufficient to produce a haematologic malignancy; however, the expanding HSPC clones increasingly give rise to progeny leucocytes whose phenotypes can be altered by the somatic mutations that they harbour. Key findings from multiple human studies have shown that clonal haematopoiesis in the absence of overt haematologic alterations is common amongst the ageing population and associated with mortality and cardiovascular disease. Key findings from experimental studies have provided evidence for a causative role for clonal haematopoiesis in cardiovascular diseases, and aspects of these mechanisms have been elucidated. Whilst our understanding of the impact and biology of clonal haematopoiesis is in its infancy, analyses of some of the most commonly mutated driver genes suggest promising clinical scenarios involving the development of personalized therapies with immunomodulatory drugs that exploit the perturbation caused by the particular mutation. Herein, we review the accumulating epidemiological and experimental evidence, and summarize our current understanding of the importance of clonal haematopoiesis as a new causal risk factor for atherosclerotic cardiovascular disease and heart failure.

Concentration and composition of bioaerosol emissions from intensive farms: Pig and poultry livestock

Intensive farming is widespread throughout the UK and yet the health effects of bioaerosols which may be generated by these sites are currently not well researched. A scoping study was established to measure bioaerosols emitted from intensive pig (n = 3) and poultry farms (n = 3) during the period 2014-2015. The concentration of culturable mesophilic bacteria, Gram-negative bacteria, Staphylococcus spp., and fungi selecting for presumptive Aspergillus fumigatus were measured using single-stage impaction Andersen samplers, whilst endotoxin and (1 → 3)-β-D-glucan was undertaken using inhalable personal samplers. Particulate matter concentration was determined using an optical particulate monitor. Results showed that culturable bacteria, fungi, presumptive Staphylococcus aureus (confirmed only as Staphylococcus spp.) and endotoxin concentrations were elevated above background concentrations for distances of up to 250 m downwind of the source. Of all the culturable bioaerosols measured, bacteria and Staphylococcus spp. were identified as the most significant, exceeding published or proposed bioaerosol guidelines in the UK. In particular, culturable Staphylococcus spp. downwind was at least 61 times higher than background at the boundary and at least 8 times higher 70m downwind on the four farms tested. This research represents a novel dataset of intensive farm emissions within the UK. Future research should exploit the use of innovative culture-independent methods such as next generation sequencing to develop deeper insights into the make-up of microbial communities emitted from intensive farming facilities and which would better inform species of interest from a public health perspective.

Examining Nutrient Adequacy, Iron Deficiency, and Anemia in US Children 1–3 Years of Age Using Data From NHANES 2001–2016

Objectives

To assess nutrient intake adequacy from foods and beverages and to examine iron deficiency and anemia status in young US children.

Methods

National Health and Nutrition Examination Survey (NHANES) data for 2001–2016 in children 1–3 years of age were analyzed for mean dietary intake of individual nutrients (n = 5579), serum ferritin (n = 2498), and hemoglobin (n = 3919). Separate analyses for age groups 1–3 and 1–2 years were performed for gender combined and males/females separately. Dietary adequacy was assessed by comparing against estimated average requirements (EARs) and adequate intakes (AIs) as established by the IOM, as well as global recommendations for docosahexaenoic acid (DHAGR). Iron deficiency and anemia status were determined using ferritin (<10 ng/mL) and hemoglobin (<11 g/dL), respectively.

Results

The percentage of the population with intakes below the EAR for vitamin D, vitamin E, calcium, and iron were 82.7%, 70.9%, 3.6%, and 0.87% of children 1–3 years gender combined, respectively. Only 1% of children in this age group had fiber intakes greater than the AI. In addition, 97.6%-99.3% of these children did not meet the DHAGR of 70–100 mg/day. Similar results were found in the other age/gender groups. Compared to males, females had lower intakes of vitamin D, calcium and fiber, regardless of age. An estimated 6.9% of all children 1–3 years and 8.5% of all children 1–2 years appeared to be iron deficient. In comparison with other races/ethnicities sampled, Hispanic children appeared to have the highest (8.9% 1–3 years; 11.6% 1–2 years) and Non-Hispanic Black children (4.2% 1–3 years; 6.0% 1–2 years) the lowest rates of iron deficiency. Furthermore, 3.5% of all children 1–3 years and 4.3% of all children 1–2 years met the criteria for anemia.

Conclusions

Overall, dietary intake of US children 1–3 years of age appears to be adequate with the exception of vitamin D, vitamin E, calcium and fiber. Although iron intake was found to be adequate in this population, iron deficiency, as indicated by ferritin status, was still identified at 6.9% of children 1–3 years. Anemia as indicated by hemoglobin status was also identified. DHA intake was below recommendations for nearly all children. More research is needed to investigate these findings.

Funding Sources

Mead Johnson Nutrition/RB.

Mining the Literature: Assessing the Science of Milk Fat Globule Membrane and Its Components Utilizing Comprehensive Literature Search Techniques

Objectives

Milk fat globule membrane (MFGM) is the component of milk responsible for fat delivery. MFGM is a single component but contains a variety of glycosylated proteins and lipids that influence health. The objective herein is to highlight the breadth of research surrounding MFGM and its individual components.

Methods

Searches on MFGM and its components (individual proteins, lipids, and carbohydrates) were conducted August 2019 in Embase. For the ‘MFGM’ search we added specific exclusion terms to focus results around nutrition. The individual components were searched for in combination with ‘{AND} Milk’. Downloaded publications were loaded into R (version 3.6.1) for merging, filtering and categorization. MFGM and individual component searches were combined into one data frame while ensuring no duplicates. Once searches were merged, publication abstracts and titles were searched for keywords associated with study type (Clinical, Preclinical or Analytical) and functional benefit area. Finally, pediatric intervention trials were identified and summarized.

Results

Over 2150 scientific journal articles have been published on the topic of MFGM and its components since 1950. This includes analytical research characterizing MFGM structure and components, preclinical publications demonstrating mechanisms of action as well as human intervention trials. Within the Clinical and Preclinical studies, 1169 papers were categorized with Brain (36%), Gut (30%) or Immune (3%) as the predominant benefit area. Within pediatric intervention trials, over 1800 infants have been studied, with interventions lasting up to 12 months for a combined study intervention period of at least 424 weeks and follow-up measures taken up to 6 years following study initiation.

Conclusions

The growing body of literature on MFGM reflects the importance of this naturally occurring compound with multiple health benefits.

Funding Sources

All of the authors are employed by RB.

P333Left atrial function by echocardiography is independent of degree of left atrial electrical scar

Introduction

Assessment of left atrial function via transthoracic echocardiography (TTE) is performed most commonly by measuring the transmitral A wave in sinus rhythm. Left atrial (LA) fibrosis plays an important role in the pathogenesis and perpetuation of Atrial Fibrillation (AF). It may be identified by bipolar voltage (BiV) mapping, which can easily be performed at the beginning of a Pulmonary Vein Isolation (PVI) procedure. The relationship between the degree of LA fibrosis, characterised with mapping, and LA function, determined by echocardiography, has not previously been elucidated.

Methods

Patients were enrolled in a project to evaluate the degree of fibrosis during PVI procedures. Pre-procedure TTEs of those presenting in sinus rhythm were assessed and the transmitral A wave was measured and compared to the degree of scarring seen. The high density electroanatomic maps (HD-EAMs) created during the PVIs were analysed using a novel VHA algorithm after the procedure. All points with voltages < 0.5mV were defined to have electrical scar. Patients were classified into 4 quartiles based on the levels of scar seen (Figure 1).

Results

39 patients were included in the evaluation. Average age was 60.6 +/- 13.2 years. 32 (82.0%) of the patients were male. Mean CHADS2VASc score was 1.5. The mean percentage of scar was calculated as 19.6 +/- 15.9%. The average A wave was 0.62 +/- 0.18 ms-1. Pearson’s correlation coefficient showed no relationship between LA scar and either A wave velocities (r = 0.26, p = 0.11) or E:A ratio (r=-0.02, p = 0.91). A significant correlation between A wave velocity and CHADS2VASc was observed (r = 0.49, p = 0.001).

Conclusion

Our study demonstrates no relationship between degree of LA scarring and reduced LA function on TTE as assessed by the A wave. It has been established that structural remodelling in AF (such as atrial dilatation) may occur independently of the electrical remodelling. A potential explanation for our findings is that the electrical scarring in AF, which results in alterations in refractory periods, precedes the negative remodelling which ultimately results in reduced atrial function. This hypothesis would need to be further evaluated in larger studies.

Abstract Figure 1

0967 Clinical Characteristics of Children With Sleep Problems and Comorbid Psychiatric Disorders

Introduction

Anxiety and Attention Deficit Hyperactive Disorder (ADHD) are common psychiatric comorbidities in children with sleep disorders. It is known that comorbid psychiatric disorders increase the risk of sleep problems. However, no study has compared the clinical characteristics of children presenting with sleep problems and various common psychiatric disorders.

Methods

Retrospective chart review of all children presenting to the sleep clinic for sleep problems between March 2016 to June 2017 was performed. Demographics, sleep intake patient questionnaires, polysomnograms and ICD-9/10 codes for comorbidities and sleep diagnoses were collected. In children with diagnoses of anxiety (ICD-9 300/ICD-10 F41) and ADHD (ICD-9 314/ICD-10 F90), demographics, presenting symptoms, Epworth sleepiness scores and prevalence of sleep comorbidities were compared. T-test (continuous) and Chi Square (categorical) were used. Unadjusted odds ratio was calculated for presenting symptoms and sleep comorbidities. P value of <0.05 was considered significant.

Results

250 (F=145, 58%) children were evaluated. 71.2% children were diagnosed with anxiety and 28.8% diagnosed with ADHD. Mean age at presentation was 8.53 ± 4.2 years. Age, gender and race of children presenting with sleep problems and comorbid anxiety/ADHD were statistically similar. Children with anxiety spent less time in stage N3 sleep (25.2% ± 9.1 versus 28.6% ± 9.2) and had lower arousal indices (7.19 ± 3.8 versus 8.86 ± 5.5) compared to children with ADHD. Children with anxiety were more likely to present with chief complaint of “feeling tired or sleepy during the day” (OR:2.38, 1.32-4.37) and were more likely to have a diagnosis of hypersomnia (OR: 11.67, 3.19-42.75) versus children with ADHD.

Conclusion

Children with psychiatric comorbidities have distinct polysomnographic characteristics. Children with anxiety are more likely to present with daytime sleepiness and have a significantly higher prevalence of hypersomnia compared to children with ADHD.

Support

None

New insights on lake sediment DNA from the catchment: importance of taphonomic and analytical issues on the record quality

Over the last decade, an increasing number of studies have used lake sediment DNA to trace past landscape changes, agricultural activities or human presence. However, the processes responsible for lake sediment formation and sediment properties might affect DNA records via taphonomic and analytical processes. It is crucial to understand these processes to ensure reliable interpretations for “palaeo” studies. Here, we combined plant and mammal DNA metabarcoding analyses with sedimentological and geochemical analyses from three lake-catchment systems that are characterised by different erosion dynamics. The new insights derived from this approach elucidate and assess issues relating to DNA sources and transfer processes. The sources of eroded materials strongly affect the “catchment-DNA” concentration in the sediments. For instance, erosion of upper organic and organo-mineral soil horizons provides a higher amount of plant DNA in lake sediments than deep horizons, bare soils or glacial flours. Moreover, high erosion rates, along with a well-developed hydrographic network, are proposed as factors positively affecting the representation of the catchment flora. The development of open and agricultural landscapes, which favour the erosion, could thus bias the reconstructed landscape trajectory but help the record of these human activities. Regarding domestic animals, pastoral practices and animal behaviour might affect their DNA record because they control the type of source of DNA (“point” vs. “diffuse”).

P1613Brown adipose tissue dysfunction has a critical role for the development of heart failure in murine pressure overload model

Prognosis of severe heart failure is unacceptably high, and it is our urgent task to find therapies for this critical condition. It has been reported that low body temperature predicts poor clinical outcomes in patients with heart failure, however, underlying mechanisms and pathological implications are largely unknown. Brown adipose tissue (BAT) was initially characterized as a heat generating organ, and studies suggest that BAT has crucial roles for the maintenance of systemic metabolic health. Here we show that BAT dysfunction develops in a murine thoracic aortic constriction (TAC) model, and has a causal role for promoting pathologies in failing heart. TAC operation led to a significant reduction both in intraperitoneal and subcutaneous temperature. TUNEL-positive cells significantly increased in BAT during left ventricular (LV)-pressure overload, and in-vitro studies with differentiated brown adipocytes suggested that the chronic activation of adrenergic signaling promotes apoptosis in these cells. Gain of BAT function model, generated with BAT implantation into peritoneal cavity, improved thermogenesis and ameliorated cardiac dysfunction in TAC. In contrast, genetic model of BAT dysfunction promoted cardiac dysfunction. Metabolomic analyses showed that BAT dysfunction led to an increase of oxidized choline that promoted metabolic dysfunction in the failing heart. Electron microscope study showed that oxidized choline induced mitochondrial dysfunction in vitro as well as in vivo settings. Extracellular flux analyzerindicated that oxidized choline suppresses oxidative phosphorylation in mitochondria. We found that dilated cardiomyopathy patients have lower body temperature, and confirmed by metabolomic study that both choline and oxidized choline are increased in circulation. Maintenance of BAT homeostasis and suppression of oxidized choline would become a novel therapeutic target for heart failure.

Commotio Cordis Caused During Hurling Game

A teenage boy had a cardiac arrest following a blow to the chest from a hurling ball (sliotar). Prompt resuscitation and automated external defibrillation enabled a full recovery. This is the first reported case of commotio cordis caused by a sliotar although it is described in other sports. Primary prevention of commotio cordis (CC) and secondary prevention of cardiac death are discussed.

AMEE Guide No. 123 - How to read studies of educational costs

Healthcare and health professions education share many of the same problems in decision making. In both cases, there is a finite amount of resources, and so choices need to be made between alternatives. To navigate the options available requires effective decision making. Choosing one option requires consideration of its opportunity cost - the benefit forgone of the other competing options. The purpose of this abridged AMEE guide is to introduce educational decision-makers to the economic concept of cost, and how to read studies about educational costs to inform effective cost-conscious decision-making. This guide leads with a brief review of study designs commonly utilized in this field of research, followed by an overview of how study findings are commonly presented. The tutorial will then offer a four-step model for appraising and considering the results of an economic evaluation. It asks the questions: (1) Can I trust the results? (2) What are the results telling me? (3) Could the results be transferred to my context? (4) Should I change my practice?

Polypharmacy Rates among Patients over 45 years

Polypharmacy, defined as receipt of ≥5 medications in any one month, is often associated with potentially inappropriate prescribing and adverse drug interactions. High levels of polypharmacy have been observed internationally and in Ireland. The Health Service Executive Primary Care Reimbursement Services (HSE-PCRS) pharmacy claims database for the GMS eligible population was used. We conducted Chi-square tests to determine the statistical significance of perceived differences in medication use among patients aged ³ 45 years. Our results establish a national benchmark for polypharmacy in gender and various age categories in the HSE-PCRS. Of the 794,628 individuals aged ≥45 years with at least one claim in 2013, 64.3% (510,946) had polypharmacy, with higher rates among women (67.0% - 293,886 - compared to 60.8% of men - 216,444). Patients aged 45-54 years were less likely to have polypharmacy (38.6% - 69,934) compared to those aged 75 years old (82.6% - 197,565). The high levels of polypharmacy are of interest, and suggest that monitoring and evaluation of patients’ medication regimes may be required to ensure appropriateness.

Outcomes across the tuberculosis care continuum among adolescents in Haiti

Setting: GHESKIO (Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes) clinic, Port-au-Prince, Haiti. Objective: To evaluate tuberculosis (TB) care continuum outcomes among adolescents. Design: Among a retrospective cohort of 10-24 year olds diagnosed with active TB, we report completion of the following steps of the TB care continuum stratified by human immunodeficiency virus (HIV) status: diagnosis of microbiologically confirmed TB, initiation of anti-tuberculosis treatment, retention in care at 2 months on anti-tuberculosis treatment, and TB treatment success. Factors associated with attrition at each step were identified using multivariable regression. Results: A total of 1005 adolescents were diagnosed with active TB; 74 (7%) were HIV-positive at the time of TB diagnosis. HIV-positive patients had poorer outcomes than non-HIV-infected patients: 73% vs. 85% initiated anti-tuberculosis treatment (P < 0.01), 46% vs. 74% were retained in care at 2 months (P < 0.01), and 41% vs. 68% achieved TB treatment success (P < 0.01). Among those who initiated treatment, same-day initiation resulted in less treatment failure. Attrition before treatment initiation was associated with female sex and HIV coinfection. Attrition after treatment initiation was associated with age ⩾16 years and HIV coinfection. Conclusion: Outcomes across the TB care continuum are suboptimal among adolescents, with only two thirds of patients achieving treatment success. Interventions tailored to adolescents are needed to improve retention in care, particularly for those who are co-infected with HIV.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Nitrous oxide may interfere with the reconsolidation of drinking memories in hazardous drinkers in a prediction-error-dependent manner

Weakening drinking-related reward memories by blocking their reconsolidation is a potential novel strategy for treating alcohol use disorders. However, few viable pharmacological options exist for reconsolidation interference in humans. We therefore examined whether the NMDA receptor antagonising gas, Nitrous Oxide (N₂O) could reduce drinking by preventing the post-retrieval restabilisation of alcohol memories in a group of hazardous drinkers. Critically, we focussed on whether prediction error (PE; a key determinant of reconsolidation) was experienced at retrieval. Sixty hazardous drinkers were randomised to one of three groups that retrieved alcohol memories either with negative PE (Retrieval + PE), no PE (Retrieval no PE) or non-alcohol memory retrieval with PE (No-retrieval +PE). All participants then inhaled 50% N₂O for 30 min. The primary outcome was change in beer consumption and alcohol cue-driven urge to drink from the week preceding manipulation (baseline) to the week following manipulation (test). The manipulation did not affect drinking following the intended retrieval+/- PE conditions However, a manipulation check, using a measure of subjective surprise, revealed that the group-level manipulation did not achieve the intended differences in PE at retrieval. Assessment of outcomes according to whether alcohol-relevant PE was actually experienced at retrieval, showed N₂O produced reductions in drinking in a retrieval and PE-dependent fashion. These preliminary findings highlight the importance of directly testing assumptions about memory reactivation procedures in reconsolidation research and suggest that N₂O should be further investigated as a potential reconsolidation-blocking agent.

Dual endothelin-1 receptor antagonism attenuates platelet-mediated derangements of blood coagulation in Eisenmenger syndrome

Essentials Eisenmenger syndrome is characterised by thrombotic and hemorrhagic risks of unclear aetiology. Calibrated automated thrombography was used to assess these coagulation derangements. Platelet activity supported abnormalities in procoagulant and anticoagulant pathway function. Endothelin-1 antagonism appeared to ameliorate these derangements.

SUMMARY

Aims The mechanisms underlying the competing thrombotic and hemorrhagic risks in Eisenmenger syndrome are poorly understood. We aimed to characterize derangements of blood coagulation and to assess the effect of dual endothelin-1 receptor antagonism in modulating hemostasis in this rare disorder. Methods In a 10-month recruitment period at a tertiary cardiology referral center, during which time there were over 14 000 outpatient consultations, consecutive subjects with Eisenmenger syndrome being considered for macitentan therapy (n = 9) and healthy volunteers (n = 9) were recruited. Plasma thrombin generation in platelet-rich and platelet-poor plasma was assessed by calibrated automated thrombography prior to and following therapy. Results Median peak plasma thrombin generation was higher in platelet-rich plasma obtained from Eisenmenger syndrome subjects relative to controls (median peak thrombin [25th-75th percentile]: 228.3 [206.5-258.6] nm vs. 169.9 [164.3-215.8] nm), suggesting a critical mechanistic role for platelets in supporting abnormal hypercoagulability in Eisenmenger syndrome. Abnormal enhanced sensitivity to the anticoagulant activity of activated protein C was also observed in platelet-rich plasma in Eisenmenger syndrome, suggesting that derangements of platelet activity may influence the activity of anticoagulant pathways in a manner that might promote bleeding in this disease state. Following 6 months of macitentan therapy, attenuations in the derangements in both procoagulant and anticoagulant pathways were observed. Conclusions Abnormal platelet activity contributes to derangements in procoagulant and anticoagulant pathways in Eisenmenger syndrome. Therapies targeting the underlying vascular pathology appear to ameliorate these derangements and may represent a novel strategy for the management of the competing prothrombotic and hemorrhagic tendencies in this disorder.

Use of dispersion modelling for Environmental Impact Assessment of biological air pollution from composting: Progress, problems and prospects

With the increase in composting asa sustainable waste management option, biological air pollution (bioaerosols) from composting facilities have become a cause of increasing concern due to their potential health impacts. Estimating community exposure to bioaerosols is problematic due to limitations in current monitoring methods. Atmospheric dispersion modelling can be used to estimate exposure concentrations, however several issues arise from the lack of appropriate bioaerosol data to use as inputs into models, and the complexity of the emission sources at composting facilities. This paper analyses current progress in using dispersion models for bioaerosols, examines the remaining problems and provides recommendations for future prospects in this area. A key finding is the urgent need for guidance for model users to ensure consistent bioaerosol modelling practices.

Sensitivity of predicted bioaerosol exposure from open windrow composting facilities to ADMS dispersion model parameters

Bioaerosols are released in elevated quantities from composting facilities and are associated with negative health effects, although dose-response relationships are not well understood, and require improved exposure classification. Dispersion modelling has great potential to improve exposure classification, but has not yet been extensively used or validated in this context. We present a sensitivity analysis of the ADMS dispersion model specific to input parameter ranges relevant to bioaerosol emissions from open windrow composting. This analysis provides an aid for model calibration by prioritising parameter adjustment and targeting independent parameter estimation. Results showed that predicted exposure was most sensitive to the wet and dry deposition modules and the majority of parameters relating to emission source characteristics, including pollutant emission velocity, source geometry and source height. This research improves understanding of the accuracy of model input data required to provide more reliable exposure predictions.