"I'm just searching to get better": Constructions of treatment citizenship on injectable opioid agonist treatment

BACKGROUND

As part of the response to Canada's worsening overdose crisis driven by a toxic, adulterated drug supply, there has been increased attention to and expansion of drug treatment, options, including injectable opioid agonist treatment (iOAT). iOAT typically involves the, witnessed daily injection of opioids under healthcare provider supervision. There is a robust, evidence base on iOAT; however, there has been less focus on how people engage with this; treatment outside of clinical trials. This paper examines how people engage with iOAT programs, in expanded treatment settings in Canada, focusing on how the broader socio-structural context, shapes patient subjectivities in treatment.

METHODS

This study draws on critical ethnographic and community-based research approaches, conducted with people accessing four iOAT programs in Vancouver's Downtown Eastside; neighbourhood from May 2018 to November 2019. Data included in-depth baseline and followup, interviews and approximately 50 h of observation fieldwork conducted in one iOAT, program and with a subsample of participants in the surrounding neighbourhood. Analysis, leveraged the concepts of biological citizenship and structural vulnerability.

RESULTS

This analysis characterized three narrative frames-regular long-term engagers, pain, patients, and sporadic and short-term engagers-through in-depth case presentations of participants with distinct types of engagement with iOAT programs. Participants within these, narrative frames described a dominant form of iOAT citizenship, an autonomous patient who, regularly engages in treatment and avoids pleasure. However, structural vulnerabilities, including, homelessness and housing instability, entrenched poverty, criminal-legal system engagement, and unmanaged pain, shaped the ability of participants to make claims to this normative model of citizenship.

CONCLUSION

This study examined how structural vulnerabilities impact people's construction and ability to make iOAT citizenship claims. Findings point to the need for changes within and outside of iOAT programs, such as lower threshold treatment models, improved social services (e.g., secure housing), and pain management support.

Clinical outcomes following a combined vertical and horizontal alveolar ridge augmentation and two-stage implant placement using either autogenous tooth roots or autogenous bone blocks

AIM

To assess and compare the short-term clinical outcomes following a combined vertical and horizontal alveolar ridge augmentation and two-stage implant placement using either autogenous tooth roots (TR) or autogenous bone blocks (AB).

MATERIALS AND METHODS

A total of n = 27 patients (TR/AB: 13/14) exhibiting n = 31 implants (TR/AB: 14/17) were available for the analysis. Each subject had been allocated to a combined vertical and horizontal alveolar ridge augmentation using either (1) healthy TR (e.g., retained wisdom teeth), or (2) monocortical AB harvested from the retromolar area (i.e. external oblique line). Clinical parameters (e.g., bleeding on probing, BOP; probing pocket depth, PD; mucosal recession, MR) were recorded after a follow-up period of 16.03 ± 4.3 months following implant placement.

RESULTS

The survival rates amounted to 100% in both groups. TR and AB grafted sites were associated with similar changes in mean BOP (8.97 ± 27.73%; 11.90 ± 18.97%), PD (0.53 ± 0.49; 0.47 ± 0.67 mm), and MR (0.03 ± 0.13; 0.0 ± 0.02 mm) values. The incidence of peri-implant mucositis and peri-implantitis at the patient level amounted to 15.38% and 0.0% in the TR-, and 28.57% and 7.14% in the AB group.

CONCLUSIONS

Both surgical procedures were associated with peri-implant tissue health and stability on the short-term.

Perceptions of prospective pharmaceutical stimulant substitution treatments among people who use illicit stimulants in Vancouver, Canada

BACKGROUND

Stimulant-involved overdose deaths are increasing, driven by polysubstance use and adulteration of the illicit drug supply. While emerging evidence for prescription stimulant substitution is promising, there are no approved treatment options for stimulant use disorder that address the realities of an unpredictable drug supply. This study explores treatment experiences of people who use illicit stimulants (PWUS) to identify gaps and perceptions of prospective pharmaceutical stimulant substitution treatments (SST).

METHODS

In-depth qualitative interviews were conducted with 86 PWUS in Vancouver, Canada. Thematic analysis focused on experiences of available treatment options for stimulant use and perceptions of prospective SST.

RESULTS

Participants identified how primarily behavioral treatment approaches do not meet the unique needs of PWUS, in contrast with the range of medical treatments available for opioid use disorder. Participants anticipated health and social benefits if they were able to access SST, including avoiding the toxic illicit stimulant supply, reduced engagement in criminalized activities, and greater economic security. Perceptions of prospective SST were informed by knowledge of existing opioid treatments. This led some participants to be unsupportive of SST, citing concerns around agency and highly regulated operational contexts that do not align with the lived realities of stimulant use.

CONCLUSION

Findings demonstrate the need for SST pilot programs in real-world settings and underscore the health and social advantages SST may offer; although drawing on existing opioid treatment models to implement SST pilots may limit success. Thus, any novel treatments for stimulant use must centre the lived realities of PWUS.

Analysis of EURADOS neutron intercomparison results according to new ISO standards criteria

The European Radiation Dosimetry Group has carried out several different types of intercomparison (IC) exercises in the past that qualify as proficiency tests for different dosimetry systems and types of radiation. The first neutron dosemeter IC was held in 2012 (IC2012n) and was followed by a second in 2017/2018 (IC2017n). In sum, 31 Individual Monitoring Services (IMSs) entered 34 dosimetry systems in IC2012n, and 32 IMSs entered 33 dosimetry systems for IC2017n. Such exercises provided a rare opportunity to see how neutron dosemeters perform. For the IC2012n exercise, there were no applicable performance standards for neutron personal dosemeters. ISO/TC85/SC2 updated the ISO Standard 14146 in 2018 (ISO 14146:2018. Radiation protection-Criteria and performance limits for the periodic evaluation of dosimetry services) to include neutron dosimetry. It was thus possible to analyse the IC2017n exercise in accordance with the requirements given by this new standard. It is now of interest to reanalyse the results of IC2012n to quantify any modifications to the conclusions.

Women's experiences in injectable opioid agonist treatment programs in Vancouver, Canada

BACKGROUND

Injectable opioid agonist treatment (iOAT) has recently been expanded in some geographical contexts in Canada as part of a response to the escalating overdose crisis. Complex gendered dynamics, including power differentials, violence, and social norms, shape the overdose crisis and drug treatment programs which can adversely impact women's experiences. This qualitative study examines how social (e.g., gender, income, housing) and structural factors (e.g., program policies) impact women's experiences of iOAT.

METHODS

Qualitative interviews were completed with 16 women enrolled in four iOAT programs in Vancouver, Canada. Approximately 50 hours of ethnographic observations were conducted. Interview transcripts and ethnographic fieldnotes were analyzed using a critical feminist lens by applying the concepts of embodiment, relationality, and social control to understand women's engagement and self-reported treatment outcomes.

RESULTS

Initial iOAT engagement was a relational process, including initiating treatment with a partner and engaging with iOAT to (re)build personal relationships. Relationships with iOAT providers, including flexibility and support with medication administration, were important to women, providing an affirming embodied experience and a greater sense of agency. However, program operations (e.g., mandated daily attendance, program crowding) incompatible with women's needs (e.g., employment) could undermine these positive experiences. Women's reported outcomes highlight a tension between achieving more agency and the constraints of intensive and stigmatized treatment.

CONCLUSION

This study highlights how iOAT is both a source of care and control for women from a relational and embodied perspective. Findings underscore the need for gender-attentive and flexible drug treatment services to meet the varied needs of women and the importance of providing relational care for women accessing iOAT.

Emergency department experiences of people who use drugs who left or were discharged from hospital against medical advice

BACKGROUND

People who use drugs (PWUD) frequent emergency departments at a higher rate than the general population, and experience a greater frequency of soft tissue infections, pneumonia, and chronic conditions such as, HIV/AIDs and hepatitis C. This population has distinct health care considerations (e.g. withdrawal management) and are also more likely to leave or be discharged from hospital against medical advice.

METHODS

This study examines the experiences of PWUD who have left or been discharged from hospital against medical advice to understand the structural vulnerabilities that shape experiences with emergency departments. Semi-structured qualitative interviews were conducted with 30 PWUD who have left or been discharged from hospital against medical advice within the past two years as part of a larger study on hospital care and drug use in Vancouver, Canada.

RESULTS

Findings characterize the experiences and perceptions of PWUD in emergency department settings, and include: (1) stigmatization of PWUD and compounding experiences of discrimination; (2) perceptions of overall neglect; (3) inadequate pain and withdrawal management; and (4) leaving ED against medical advice and a lack of willingness to engage in future care.

CONCLUSIONS

Structural vulnerabilities in ED can negatively impact the care received among PWUD. Findings demonstrate the need to consider how structural factors impact care for PWUD and to leverage existing infrastructure to incorporate harm reduction and a structural competency focused care. Findings also point to the need to consider how withdrawal and pain are managed in emergency department settings.

International comparability of reference unit costs of education services: when harmonizing methodology is not enough (PECUNIA project)

BACKGROUND

Health problems can lead to costs in the education sector. However, these costs are rarely incorporated in health economic evaluations due to the lack of reference unit costs (RUCs), cost per unit of service, of education services and of validated methods to obtain them. In this study, a standardized unit cost calculation tool developed in the PECUNIA project, the PECUNIA RUC Template for services, was applied to calculate the RUCs of selected education services in five European countries.

METHODS

The RUCs of special education services and of educational therapy were calculated using the information collected via an exploratory gray literature search and contact with service providers.

RESULTS

The RUCs of special education services ranged from €55 to €189 per school day. The RUCs of educational therapy ranged from €6 to €25 per contact and from €5 to €35 per day. Variation was observed in the type of input data and measurement unit, among other.

DISCUSSION

The tool helped reduce variability in the RUCs related to costing methodology and gain insights into other aspects that contribute to the variability (e.g. data availability). Further research and efforts to generate high quality input data are required to reduce the variability of the RUCs.

Implementation of Safe Supply Alternatives During Intersecting COVID-19 and Overdose Health Emergencies in British Columbia, Canada, 2021

Objectives. To explore the implementation and effectiveness of the British Columbia, Canada, risk mitigation guidelines among people who use drugs, focusing on how experiences with the illicit drug supply shaped motivations to seek prescription alternatives and the subsequent impacts on overdose vulnerability. Methods. From February to July 2021, we conducted qualitative interviews with 40 people who use drugs in British Columbia, Canada, and who accessed prescription opioids or stimulants under the risk mitigation guidelines. Results. COVID-19 disrupted British Columbia's illicit drug market. Concerns about overdose because of drug supply changes, and deepening socioeconomic marginalization, motivated participants to access no-cost prescription alternatives. Reliable access to prescription alternatives addressed overdose vulnerability by reducing engagement with the illicit drug market while allowing greater agency over drug use. Because prescriptions were primarily intended to manage withdrawal, participants supplemented with illicit drugs to experience enjoyment and manage pain. Conclusions. Providing prescription alternatives to illicit drugs is a critical harm reduction approach that reduces exposure to an increasingly toxic drug supply, yet further optimizations are needed. (Am J Public Health. 2022;112(S2):S151-S158. https://doi.org/10.2105/AJPH.2021.306692).

T1-independent exchange rate quantification using saturation- or phase sensitive-water exchange spectroscopy

PURPOSE

Water Exchange Spectroscopy (WEX) is a direct measurement of the exchange rate k_sw of labile protons from a solute to water in which the exchange time is varied. However the useful information can be masked by the T₁-decay of the solvent pool. We propose Saturation-WEX and Phase Sensitive WEX (PS-WEX) as an extension upon the WEX approach to reduce T₁-masking. Additionally PS-WEX takes advantage of the phase information contained in the WEX signal to improve the dynamic range.

METHODS

By introducing an additional RF-pulse and fixing the exchange time delay the T₁-dependence of the signal is reduced. By exploiting the phase sensitivity of the WEX pathway the dynamic range can be increased. This approach is validated using simulations as well as phantom measurements.

RESULTS

The improved dynamic range is demonstrated in measurements. The fixed exchange time reduces the influence of the T₁-decay on the signal curve leading to improved fit quality.

CONCLUSION

Sat-WEX and PS-WEX are an extension to the well established WEX approach with a less complex fit equation and in the case of PS-WEX improved dynamic range, allowing more accurate quantification.

Lipid testing trends before and after hospitalization for myocardial infarction among adults in the U.S., 2008–2019

Background

Routine monitoring of low-density lipoprotein cholesterol (LDL-C) identifies patients who are candidates for initiation of lipid-lowering therapies (LLT), assesses adherence and response, and measures clinical indications for modifications to treatment. This study investigated LDL-C testing trends among patients hospitalized for incident myocardial infarction (MI), a population at high risk of future atherosclerotic cardiovascular disease (ASCVD) events who may benefit from additional LLT.

Purpose

Our objective was to estimate rates of LDL-C testing before and after MI hospitalization, hypothesizing that testing rates would increase following MI.

Methods

Using claims data from a large population with Medicare supplemental or commercial insurance, we identified U.S. adults aged ≥20 years discharged from a MI hospitalization. Patients qualified for the study cohort if their first MI hospitalization occurred during 1/1/2008–3/31/2019, with one year of continuous enrolment in insurance leading up to the hospitalization. Patients were required to be discharged alive to the community (excluded if died or transferred to another facility). LDL-C testing was assessed in the year before admission (pre-MI) and for up to one year after discharge (post-MI), with censoring due to insurance plan disenrollment. To evaluate changes in LDL-C testing, we fit an overdispersed Poisson model to the time-series of pre-MI rates and extrapolated the model to the post-MI period, accounting for person-time and seasonality. We predicted the LDL-C testing rates if no MI occurred (i.e., based only on pre-MI testing trends) and estimated rate differences with 95% confidence intervals (contrasting observed vs. model-predicted rates).

Results

A total of 389,367 patients were hospitalized for their first MI during the study period with 60% aged <65 years, 64% were male, and 51% filled a statin prescription after discharge (half being high-intensity statins). In the year pre-MI, 25% had a history of diabetes mellitus, 35% used statins, and 4% used ezetimibe. In the year post-MI, only 52% had an LDL-C test. Mean observed rates (tests per 1,000 patients per month) in the pre- and post-MI periods were 51.9 (95% CI: 51.7, 52.1) and 84.4 (95% CI: 84.1, 84.6), respectively. Across the 12 months post-MI, observed rates were higher than model-predicted rates, with the magnitude of rate differences changing over time (Figure). The observed testing rate peaked two months post-MI (rate difference: 65.7, 95% CI: 64.6, 66.7).

Conclusions

Our findings indicate that LDL-C testing rates increased following a MI hospitalization and stayed elevated throughout the following year. Despite this increase, overall rates remained low, with only one in two patients receiving an LDL-C test in the year after MI. These results highlight a potential gap in care, particularly given the importance of LDL-C monitoring for this population to reduce risk of future ASCVD events.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This study was funded by Amgen, Inc. Several authors are employees and own stock in Amgen.

Negotiating sex work and client interactions in the context of a fentanyl-related overdose epidemic

Despite awareness of the role of drug use in shaping sex worker/client interactions, these dynamics remain poorly understood in the context of illicit fentanyl-driven overdose epidemics. This study examined sex workers' experiences negotiating client interactions amidst a toxic drug supply in Vancouver, Canada. Findings draw from two ethnographic studies. The first, conducted between December 2016 and May 2017, examined the rapid implementation of several low-threshold supervised consumption sites. The second investigated experiences of women accessing a women-only site from May 2017 to June 2018. Data included 200 hours of fieldwork and in-depth semi-structured interviews with 34 street-based sex workers who use illicit drugs. Data were analysed thematically with attention to the risk environment. Participants described providing harm reduction services to clients as a means to reduce overdose-related risks, thus increasing sex workers' hidden labour. Participants, comments regarding criminalisation and stigma surrounding drug use and sex work indicated a reticence to report overdoses, thereby potentially increasing the risks of overdose-related harms, including death. There is an urgent need for sex worker-led overdose prevention strategies that prioritise health and safety of sex workers and their clients with specific attention to how the criminalisation of particular drugs, practices and people contributes to overdose-related risks.

Middle Meningeal Artery Embolization Using Combined Particle Embolization and n-BCA with the Dextrose 5% in Water Push Technique for Chronic Subdural Hematomas: A Prospective Safety and Feasibility Study

BACKGROUND AND PURPOSE

Embolization of the middle meningeal artery for treatment of refractory or recurrent chronic subdural hematomas has gained momentum during the past few years. Little has been reported on the use of the n-BCA liquid embolic system for middle meningeal artery embolization. We present the technical feasibility of using diluted n-BCA for middle meningeal artery embolization.

MATERIALS AND METHODS

We sought to examine the safety and technical feasibility of the diluted n-BCA liquid embolic system for middle meningeal artery embolization. Patients with chronic refractory or recurrent subdural hematomas were prospectively enrolled from September 2019 to June 2020. The primary outcome was the safety and technical feasibility of the use of diluted n-BCA for embolization of the middle meningeal artery. The secondary end point was the efficacy in reducing hematoma volume.

RESULTS

A total of 16 patients were prospectively enrolled. Concomitant burr-hole craniotomies were performed in 12 of the 16 patients. Two patients required an operation following middle meningeal artery embolization for persistent symptoms. The primary end point was met in 100% of cases in which there were no intra- or postprocedural complications. Distal penetration of the middle meningeal artery branches was achieved in all the enrolled cases. A 7-day post-middle meningeal artery embolization follow-up head CT demonstrated improvement (>50% reduction in subdural hematoma volume) in 9/15 (60%) patients, with 6/15 (40%) showing an unchanged or stable subdural hematoma. At day 21, available CT scans demonstrated substantial further improvement (>75% reduction in subdural hematoma volume).

CONCLUSIONS

Embolization of the middle meningeal artery using diluted n-BCA and ethiodized oil (1:6) is safe and feasible from a technical standpoint. The use of a dextrose 5% bolus improves distal penetration of the glue.

"It's Helped Me a Lot, Just Like to Stay Alive": a Qualitative Analysis of Outcomes of a Novel Hydromorphone Tablet Distribution Program in Vancouver, Canada

North America is experiencing an overdose crisis driven by fentanyl, related analogues, and fentanyl-adulterated drugs. In response, there have been increased calls for "safe supply" interventions based on the premise that providing a safer alternative (i.e., pharmaceutical drugs of known quality/quantity, non-adulterated, with user agency in consumption methods) to the street drug supply will limit people's use of fentanyl-adulterated drugs and reduce overdose events. This study examined outcomes of a hydromorphone tablet distribution program intended to prevent overdose events among people who use drugs (PWUD) at high risk of fatal overdose. Semi-structured qualitative interviews were conducted with 42 people enrolled in the hydromorphone distribution program. Additionally, over 100 h of ethnographic observation were undertaken in and around the study site. Transcripts were coded using NVivo and based on categories extracted from the interview guides and those identified during initial interviews and ethnographic fieldwork. Analysis focused on narratives around experiences with the program, focusing on program-related outcomes. Our analysis identified the following positive outcomes of being enrolled in the hydromorphone tablet distribution program: (1) reduced street drug use and overdose risk, (2) improvements to health and well-being, (3) improvements in co-management of pain, and (4) economic improvements. Our findings indicate that the hydromorphone distribution program not only is effective in responding to the current overdose crisis by reducing people's use of illicit drugs but also addresses inequities stemming from the intersection of drug use and social inequality. Safe supply programs should be further implemented and evaluated in both urban and rural setting across North America as a strategy to reduce exposure to the toxic drug supply and fatal overdose.

Understanding concurrent stimulant use among people on methadone: A qualitative study

INTRODUCTION AND AIMS

Opioid-related overdoses are an epidemic in North America, prompting a greater use of medications for opioid use disorder, such as methadone. Although many people work toward overall drug abstinence while on methadone, a sub-population of people with and without histories of polysubstance use engage in stimulant use while on methadone treatment. This study explores motivations for concurrent stimulant and methadone use in a street-involved drug-using population.

DESIGN AND METHODS

Semi-structured qualitative interviews were conducted with 39 people on methadone in Vancouver, Canada. Participants were recruited from among the participants in two community-based prospective cohort studies consisting of HIV-positive and HIV-negative people who use drugs. Interview transcripts were analysed using an inductive and iterative approach.

RESULTS

Our analysis identified three primary themes. First, participants articulated how stimulants were used to counter the sedating effects of methadone and enable them to engage in daily and survival activities (e.g. income generation). Second, participants described increased stimulant use to compensate for reduced stimulant intoxication while taking methadone. Finally, participants described the desire to achieve intoxication on stimulants once stable on methadone, as their substance use treatment goals did not involve drug abstinence.

DISCUSSION AND CONCLUSION

Among a street-involved drug-using population in which people do not have abstinence-based treatment goals, there are several functional reasons to use stimulants concurrently while on methadone. A deeper and more nuanced understanding of substance use motivators may contribute to further research and inform policy and guideline changes that support low threshold and harm reduction-focused methadone treatment programs and other interventions to reduce drug-related harms.

Motivations to initiate injectable hydromorphone and diacetylmorphine treatment: A qualitative study of patient experiences in Vancouver, Canada

BACKGROUND

Within the context of the ongoing overdose crisis and limitations of conventional opioid treatments, the scale-up of injectable hydromorphone (HDM) and diacetylmorphine (DAM) as evidenced-based treatments is currently underway in some settings in Canada. Past research has underscored the importance of treatment initiation in shaping onward treatment trajectories, however structural factors that influence participants' motivations to access injectable HDM or DAM have not been fully characterized. This study examines peoples' motivations for accessing HDM/DAM treatment and situates these within the social and structural context that shapes treatment delivery by employing the concept of structural vulnerability.

METHODS

Fifty-two individuals enrolled in injectable HDM/DAM programs were recruited from four community-based clinical programs in Vancouver, Canada to participate in qualitative semi-structured interviews. Approximately 50 h of ethnographic fieldwork was also completed in one clinical setting, and one-on-one with participants public spaces. Interview transcripts and ethnographic fieldnotes were analyzed through a structural vulnerability lens with a focus on treatment initiation.

RESULTS

Participants' previous experiences and perceptions of other drug treatments (e.g. methadone) foregrounded their initiation of injectable HDM/DAM. Social and structural factors (e.g. fentanyl-adulterated drug supply, poverty, drug criminalization) influenced participants' motivations to address immediate physical risks and their initial perception of this treatment's ability to align with their opioid use experiences. Similar social and structural factors that drive immediate physical risks, were also evidenced in participants' motivations to make changes in their daily lives and to address broader opioid use goals.

CONCLUSION

Participants descriptions of their motivations to initiate HDM/DAM highlight how structural vulnerabilities shaped participants' experiences initiating injectable HDM/DAM.

Barriers and facilitators to a novel low-barrier hydromorphone distribution program in Vancouver, Canada: a qualitative study

BACKGROUND

North America is experiencing an overdose crisis driven by illicitly-manufactured fentanyl, related analogues, and fentanyl-adulterated drugs. The concept of 'safe supply' has been suggested as a potential measure to address the overdose crisis by providing a regulated alternative to illicit opioids to people at high risk of fatal overdose. In January 2019, a novel hydromorphone tablet distribution program was implemented within an overdose prevention site in Vancouver, Canada's Downtown Eastside neighbourhood. This study explored barriers and facilitators to engagement with this program.

METHODS

In-depth interviews were conducted with 42 participants enrolled in the hydromorphone tablet distribution program, and over 100 h of ethnographic observation were conducted in and around the study site. Thematic analysis of the interviews and ethnographic observation focused on program operation, including barriers and facilitators to program uptake, access, and engagement.

RESULTS

Barriers to program engagement identified include: limited operating hours and dose schedule, co-location within the overdose prevention site (e.g., wait times), and receiving the generic formulation of hydromorphone. Facilitators identified include: having access to a reliable source of opioids, co-location within the overdose prevention site (e.g., low-barrier design), experiences of agency, and program flexibility.

CONCLUSION

Our findings demonstrate key implementation and operational considerations of safe supply programs. In particular, lower-barrier design and operational features should be considered to improve uptake and engagement. Safe opioid supply programs are a promising intervention to address North America's ongoing overdose crisis by providing people at high risk of fatal overdose an alternative to the toxic drug supply.

OP0236 RELEVANCE OF BIASED PAR2 INHIBITORS IN REDUCING INFLAMMATION AND CARTILAGE DEGRADATION IN IN VITRO AND IN VIVO MODELS OF RHEUMATOID ARTHRITIS

Background:

Protease-activated receptor-2 (PAR2) is a member of a family of G-protein-coupled receptors involved in multiple physiological mechanisms. Compelling evidences have unravelled the key roles of PAR2 in the pathology of both rheumatoid arthritis (RA) and osteoarthritis (OA)1. Indeed, in vitro, in vivo and ex vivo experiments showed that this receptor promotes inflammation, cartilage erosion (and subsequent bone degradation), and pain. However, the signalling pathways involved in these functions are not well understood2. This is of importance as some pathways can promote the pathogenesis3while others prevent it4. We developed a new series of small molecules as novel biased PAR2 inhibitors to treat rheumatic diseases.

Objectives:

To evaluate the efficacy and mechanism of action of new biased PAR2 inhibitors on cartilage erosion and inflammation.

Methods:

The potency of compounds to inhibit human PAR2 signalling was evaluated in vitro by FLIPR calcium assay in HEK293 cells. The same assay was used to determine their selectivity over human PAR1 and PAR4 as well as murine versions of PAR2. The effect of several PAR2 inhibitors on 9 signalling pathways (Gi2, GoB, Gz, Gq, G13, G14, G15, B arrestin 2, EPAC) was evaluated by the BRET-based bioSens-All™ technology. In vitro anti-hypertrophic effect was determined by measuring the mRNA level of type II collagen, aggrecan and MMP13 in rat chondrocytes after IL1β stimulation. In vitro anti-inflammatory effect was determined by measuring the secretion of IL6, IL8, IL1β, TNFα and IFNγ by human monocytes. In vivo, the pharmacodynamic of our small molecules was assessed after intravenous and oral administration. Therapeutic efficacy of a compound was then evaluated in a collagen-induced arthritis model in DBA1/J mice. In this model, measures of the arthritis index score, body weight, plasma level of TNFα, IL6, IL8 and IL1β and histological evaluation of cartilage erosion were performed.

Results:

Our new series of small molecules are potent PAR2 inhibitors (IC50<1nM in calcium assay) with some selectivity over PAR1 and PAR4. Our compounds significantly inhibited PAR2 mediated recruitment of Gz, Gq, G13, G14 and G15. However, surprisingly, these small molecules had no effect on B arrestin 2, EPAC, Gi2 and GoB demonstrating that they are biased inhibitors. The effect of our compounds on PAR2 signalling was clearly different from 3 already existing PAR2 inhibitors described in the literature (I-117, AZ3451 and P2pal-18s). We compared the in vitro anti-hypertrophic effect on chondrocyte and anti-inflammatory effect on monocytes of these compounds to determine the importance of PAR2 signalling pathways in these cellular functions. In vivo, our small molecules had good bioavailability after oral administration of 10mg/kg in mice (clearance = 0.038L/h/kg; T½ = 9.9h; AUC= 162564 ng.h/mL; Cmax = 9005 ng/mL). The in vivo therapeutic efficacy of a biased PAR2 inhibitor in a model of collagen-induced arthritis will be presented.

Conclusion:

Our results show the potency of biased PAR2 inhibitors to reduce both the inflammation and cartilage erosion in rheumatoid arthritis. They confirm the huge potential of PAR2 as a therapeutic target and unravel the relevance of biased antagonism of this receptor to treat rheumatic diseases.

References:

[1]McCulloch et al., Frontiers in Endocrinology, 2018;2Hollenberg et al., British Journal of Pharmacology, 2014;3Sharma et al., Genes and Immunity, 2015;4Rayees et al., Cell Reports, 2019

Disclosure of Interests:

Thibaut Brugat Employee of: Domain Therapeutics, Baptiste Rugeri Employee of: Domain Therapeutics, Gaël Hommet Employee of: Domain Therapeutics, Alexia Dumont Employee of: Domain Therapeutics, Luc Baron Employee of: Domain Therapeutics, Célia Halter Employee of: Domain Therapeutics, Meriem Sémache Employee of: Domain Therapeutics, Arturo Mancini Employee of: Domain Therapeutics, Camille Amalric Employee of: Domain Therapeutics, Marie Giambelluco Employee of: Domain Therapeutics, Nathalie Lenne Employee of: Domain Therapeutics, Marjorie Sidhoum Employee of: Domain Therapeutics, Christel Franchet Employee of: Domain Therapeutics, Stanislas Mayer Employee of: Domain Therapeutics, Xavier Leroy Employee of: Domain Therapeutics, Stephan Schann Employee of: Domain Therapeutics

A Low-Barrier and Comprehensive Community-Based Harm-Reduction Site in Vancouver, Canada

"The Molson" is a low-barrier, peer-staffed, supervised consumption site located in Vancouver, Canada. In addition to overdose response, this site offers drug checking and a colocated injectable hydromorphone treatment program, and it distributes tablet and liquid hydromorphone to service users at high risk of overdose. Our evaluation suggests benefits of this program in creating service continuums and preventing overdose deaths. From September 2017 to August 2019, the site had 128 944 visits, reversed 770 overdoses, and had no overdose deaths.

"Bed Bugs and Beyond": An ethnographic analysis of North America's first women-only supervised drug consumption site

BACKGROUND

Attention to how women are differentially impacted within harm reduction environments is salient amidst North America's overdose crisis. Harm reduction interventions are typically 'gender-neutral', thus failing to address the systemic and everyday racialized and gendered discrimination, stigma, and violence extending into service settings and limiting some women's access. Such dynamics highlight the significance of North America's first low-threshold supervised consumption site exclusively for women (transgender and non-binary inclusive), SisterSpace, in Vancouver, Canada. This study explores women's lived experiences of this unique harm reduction intervention.

METHODS

Ethnographic research was conducted from May 2017 to June 2018 to explore women's experiences with SisterSpace in Vancouver's Downtown Eastside, an epicenter of Canada's overdose crisis. Data include more than 100 hours of ethnographic fieldwork, including unstructured conversations with structurally vulnerable women who use illegal drugs, and in-depth interviews with 45 women recruited from this site. Data were analyzed in NVivo by drawing on deductive and inductive approaches.

FINDINGS

The setting (non-institutional), operational policies (no men; inclusive), and environment (diversity of structurally vulnerable women who use illegal drugs), constituted a space affording participants a temporary reprieve from some forms of stigma and discrimination, gendered and social violence and drug-related harms, including overdose. SisterSpace fostered a sense of safety and subjective autonomy (though structurally constrained) among those often defined as 'deviant' and 'victims', enabling knowledge-sharing of experiences through a gendered lens.

CONCLUSION

SisterSpace demonstrates the value and effectiveness of initiatives that engage with socio-structural factors beyond the often narrow focus of overdose prevention and that account for the complex social relations that constitute such initiatives. In the context of structural inequities, criminalization, and an overdose crisis, SisterSpace represents an innovative approach to harm reduction that accounts for situations of gender inequality not being met by mixed-gender services, with relevance to other settings.

Policing space in the overdose crisis: A rapid ethnographic study of the impact of law enforcement practices on the effectiveness of overdose prevention sites

North America is in the midst of an overdose crisis. In some of the hardest hit areas of Canada, local responses have included the implementation of low-threshold drug consumption facilities, termed Overdose Prevention Sites (OPS). In Vancouver, Canada the crisis and response occur in an urban terrain that is simultaneously impacted by a housing crisis in which formerly 'undesirable' areas are rapidly gentrifying, leading to demands to more closely police areas at the epicenter of the overdose crisis. We examined the intersection of street-level policing and gentrification and how these practices re/made space in and around OPS in Vancouver's Downtown Eastside neighborhood. Between December 2016 and October 2017, qualitative interviews were conducted with 72 people who use drugs (PWUD) and over 200 h of ethnographic fieldwork were undertaken at OPS and surrounding areas. Data were analyzed thematically and interpreted by drawing on structural vulnerability and elements of social geography. While OPS were established within existing social-spatial practices of PWUD, gentrification strategies and associated police tactics created barriers to OPS services. Participants highlighted how fear of arrest and police engagement necessitated responding to overdoses alone, rather than engaging emergency services. Routine policing near OPS and the enforcement of area restrictions and warrant searches, often deterred participants from accessing particular sites. Further documented was an increase in the number of police present in the neighborhood the week of, and the week proceeding, the disbursement of income assistance cheques. Our findings demonstrate how some law enforcement practices, driven in part by ongoing gentrification efforts and buttressed by multiple forms of criminalization present in the lives of PWUD, limited access to needed overdose-related services. Moving away from place-based policing practices, including those driven by gentrification, will be necessary so as to not undermine the effectiveness of life-saving public health interventions amid an overdose crisis.

EURADOS education and training activities

This paper provides a summary of the Education and Training (E&T) activities that have been developed and organised by the European Radiation Dosimetry Group (EURADOS) in recent years and in the case of Training Courses over the last decade. These E&T actions include short duration Training Courses on well-established topics organised within the activity of EURADOS Working Groups (WGs), or one-day events integrated in the EURADOS Annual Meeting (workshops, winter schools, the intercomparison participants' sessions and the learning network, among others). Moreover, EURADOS has recently established a Young Scientist Grant and a Young Scientist Award. The Grant supports young scientists by encouraging them to perform research projects at other laboratories of the EURADOS network. The Award is given in recognition of excellent work developed within the WGs' work programme. Additionally, EURADOS supports the dissemination of knowledge in radiation dosimetry by promoting and endorsing conferences such as the individual monitoring (IM) series, the neutron and ion dosimetry symposia (NEUDOS) and contributions to E&T sessions at specific events.

Peer worker involvement in low-threshold supervised consumption facilities in the context of an overdose epidemic in Vancouver, Canada

Overdose prevention sites (OPS) are a form of supervised consumption facility that have been implemented in Vancouver, Canada as an innovative response to an ongoing overdose epidemic. OPS are primarily staffed by peers - people who use(d) drugs (PWUD) - trained in overdose response. We sought to characterize peer worker involvement in OPS programming, including how this shapes service dynamics and health outcomes among PWUD. Data were drawn from a rapid ethnographic study examining the implementation, operations and impacts of OPS in Vancouver from December 2016 to April 2017. We conducted approximately 185 h of observational fieldwork at OPS and 72 in-depth qualitative interviews with PWUD. Data were analyzed thematically, with a focus on peer worker involvement at OPS and related outcomes. OPS implementation and operations depended on peer worker involvement and thus allowed for recognition of capacities developed through roles that peers were already undertaking through local programming for PWUD. Peer involvement at OPS enhanced feelings of comfort and facilitated engagement with OPS among PWUD. These dynamics and appreciation of peer worker expertise enabled communication with staff in ways that fostered harm reduction practices and promoted health benefits. However, many peer workers received minimal financial compensation and experienced considerable grief due to the emotional toll of the epidemic and lack of supports, which contributed to staff burnout. Our findings illustrate the specific contributions of task shifting OPS service delivery to peer workers, including how this can enhance service engagement and promote the reduction of harms among PWUD. Amidst an ongoing overdose epidemic, expanding formalized peer worker involvement in supervised consumption programming may help to mitigate overdose-related harms, particularly in settings where peers are actively involved in existing programming. However, efforts are needed to ensure that peer workers receive adequate financial support and workplace benefits to promote the sustainability of this approach.

Surgery for Pediatric Ureteropelvic Junction Obstruction-Comparison of Outcomes in Relation to Surgical Technique and Operating Discipline in Germany

INTRODUCTION

 Surgery for ureteropelvic junction obstruction (UPJO) is performed by both pediatric surgeons (PS) and urologists (URO). The aim of this study was to analyze treatment modalities for UPJO and results in relation to the surgical technique and the operating discipline in Germany.

MATERIALS AND METHODS

 Data of patients aged 0 to 18 years were extracted from a major public health insurance (covering ∼5.7 million clients) during 2009 to 2016 and were analyzed for sociodemographic variables, surgical technique, and treating discipline. Logistic regression analysis was performed for the risk of a complication within the first postoperative year.

RESULTS

 A total of 229 children (31.0% female) were included. Laparoscopic pyeloplasty (LP) was performed in 58 (25.3%) patients (8.6 ± 6.4 years), and open pyeloplasty (OP) was applied in 171 (74.7%; 4.6 ± 5.9 years). LP was the dominant technique in females (p < 0.02); males preferentially underwent OP (p < 0.02). Length of hospital stay was 4.3 days (p = 0.0005) shorter in LP compared with that in OP, especially in children ≤ 2 years (6.7 days, p = 0.007). PS operated on 162 children (70.7%), and URO performed surgery on 67 patients (29.3%). The mean age of children operated by PS (3.5 ± 4.7 years) was significantly younger compared with that operated by URO (10.8 ± 6.5 years, p < 0.0001). Complication rates were independent of surgical technique or treating specialty.

CONCLUSION

 In Germany, UPJO was treated by LP in 25.3% of patients, which was associated with a shorter length of stay, especially in children ≤ 2 years. Complication rates were independent of the operating specialty and surgical technique. Therefore, LP should be further promoted for the treatment of UPJO in small children.

Characterizing fentanyl-related overdoses and implications for overdose response: Findings from a rapid ethnographic study in Vancouver, Canada

BACKGROUND

North America is experiencing an opioid overdose epidemic, fuelled by the proliferation of fentanyl, related analogues, and fentanyl-adulterated opioids. British Columbia, Canada has similarly experienced a rapid increase in the proportion of opioid overdose deaths associated with fentanyl. This study builds off of research characterizing fentanyl exposure to further explore the presentation of fentanyl use and related overdoses among people who use drugs.

METHODS

From December 2016 to April 2017, rapid ethnographic fieldwork was conducted in Vancouver, Canada to examine the implementation of low-threshold overdose prevention sites, where people use drugs under the supervision of staff and peers trained to respond to overdose. Data collection included 185 h of ethnographic observation and in-depth interviews with 72 people who inject drugs, 44 of whom reported experiencing an overdose in the year prior to the interviews.

RESULTS

While most participants had experienced previous opioid-related overdose, they characterized how fentanyl was markedly distinct in terms of: potency, and rapid onset. Ethnographic observations and participant narratives highlighted how fentanyl use and related overdoses had implications for frontline response, including: rapid onset, multiple concurrent overdoses, body and chest rigidity, and the need to administer larger doses of naloxone.

CONCLUSIONS

Participant narratives and observational data documented distinct symptoms for fentanyl-attributed overdoses compared to other opioid related overdose events, which had implications for response. Findings may serve to inform best practices in responding to fentanyl-related overdoses including; the provision of oxygen and effective doses of naloxone, and also considerations regarding overdose identification.

Gendered violence and overdose prevention sites: a rapid ethnographic study during an overdose epidemic in Vancouver, Canada

BACKGROUND AND AIMS

North America's overdose epidemic is increasingly driven by fentanyl and fentanyl-adulterated drugs. Supervised consumption sites, including low-threshold models (termed overdose prevention sites; OPS), are now being debated in the United States and implemented in Canada. Despite evidence that gendered and racialized violence shape access to harm reduction among women who use drugs (WWUD), this has not been examined in relation to OPS and amid the overdose epidemic. This study explores how overlapping epidemics of overdose and gendered and racialized violence in Vancouver's Downtown Eastside, one of North America's overdose epicenters, impacts how marginalized WWUD experience OPS.

DESIGN

Qualitative analysis using rapid ethnographic fieldwork. Data collection included 185 hours of naturalistic observation and in-depth interviews; data were analyzed thematically using NVivo.

SETTING

Vancouver, Canada.

PARTICIPANTS

Thirty-five WWUD recruited from three OPS.

MEASUREMENTS

Participants' experiences of OPS and the public health emergency.

FINDINGS

The rapid onset and severity of intoxication associated with the use of fentanyl-adulterated drugs in less regulated drug use settings not only amplified WWUD's vulnerability to overdose death but also violence. Participants characterized OPS as safer spaces to consume drugs in contrast to less regulated settings, and accommodation of assisted injections and injecting partnerships was critical to increasing OPS access among WWUD. Peer-administered injections disrupted gendered power relations to allow women increased control over their drug use; however, participants indicated that OPS were also gendered and racialized spaces that jeopardized some women's access.

CONCLUSION

Although women who use drugs in Vancouver, Canada appear to feel that overdose prevention sites address forms of everyday violence made worse by the overdose epidemic, these sites remain 'masculine spaces' that can jeopardize women's access.

Alone in a Crowd? Parents of Children with Rare Diseases' Experiences of Navigating the Healthcare System

A disorder is considered a rare disease if it affects 1 in 2000, hence, while independently unique, collectively, these conditions are quite common. Many rare diseases are diagnosed during childhood, and therefore parents become primary caregivers in addition to their parental role. Despite the prevalence of rare diseases among children, there has been little research focused on parents' experiences of navigating the healthcare system, a gap we begin to address in this study. Guided by an interpretive description methodology, participants were recruited through online listservs and posting flyers at a pediatric hospital in Western Canada. Sixteen parents (15 mothers and 1 father) participated in in-depth, semi-structured interviews between April 2013 and March 2014. Data were analyzed inductively, generating the main study themes. Findings illuminated the challenges parents' experienced on their child's diagnostic journey-from seeking, to receiving, to adjusting to the rare disease diagnosis. Following diagnosis, gaps, and barriers to services resulted in parents pursuing services that could support their child's unique care needs, which often resulted in out-of-pocket payments and changes to employment. Parents found peer support, both online and in person, to be an effective resource. This study illustrates the common challenges experienced by parents of children with rare diseases as they navigate the healthcare system. Parents' role as "expert caregiver" was rarely acknowledged by healthcare providers, pointing to the need to foster more egalitarian relationships. As well, parents were burdened with the additional role of care coordinator, a role that could be filled formally by a healthcare provider. Lastly, peer support was a key resource in terms of information and emotional support for parents who often begin their journey feeling isolated and alone. Policies and programs are needed that validate the invisible care work of parents and ensure adequate formal supports are in place to mitigate potential sources of inequity for these families. Furthermore, genetic counselors can play a key role in ensuring parents' informational needs are addressed at the time of diagnosis and in connecting families who share common experiences regardless of the rare disease diagnosis.

The Inhibitory Action of Adsorbed Undiluted Plasma (normal or pathological) on the Thromboplastin Generation Test

In considering errors made during the search for a weak inhibitor of thromboplastin generation in a patient suffering from multiple myeloma, the authors recall the inhibitory action of adsorbed undiluted plasma added to a thromboplastin generation test. They stress the non-specificity of this inhibitory action which is common to all adsorbed plasma (normal, myelomatous or hemophilic) added undiluted to the test of Biggs and Douglas.

The „Bridge Effect”

The “Bridge effect“ consists in the fact that an incomplete thromboplastin, tested by the thromboplastin generation test of Biggs and Douglas on a substrate having a deficiency in its own thromboplastin generation, coagulates it more slowly than a normal substrate. It is observed when the factorial deficiencies of the substrate and the thromboplastin correspond with each other (hemophilic — hemophilic, Christmas — Christmas), it is weak and inconstant (Christmas thromboplastin — hemophilic substrate) or non existent (hemophilic thromboplastin — Christmas substrate) when they are crossed. It is eliminated by an adequate correction of the substrate (AHG added to the hemophilic substrate, PTC added to the Christmas substrate). The “Bridge effect“ is a source of error which must be taken into account in the manipulation of thromboplastin generation tests.

Aging Together: Caring Relations in Families of Adults With Intellectual Disabilities

Purpose of the Study

To examine the dynamics of caring relations in older families that include an adult with Intellectual Disabilities (ID). To date, there has been very little research exploring the experiences of aging families of community-dwelling adults with ID.

Design and Methods

An exploratory, qualitative study was conducted in British Columbia, Canada. Eight participants were recruited through purposive sampling. In-depth, semistructured interviews were conducted to explore the experience of aging concurrently with a community-dwelling relative with ID. Data were analyzed using a thematic approach.

Results

Three main themes emerged: (a) Recognizing the Changes of Aging, (b) Strengthening Connections, and (c) Planning for the Future.

Implications

Aging concurrently with a community-dwelling relative with ID is a unique experience for older adults and challenges traditional views of familial caring relations. These relationships are characterized by evolving patterns of care and exchange. There is also a sense of urgency to securing future care arrangements for the adult relative with ID. Advanced care-planning is complicated by the adult with ID' understanding of death and dying. Family caregiving policies and practices that take into account the complexities of these relationships are needed.

[Cavernomas of the central nervous system : Observational study of 111 patients]

PURPOSE

The prevalence of cavernomas (cavernous hemangioma) is 0.1-0.7%. Cavernomas are often found as an incidental finding within the framework of magnetic resonance imaging (MRI) examinations in mainly young and healthy patients. In the literature, the reported risk of hemorrhage varies greatly and is sometimes higher than that of aneurysms, which is surprising given that cavernomas are part of the low blood pressure system. After the diagnosis the medical practitioner and the patient have to decide on the further therapy, either surgical removal or the strategy of watchful waiting (conservative treatment). The aim of our study was to determine the frequency of bleeding of cavernomas and the consequences and to determine the satisfaction of patients with treatment. All these aspects should make the therapeutic decision easier for medical practitioners.

MATERIAL AND METHODS

The study included all patients who were treated in the military hospital in Ulm during the period 2002-2012 and with the diagnosis of one or more cavernomas of the central nervous system (CNS) detected by MRI. This resulted in a total number of 111 patients. We recorded the epidemiological data and analyzed all cavernomas with respect to the location, size, treatment, side effects, etc. Furthermore, all included patients were sent a comprehensive questionnaire about symptoms, course of the disease and the quality of life. The response rate was 38%. All the collected data were analyzed with respect to the various aspects.

RESULTS

Depending on the definition of a bleeding event of a cavernoma and selection of the observational period, the probability of a hemorrhage risk ranged from 1.3% to 5.9% per patient year. This relatively high proportion is, however, put into perspective by the mostly mild consequences of a bleeding event. Many cavernomas, which were detected as an incidental finding showed signs of previous bleeding but the patients remained free of symptoms. Additionally, there was no patient in this collective who suffered serious consequences due to a bleeding event. Of the patients with temporal cavernomas 45% had symptomatic epilepsy. The results of the patient survey were heterogeneous. Some patients stated that in retrospect they would not choose surgical treatment again.

CONCLUSION

As a result of our findings we think it is important to critically look at the indications for surgical removal of cavernomas and special attention must be paid to informed consent of the patient. The frequent appearance of temporal cavernomas and their propensity to epileptic seizures is an essential aspect, which certainly influences the therapeutic decision. Although cavernomas are a venous malformation in the low blood pressure system, the determined frequency of hemorrhage was 5.9%, which was higher than expected but which is confirmed by other studies. Reports on severe sequelae of cavernoma bleeding are also rare in the literature, which relativizes the resulting danger of the relatively high probability of hemorrhage.

EURADOS IC2012N: FURTHER INFORMATION DERIVED FROM AN EURADOS INTERNATIONAL COMPARISON OF NEUTRON PERSONAL DOSEMETERS

In 2012, the European Radiation Dosimetry Group (EURADOS) performed an intercomparison for neutron dosemeters that are intended to measure personal dose equivalent, Hp(10). A total of 31 participants registered with 34 dosimetry systems. The irradiation tests were chosen to provide the participants with useful information on their dosimetry systems, i.e. linearity, reproducibility, responses for different energies and angles and to simulated workplace fields. This paper gives details of the extensive information derived from the exercise.

OCCUPATIONAL EXPOSURE TO EXTERNAL RADIATION IN SWITZERLAND

Individual monitoring for both external and internal exposures is well regulated in Switzerland. The article gives an overview on the occupational exposure to external radiation of workers based on the data collected in the Swiss national dose registry (NDR) in 2013. The NDR records the monthly doses of radiation workers since the introduction of ICRP 60 recommendations and is manifested in the Swiss ordinance since 1994. Annual dose limits for effective dose are typically exceeded once a year in Switzerland, mostly in medicine. The NDR is a useful optimisation tool to identify and characterise areas with the highest exposures. While exceeded dose limits were often related to accidental acute exposure in the past, they are now more related to continuous exposure during normal work, especially in medicine.

COMPARISON OF DIFFERENT PADC MATERIALS AND ETCHING CONDITIONS FOR FAST NEUTRON DOSIMETRY

Etched-track polyallyl diglycol carbonate (PADC) dosemeters have been in use at the Paul Scherrer Institute since 1998 in neutron dosimetry for individual monitoring. In the last years, the availability of PADC materials from different manufacturers has grown, and different etching conditions were proposed, with the intention to improve the quality and overall performance of PADC in individual neutron monitoring. The goal of the present study was to compare the performance of different PADC materials and to investigate the influence of different etching conditions on sensitivity to fast neutrons and lower detection limit. The comparison covers six different PADC materials and eight different etching conditions.

INVESTIGATION OF THE EXTENDED RANGE REM-COUNTER SMARTREM-LINUS IN REFERENCE AND WORKPLACE FIELDS EXPECTED AROUND HIGH-ENERGY ACCELERATORS

Radiation survey instrumentation is adequate for the use around high-energy accelerators if capable to measure the dose arising from neutrons with energies ranging from thermal up to a few gigaelectronvolts. The SmartREM-LINUS is a commercial extended range rem-counter, consisting of a central (3)He-proportional counter surrounded by a spherical moderator made of borated polyethylene with an internal shield made of lead. The dose rate indicated by the SmartREM-LINUS was investigated for two different irradiation conditions. The linearity and the angular dependence of the indicated dose rate were investigated using reference neutron fields produced by (241)AmBe and (252)Cf. Additional measurements were performed in two different workplace fields with a component of neutrons with energies >20 MeV, namely the CERN-EU high-energy reference field and near the beam dump of the SwissFEL injector test facility. The measured dose rates were compared to a commercial rem-counter (WENDI2) and the results of Monte Carlo simulations.

Abstract TP387: An Interdisciplinary Approach to Improving Acute Treatment- Implementation of the Rapid Acute Stroke Protocol

Background: Recent emergence of evidence for the effectiveness of intra-arterial treatment (IAT) of acute ischemic stroke secondary to large vessel occlusion (LVO) has prompted hospitals to examine the efficiency of their initial evaluation process. Mount Sinai Hospital has taken an interdisciplinary approach to hyper acute stroke care. It streamlined its process focusing on rapid triage of stroke, stroke team assessment, IV tPA administration and detection of LVO.

Rapid Acute Stroke Protocol (RASP), including early stroke team activation by the triage nurse was implemented in December 2014. Triage nurses were trained in the identification of stroke and stroke team activation. Feedback was provided to nursing leadership and individual participants on every treated case. A ‘team member of the month’ was established to promote ongoing enthusiasm and team rapport.

We hypothesized that the combination of new evidence and the introduction of RASP would increase the number of patients treated, decrease time to stroke team assessment and door to puncture (DTP) time.

Method: In this retrospective review of 51 consecutive patients with AIS treated with IAT from January 2014 until July 2015, the population was divided into two cohorts. Cohort 1 included patients treated from January 2014 through November 2014, prior to RASP initiation. Cohort 2 included patients treated from December 2014 through July 2015. Outcomes included number of patients treated, arrival to stroke team assessment, and DTP time.

Results: In cohort 1, .9 cases per month were treated with IAT compared to 5.1 per month in cohort 2, a 5.2 fold increase. A greater percentage of these patients arrived in the ED via inter-hospital transfer 56% vs 30%. There was a decrease in arrival time to stroke team assessment for cohort 2 vs cohort 1 (3 vs 9 minutes) and a reduction of 46.6% from DTP time (79 minutes vs 148 minutes p=<.001).

Conclusion: These findings demonstrate how an interdisciplinary approach to hyper acute care can have a dramatic effect on the stroke patient. Improved prenotification by EMS or the originating hospital contributed to immediate stroke team availability. However, key to RASP was empowering the triage nurse with the responsibility of stroke recognition and activation of the stroke code.

EURADOS strategic research agenda: vision for dosimetry of ionising radiation

Since autumn 2012, the European Radiation Dosimetry Group (EURADOS) has been developing its Strategic Research Agenda (SRA), which is intended to contribute to the identification of future research needs in radiation dosimetry in Europe. The present article summarises-based on input from EURADOS Working Groups (WGs) and Voting Members-five visions in dosimetry and defines key issues in dosimetry research that are considered important for the next decades. The five visions include scientific developments required towards (a) updated fundamental dose concepts and quantities, (b) improved radiation risk estimates deduced from epidemiological cohorts, (c) efficient dose assessment for radiological emergencies, (d) integrated personalised dosimetry in medical applications and (e) improved radiation protection of workers and the public. The SRA of EURADOS will be used as a guideline for future activities of the EURADOS WGs. A detailed version of the SRA can be downloaded as a EURADOS report from the EURADOS website (www.eurados.org).

Reference instruments based on spectrometric measurement with Lucas Cells

The Bundesamt für Strahlenschutz (Berlin, Germany) and the Paul Scherrer Institute (Villigen, Switzerland) both operate accredited calibration laboratories for radon gas activity concentration. Both the institutions use Lucas Cells as detector in their reference instrumentation due to the low dependence of this detector type on variations in environmental conditions. As a further measure to improve the quality of the reference activity concentration, a spectrometric method of data evaluation has been applied. The electric pulses from the photomultiplier tube coupled to the Lucas Cells are subjected to a pulse height analysis. The stored pulse height spectra are analysed retrospectively to compensate for fluctuations in the electric parameters of the instrumentation during a measurement. The reference instrumentation of both the laboratories is described with the respective spectrum evaluation procedures. The methods of obtaining traceability to the primary calibration laboratories of Germany and Switzerland and data of performance tests are presented.