COVID-19's impact on a community-based physical activity program for adults with moderate-to-severe TBI

PURPOSE

Physical activity (PA) is proposed for long-term problems after traumatic brain injury (TBI) with mood, quality of life, and participation. However, COVID-19 mitigation strategies resulted in widespread closures of community-based fitness centres, including one housing a peer-assisted PA program (TBI-Health). The purpose of this study was to provide an in-depth exploration of COVID-19's impact on the TBI-Health program for adults with moderate-to-severe TBI and determine how their PA behaviours could be supported in the pandemic.

METHODS

Interpretative phenomenological analysis was employed to collect and analyze data from semi-structured Zoom-facilitated interviews with seven female and nine male adults with moderate-to-severe TBI (including program participants and mentors).

RESULTS

Three major themes were identified. Need for PA after TBI included specific benefits of PA after TBI and desire for an adapted PA program. Lasting Impacts of the TBI-Health Program identified belonging to the TBI-Health community, benefits, and knowledge transfer from the program. Resilience and Loss through the Pandemic comprised the repercussions of COVID-19, loss of the PA program, adapting PA to the pandemic, and resilience after TBI.

CONCLUSION

This study provides insights about impacts of participating in community-based peer-assisted PA programs after moderate-to-severe TBI and ways to support PA in unforeseen circumstances.

Approach to machine learning for extraction of real-world data variables from electronic health records

Background: As artificial intelligence (AI) continues to advance with breakthroughs in natural language processing (NLP) and machine learning (ML), such as the development of models like OpenAI's ChatGPT, new opportunities are emerging for efficient curation of electronic health records (EHR) into real-world data (RWD) for evidence generation in oncology. Our objective is to describe the research and development of industry methods to promote transparency and explainability. Methods: We applied NLP with ML techniques to train, validate, and test the extraction of information from unstructured documents (e.g., clinician notes, radiology reports, lab reports, etc.) to output a set of structured variables required for RWD analysis. This research used a nationwide electronic health record (EHR)-derived database. Models were selected based on performance. Variables curated with an approach using ML extraction are those where the value is determined solely based on an ML model (i.e. not confirmed by abstraction), which identifies key information from visit notes and documents. These models do not predict future events or infer missing information. Results: We developed an approach using NLP and ML for extraction of clinically meaningful information from unstructured EHR documents and found high performance of output variables compared with variables curated by manually abstracted data. These extraction methods resulted in research-ready variables including initial cancer diagnosis with date, advanced/metastatic diagnosis with date, disease stage, histology, smoking status, surgery status with date, biomarker test results with dates, and oral treatments with dates. Conclusion: NLP and ML enable the extraction of retrospective clinical data in EHR with speed and scalability to help researchers learn from the experience of every person with cancer.

Exploring a peer-based physical activity program in the community for adults with moderate-to-severe traumatic brain injury

PRIMARY OBJECTIVE

To explore the experiences of program mentors, participants, and employees involved in a peer-based physical activity (PA) program for adults with moderate-to-severe TBI, being piloted by a community fitness center, to develop the program as a measurable intervention.

RESEARCH DESIGN

We adopted an exploratory case study approach through an interpretivist paradigm, which focused on discovering realities about the peer-based PA program across the study participants' views, backgrounds, and experiences.

METHODS AND PROCEDURES

Semi-structured focus groups and individual interviews were conducted with nine adult program participants (3 peer mentors, 6 participants), and three program employees. Inductive content analysis was used to develop themes about their perceived experiences.

MAIN OUTCOMES AND RESULTS

44 open-codes were grouped into 10 subthemes and three final themes: 1) program impacts identified the importance of the program in daily life and resulting psychological, physical, and social outcomes; 2) program characteristics highlighted program leaders, accessibility, and social inclusion; 3) program sustainability included program adherence, benefits for the center, and the program's future.

CONCLUSIONS

Perceptions of program experiences and outcomes identified how peer-based PA for adults with moderate-to-severe TBI can lead to meaningful activities, functioning better, and buy-in from all parties. Implications for research and practice related to supporting health-related behaviors after TBI through group-based, autonomy-supporting approaches are discussed.

Patient-centred models of hepatitis C treatment for people who inject drugs: a multicentre, pragmatic randomised trial

BACKGROUND

To achieve WHO targets for the elimination of hepatitis C virus (HCV) as a public threat, an increased uptake of HCV treatment among people who inject drugs (PWID) is urgently needed. Optimal HCV co-located treatment models for PWID have not yet been identified. We aimed to compare two patient-centred models of HCV care in PWID with active drug use.

METHODS

We did a pragmatic randomised controlled trial at eight US cities in eight opioid treatment programmes and 15 community health centres. PWID actively injecting within 90 days of study entry were randomly assigned (1:1) to either patient navigation or modified directly observed therapy (mDOT) using computer-generated variable block sizes of 2-6 stratified by city, clinical settings, and cirrhosis status. The randomisation code was concealed, in a centralised REDCap database platform, from all investigators and research staff except for an authorised data manager at the data coordinating centre. All participants received a fixed-dose combination tablet (sofosbuvir 400 mg plus velpatasvir 100 mg) orally once daily for 12 weeks. The primary outcome was sustained virological response (SVR; determined by chart review between 70 days and 365 days after end of treatment and if unavailable, by study blood draws), and secondary outcomes were treatment initiation, adherence (measured by electronic blister packs), and treatment completion. Analyses were conducted within the modified intention-to-treat (mITT; all who initiated treatment), intention-to-treat (all who were randomised), and per-protocol populations. This trial is registered with ClinicalTrials.gov, NCT02824640.

FINDINGS

Between Sept 15, 2016, and Aug 14, 2018, 1891 individuals were screened and 1136 were excluded (213 declined to participate and 923 did not meet the eligibility criteria). We randomly assigned 755 participants to patient navigation (n=379) or mDOT (n=376). In the mITT sample of participants who were randomised and initiated treatment (n=623), 226 (74% [95% CI 69-79]) of 306 participants in the mDOT group and 236 (76% [69-79]) of 317 in the patient navigation group had an SVR, with no significant difference between the groups (adjusted odds ratio [AOR] 0·97 [95% CI 0·66-1·42]; p=0·35). In the ITT sample (n=755), 226 (60% [95% CI 55-65]) of 376 participants in the mDOT group and 236 (62% [57-67]) of 379 in the patient navigation group had an SVR (AOR 0·92 [0·68-1·25]; p=0·61) and in the per-protocol sample (n=501), 226 (91% [87-94]) of 248 participants in the mDOT group and 235 (93% [89-96]) of 253 in the patient navigation group had an SVR (AOR 0·79 [0·41-1·55]; p=0·44). 306 (81%) of 376 participants in the mDOT group and 317 (84%) of 379 participants in the patient navigation group initiated treatment (AOR 0·86 [0·58-1·26]; p=0·44) and, among those, 251 (82%) participants in the mDOT group and 264 (83%) participants in the patient navigation group completed treatment (AOR 0·90 [0·58-1·39]; p=0·63). Mean daily adherence was higher in the mDOT group (78% [95% CI 75-81]) versus the patient navigation group (73% [70-77]), with a difference of 4·7% ([1·9-7·4]; p=0·0010). 421 serious adverse events were reported (217 in the mDOT group and 204 in the patient navigation group), with the most common being hospital admission (176 in the mDOT group vs 161 in the patient navigation group).

INTERPRETATION

In this trial of active PWID, both models resulted in high SVR. Although adherence was significantly higher in the mDOT group versus the patient navigation group, there was no significant difference in SVR between the groups. Increases in adherence and treatment completion were associated with an increased likelihood of SVR. These results suggest that active PWID can reach high SVRs in diverse settings with either mDOT or patient navigation support.

FUNDING

Patient-Centered Outcomes Research Institute, Gilead Sciences, Quest Diagnostics, Monogram Biosciences, and OraSure Technologies.

POS0011 COMPARISON OF PSYCHOMETRIC PROPERTIES OF FOUR GLOBAL MEASURES OF PRESENTEEISM IN PATIENTS WITH OSTEOARTHRITIS AND INFLAMMATORY ARTHRITIS: A EULAR-PRO STUDY

Background

Work is an important outcome for people with inflammatory arthritis (IA including PsA, RA, AxSpA) and osteoarthritis (OA). It is known that people with IA and OA are at increased risk of sick leave and have to stop working early due to ill health. In addition to being at increased risk of becoming work disabled and increased absenteeism, high levels of presenteeism (i.e. reduced productivity/limited ability to work due to ill health whilst at work) have also been reported. Several instruments exist to measure presenteeism, including single-item global measures and multi-item instruments. In some studies using single-item global instruments may be more feasible. However, available global instruments differ in concept, recall period and reference. It is important to understand which of the measures have good psychometric properties before using them in clinical studies.

Objectives

To assess the psychometric properties of four global presenteeism instruments.

Methods

Patients with IA or OA were recruited via rheumatology outpatient clinics to a large international, longitudinal observational study including 8 European countries and Canada. Participants completed a survey at baseline, 1, 2, 3, 4 wks, 2 months and 3 months. The four global measures of presenteeism included: Work Productivity and Activity Impairment Questionnaire (WPAI), Work Productivity Scale–Rheumatoid Arthritis (WPS-RA), Work Ability Index (WAI) and the Quality*Quantity questionnaire (QQtotal/10) scale. To facilitate score interpretation the WAI and QQtotal were reversed. Pain was measured using an 11-point Likert scale. Spearman correlations were calculated between the presenteeism measures and the Workplace Activity Limitations Scale (WALS), a validated multi-item measure of presenteeism, and HAQ to evaluate construct validity (validity: r <0.50=low; r >0.50-<0.70=moderate; r >0.70=high). Test-retest reliability of the 4 presenteeism scales (baseline-1wk) was measured applying ICC in patients with stable disease (i.e. same pain score at baseline and 1wk) (reliability: ICC<0.40=poor; ICC 0.40-0.75=fair to good; ICC >0.75=excellent). Responsiveness during 3 months was measured comparing patients with improvement in pain score (>1 point improvement in pain score (~MCID pain)) with patients with no change or worsening in pain score. The two groups were compared applying Mann Whitney U test.

Results

This international study included 550 patients with a mean age of 47.8 (SD 9.9) yrs and 61.4% were female. Mean (SD) disease duration since diagnosis was 10.8 (10.4) yrs and 91.2% had IA. Mean (SD) presenteeism scores at baseline were: WPAI=2.9 (2.7); WPS-RA=3.4 (2.7); WAI=2.7 (2.4); and QQtotal=3.1 (3.2). The correlations between the global measures and with WALS and HAQ were moderate to good, except for QQtotal and HAQ which was low (Table 1). In patients with the same stable pain scores at baseline-1wk (n=141) ICC scores were good to excellent, respectively: WPAI (0.771), WPS-RA (0.752), WAI (0.663), and QQtotal (0.650). An improvement in pain during the 3 month study duration was observed in 145/381 (38%) of the patients. In these patients a significant reduction in mean (SD) change presenteeism was observed for all four presenteeism scales compared to those with no change or worsening of the pain score: WPAI (-1.0 (2.37) vs 0.68 (2.40), p<0.01); WPS-RA (-0.76 (2.57) vs 0.43 (2.10), p<0.001); WAI (-0.09 (2.34) vs 0.41 (2.46), p<0.001); QQtotal (-0.57 (3.16) vs 0.79 (3.1), p<0.01).

Table 1.WPAIWPS-RAWAIQQtotalWALSHAQWPAI-0.81640.59920.51840.62690.5592WPS-RA-0.58360.52170.60550.5669WAI-0.58660.52310.5168QQtotal-0.50250.4367

Conclusion

The psychometric properties of all 4 global presenteeism scales were moderate to good, with slightly better scores for both the WPS-RA and WPAI instruments both measuring the impact of OA and IA on productivity.

Disclosure of Interests

Suzanne Verstappen Consultant of: EUOSHA, Grant/research support from: AbbVie, BMS. EULAR, Annelies Boonen Speakers bureau: Abbvie / Galapagos, Consultant of: Galapagos, Sarah Wilkinson: None declared, Dorcas Beaton: None declared, Ailsa Bosworth: None declared, José Canas da Silva: None declared, Gloria Crepaldi: None declared, Sabrina Dadoun: None declared, Cathie Hofstetter: None declared, Carina Mihai Speakers bureau: Boehringer-Ingelheim, Mepha, MED Talks Switzerland, Consultant of: Boehringer-Ingelheim, Janssen, Grant/research support from: Roche, Boehringer-Ingelheim, Sofia Ramiro Consultant of: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, UCB, Sanofi, Grant/research support from: Grant: AbbVie, Galapagos, Novartis, Pfizer, UCB, Garifallia Sakellariou Consultant of: Abbvie, BMS and Galapagos., Grant/research support from: Abbvie, BMS and Galapagos., Sandra Meisalu: None declared, Johan K Wallman Consultant of: AbbVie, Amgen, Celgene, Eli Lilly, Novartis, Grant/research support from: AbbVie, Amgen, Eli Lilly, Novartis, Pfizer., Diane Lacaille: None declared

Chronic postoperative Cutibacterium acnes endophthalmitis with implantable collamer lens

Purpose

We report a case of chronic post-operative endophthalmitis secondary to Cutibacterium acnes (C. acnes) in a patient with an implantable collamer lens (ICL).

Observations

A 45-year-old male presented three months after ICL implantation of the right eye with blurry vision, redness, and ocular pain in the setting of prolonged post-operative anterior chamber (AC) cell. Reduced visual acuity (VA) at 20/30-1, keratic precipitates, 1+ AC cell, and white ICL precipitates were concerning for chronic post-operative endophthalmitis. Anaerobic cultures from a vitreous tap grew C. acnes. Multiple intravitreal and intracameral injections with topical steroids were required to maintain a stable VA at 20/30; however, inflammation persisted and removal of the ICL and his native lens was ultimately required.

Conclusions and importance

Chronic post-operative inflammation and white plaque after ICL implantation should raise high suspicion for endophthalmitis secondary to C. acnes. Anaerobic vitreous cultures can confirm the diagnosis. Removal of the ICL implant is often necessary for treatment. More research is needed to best manage this vision threatening condition.

O03 ST97 Staphylococcus aureus and oxacillin resistance: an emerging challenge for microbiologists?

Background

The presence of cefoxitin and oxacillin resistance in Staphylococcus aureus isolates is suggestive of methicillin resistance (MRSA) with molecular detection of the mecA or mecC genes providing confirmation. The UK SMI and EUCAST guidelines for MRSA detection describe a subset of strains that exhibit reduced susceptibility to oxacillin and cefoxitin, though negative for mecA and mecC genes—frequently named borderline oxacillin-resistant S. aureus (BORSA). Local data noted a number of S. aureus isolates that matched the above phenotype leading to laboratory, clinical and epidemiological questions.

Methods

Routine samples were collected between August 2020 and April 2021 at West Midlands Health Security Agency Laboratory, Birmingham. If provisional results suggested an MRSA isolate, the following confirmatory tests were undertaken. Locally, clinical samples underwent susceptibility testing with cefoxitin disc diffusion and oxacillin gradient diffusion (MRSA screens) or Vitek 2 (non-MRSA screens). Isolates with discrepant results [susceptible to cefoxitin; resistant to oxacillin (MIC >2 mg/L) or vice versa] were sent to the reference laboratory at Colindale, UK for further testing, which included mecA or mecC gene detection by PCR and serotyping with Illumina sequencing for all isolates.

Results

In total, 53 isolates were sent to the reference lab of which 22 were confirmed to have an ST97 serotype. All 53 were negative by PCR for mecA and mecC genes. For the 22 isolates of ST97, local oxacillin MIC values ranged from 2 to 6 mg/L. Cefoxitin susceptibility was confirmed locally in all isolates. The 22 isolates were from 15 patients; wound swabs (n = 18); blood culture (n = 1), sputum (n = 1) and MRSA screen (n = 2). Median patient age was 48 years (IQR 38–59) with 5 being female and 10 male. A history of injecting drug use was documented in 53% (8/15).

Conclusions

BORSA remains a problem from a laboratory, clinical and infection control perspective. This work raises two important questions: what is the most appropriate local laboratory testing pathway and what is the clinical relevance of these isolates (i.e. can flucloxacillin be relied upon in treatment)? The ST97 serotype appears to be associated with skin and soft tissue infection and may be linked to people who inject drugs.

Polarisation-sensitive optical coherence tomography measurement of retardance in fibrosis, a non-invasive biomarker in patients with systemic sclerosis

Polarisation-sensitive optical coherence tomography (PS-OCT) offers a novel, non-invasive method of assessing skin fibrosis in the multisystem disease systemic sclerosis (SSc) by measuring collagen retardance. This study aimed to assess retardance as a biomarker in SSc. Thirty-one patients with SSc and 27 healthy controls (HC) underwent PS-OCT imaging. 'Skin score' was assessed by clinical palpation (0-3 scale). A subset of ten patients and ten age/sex-matched HC had a biopsy and longitudinal imaging. Histological assessment included quantification of epidermal thickness, collagen content (to assess fibrosis) and matrix metalloproteinase (MMP) activity (in situ zymography). PS-OCT images were assessed for epidermal thickness (structure) and fibrosis (retardance). Positive correlation was observed between epidermal thickness as measured by histology and structural PS-OCT (r = 0.79; p < 0.001). Retardance was: HC mean 0.21 (SD 0.21) radian/pixel; SSc skin score 0, 0.30 (0.19); skin score 1, 0.11 (0.16); skin score 2, 0.06 (0.12); skin score 3, 0.36 (0.35). Longitudinal retardance decreased at one-week across groups, increasing at one-month for HC/skin score 0-1; HC biopsy site retardance suggests scarring is akin to fibrosis. Relationships identified between retardance with both biopsy and skin score data indicate that retardance warrants further investigation as a suitable biomarker for SSc-related fibrosis.

Development of polymorphic markers in the immune gene complex loci of cattle

The addition of cattle health and immunity traits to genomic selection indices holds promise to increase individual animal longevity and productivity, and decrease economic losses from disease. However, highly variable genomic loci that contain multiple immune-related genes were poorly assembled in the first iterations of the cattle reference genome assembly and underrepresented during the development of most commercial genotyping platforms. As a consequence, there is a paucity of genetic markers within these loci that may track haplotypes related to disease susceptibility. By using hierarchical assembly of bacterial artificial chromosome inserts spanning 3 of these immune-related gene regions, we were able to assemble multiple full-length haplotypes of the major histocompatibility complex, the leukocyte receptor complex, and the natural killer cell complex. Using these new assemblies and the recently released ARS-UCD1.2 reference, we aligned whole-genome shotgun reads from 125 sequenced Holstein bulls to discover candidate variants for genetic marker development. We selected 124 SNPs, using heuristic and statistical models to develop a custom genotyping panel. In a proof-of-principle study, we used this custom panel to genotype 1,797 Holstein cows exposed to bovine tuberculosis (bTB) that were the subject of a previous GWAS study using the Illumina BovineHD array. Although we did not identify any significant association of bTB phenotypes with these new genetic markers, 2 markers exhibited substantial effects on bTB phenotypic prediction. The models and parameters trained in this study serve as a guide for future marker discovery surveys particularly in previously unassembled regions of the cattle genome.

The evolution of pulmonary function in childhood onset Mucopolysaccharidosis type I

Respiratory outcomes in Mucopolysaccharidosis Type I (MPS I), have mainly focused on upper airway obstruction, with the evolution of the restrictive lung disease being poorly documented. We report the long-term pulmonary function outcomes and examine the potential factors affecting these in 2 cohorts of MPS I patients, those who have undergone Haematopoietic Stem Cell Transplantation (HSCT) and those treated with Enzyme Replacement Therapy (ERT). The results were stratified using the American Thoracic Society (ATS) guidelines. 66 patients, capable of adequately performing testing, were identified by a retrospective case note review, 46 transplanted (45 Hurler, 1 Non-Hurler) and 20 having ERT (17 Non-Hurler and 3 Hurler diagnosed too late for HSCT). 5 patients died; 4 in the ERT group including the 3 Hurler patients. Overall 14% of patients required respiratory support (non-invasive ventilation (NIV) or supplemental oxygen)) at the end of follow up. Median length of follow-up was 12.2 (range = 4.9-32) years post HSCT and 14.34 (range = 3.89-20.4) years on ERT. All patients had restrictive lung disease. Cobb angle and male sex were significantly associated with more severe outcomes in the HSCT cohort, with 49% having severe to very severe disease. In the 17 Non-Hurler ERT treated patients there was no variable predictive of severity of disease with 59% having severe to very severe disease. During the course of follow up 67% of the HSCT cohort had no change or improved pulmonary function as did 52% of the ERT patients. However, direct comparison between therapeutic modalities was not possible. This initial evidence would suggest that a degree of restrictive lung disease is present in all treated paediatrically diagnosed MPS I and is still a significant cause of morbidity, though further stratification incorporating diffusing capacity for carbon monoxide (DLCO) is needed.

Radiological characterisation of graphite components in Advanced Gas-cooled Reactor cores

As the Advanced Gas-cooled Reactors approach the end of generation, research and characterisation are required to support the decommissioning strategy. Radiological data for AGR graphite are negligible and the radiological inventory of the AGR core and other graphite components rely on activation modelling. This is the first study of C-14 activity and its release behaviour in AGR core graphite and its associated carbonaceous deposits and provides valuable information that can support decommissioning activities. In combination with corresponding studies on Magnox core graphite, significant understanding is attained on the main C-14 precursors in the graphite and the deposits. In addition, this study reports C-14, H-3 and gamma spectrometry data on AGR graphite fuel sleeves. This is a waste stream that is currently stored in heavily engineered stores at a significant cost. The data indicate that alternative storage and disposal options with a lower environmental and financial impact are worth considering.

Recovery of an urbanised estuary: Clean-up, de-industrialisation and restoration of redundant dock-basins in the Mersey

For much of the 20th century, the Mersey in North West England was one of the worst polluted estuaries in Europe. Water from a range of polluting industries plus domestic sewage was discharged into the Mersey Catchment and Estuary. Recovery came through a concerted clean-up campaign and tightening environmental regulations, partly driven by European Commission Directives, coupled with de-industrialisation from the 1970s onward. Recovery of oxygen levels in the Estuary led to the return of a productive ecosystem. This led to conservation designations, but also concerns about transfer of pollutants to higher trophic levels in fish, birds and humans. As part of urban renewal, ecosystems in disused dock basins were restored using mussel biofiltration and artificial de-stratification, facilitating commercial redevelopment and creation of a tourist destination. The degradation and recovery of the Mersey from peak-pollution in the mid-20th century is put in the context of wider environmental change and briefly compared to other systems to develop a hysteresis model of degradation and recovery, often to novel ecosystems.

Coronavirus disease 2019 communication: novel sign language system to aid surgical tracheostomy whilst wearing a respirator

BACKGROUND

The coronavirus disease 2019 pandemic has necessitated rapid adaptations to all levels of clinical practice. Recently produced guidelines have suggested additional considerations for tracheostomy and advocated full personal protective equipment, including filtering facepiece code 3 masks. Air seal with filtering facepiece code 3 masks is often challenging, and full-face respirators and powered air-purifying respirators with hoods need to be employed. The infection prevention benefits of this equipment are accompanied by potential issues in communication.

OBJECTIVE

In an attempt to minimise surgical error through miscommunication, the authors sought to introduce a simple sign language system that could be used as an adjunct during surgery.

RESULTS

Following evaluation of pre-existing sign language platforms and consideration of multiple surgical factors, 14 bespoke hand signals were ultimately proposed.

CONCLUSION

Whilst this novel sign language system aims to bridge the communicative gap created by additional personal protective equipment, further development and validation of the proposed tool might be beneficial.

A Randomized Controlled Trial of Video Psychoeducation for Electroconvulsive Therapy in the United States

OBJECTIVE

Electroconvulsive therapy (ECT) is a highly effective psychiatric treatment that remains largely underutilized. Patient psychoeducation about ECT may improve uptake of this treatment.

METHODS

This randomized controlled trial compared two forms of psychoeducation about ECT: video psychoeducation and an informational brochure. In 2019, a national sample of 556 U.S. adults who screened positive for depression were recruited and randomly assigned to receive one of these educational interventions online. Participant perceptions, knowledge, and willingness to receive ECT were assessed before and after psychoeducation.

RESULTS

Both the video psychoeducation and brochure groups showed significantly more positive perceptions and knowledge about ECT following the intervention, with no significant differences between groups. The proportion of participants who reported being willing to receive ECT increased significantly after receipt of psychoeducation (from 31% to 63% in the video psychoeducation group and from 29% to 56% in the brochure group). Female gender, severity of depression, and comorbid mental and substance use disorders were associated with positive changes in ECT perceptions and increased willingness to receive ECT.

CONCLUSIONS

These findings suggest brief psychoeducation for ECT is needed and may improve acceptance of this robust treatment.

ASSOCIATIONS OF ADVERSE CHILDHOOD EXPERIENCES WITH DSM-5 DEPRESSIVE DISORDERS AND SUICIDE ATTEMPT IN OLDER ADULTS

Adverse childhood experiences (ACEs) may have long-term effects on mental health. Using a life-course perspective, this study examines prevalence of ACEs and the associations of ACEs with depressive disorders and suicide attempt in US older adults. The study sample were those aged 65 and older who participated in the 2012-2013 National Epidemiological Survey on Alcohol and Related Conditions Wave III (n=5,806 unweighted). ACEs, the key independent variable, were assessed using validated measures and outcome variables included lifetime and past-year major depressive disorder (MDD) and dysthymia using DSM-5 criteria, and lifetime suicide attempt. We estimated national prevalence of ACEs in older adults and used multivariable-adjusted logistic regression analyses to assess the association between ACEs and the outcomes after adjusting for socio-demographics and clinical co-morbidities. Overall, 34.7% of older adults, representative of 14.3 million older adults nationwide, reported some form of ACEs. The most common type was parental psychopathology (20.8%), followed by neglect (14.8%), and physical/psychological abuse (8.4%) (non-mutually exclusive). Having experienced any ACEs was associated with higher odds of having a past-year MDD diagnosis (adjusted odds ratio [aOR]=1.77; 95% confidence intervals [CI]=1.36, 2.29). Similar results were found for other depressive disorders. ACEs were also associated with higher odds of having a lifetime suicide attempt (aOR=4.34; 95% CI=2.64, 7.14). In conclusion, ACEs may expose older adults to an increased risk for mood disorders and suicide attempts, even over long periods of time as seen in this sample. Reducing ACEs is an important public health goal that may yield long-term benefits.

9 Using what people value to develop new interventions in palliative care: a multilevel level review approach

Introduction

Complex interventions are common in palliative care (PC) but are difficult to evaluate. Complementary therapies (CT) are one type of widely-used complex intervention for which there is inconclusive evidence. No systematic review has been conducted in PC of trials or of qualitative studies of patients’ views of CTs. There are novel approaches with established exemplars of using both types of reviews to help develop more clinically appropriate interventions. These approaches are in their infancy in PC research and have much to offer the specialism.

Aims

Using our on-going review on CT we present as an exemplar in PC an approach to draw together the findings of trials and qualitative studies in a data table (matrix) to contrast what patients value and want with how the intervention is tested.

Methods

We sought trials on the effectiveness of CT and qualitative studies on patients’ perspectives about these therapies. Our primary outcomes for trials included anxiety. Eight databases were searched in 2017. Citations and full-text papers were reviewed to identify relevant studies. Meta-analyses pooled trial data where appropriate and a thematic synthesis is being undertaken to understand patient experience. These findings will be combined in a matrix to explore similarities and differences.

Results

19 trials and five qualitative studies were included. Data analysis and development of the matrix which includes intervention content and patients’ needs is currently underway. We will present the final matrix framework.

Conclusions

Our approach demonstrates a potential way in PC to enhance development of practice appropriate complex interventions.

A qualitative study of the role of Australian general practitioners in the surgical management of obesity

General practitioners (GPs) are increasingly managing patients with class 2 and 3 obesity (body mass index [BMI] > 35 and 40 kg/m² , respectively). Bariatric surgery is considered for patients with class 2 obesity and comorbidities or class 3 obesity where sustained weight loss using non-surgical interventions has not been achieved. In Australia, GPs facilitate access to surgery through referral processes, but the nature of GP involvement in bariatric pre- and post-surgery care is currently unclear. This qualitative study involved 10 in-depth interviews with GPs and 20 interviews with adults who had all undergone laparoscopic adjustable gastric banding (LAGB) for weight management in Tasmania, Australia. Interviews were transcribed and analysed thematically. Referrals for bariatric surgery commonly occurred at the patient's request or to manage comorbidity. Consistent with previous studies, for GPs, referral patterns were influenced by previous case experience and patients' financial considerations. Accessibility of surgery was also a consideration. Post-surgery, there was a lack of clarity about the role of GPs, with patients generally preferring the surgical team to manage the LAGB. In bariatric surgery, patient preference for surgery, access and comorbidity are key drivers for referral and post-surgical monitoring and support. Greater role clarity and enhanced collaboration between surgeons, GPs and patients following surgery is likely to enhance the experience and outcomes for patients.

Fine-mapping host genetic variation underlying outcomes to Mycobacterium bovis infection in dairy cows

BACKGROUND

Susceptibility to Mycobacterium bovis infection in cattle is governed in part by host genetics. However, cattle diagnosed as infected with M. bovis display varying signs of pathology. The variation in host response to infection could represent a continuum since time of exposure or distinct outcomes due to differing pathogen handling. The relationships between host genetics and variation in host response and pathological sequelae following M. bovis infection were explored by genotyping 1966 Holstein-Friesian dairy cows at 538,231 SNPs with three distinct phenotypes. These were: single intradermal cervical comparative tuberculin (SICCT) test positives with visible lesions (VLs), SICCT-positives with undetected visible lesions (NVLs) and matched controls SICCT-negative on multiple occasions.

RESULTS

Regional heritability mapping identified three loci associated with the NVL phenotype on chromosomes 17, 22 and 23, distinct to the region on chromosome 13 associated with the VL phenotype. The region on chromosome 23 was at genome-wide significance and candidate genes overlapping the mapped window included members of the bovine leukocyte antigen class IIb region, a complex known for its role in immunity and disease resistance. Chromosome heritability analysis attributed variance to six and thirteen chromosomes for the VL and NVL phenotypes, respectively, and four of these chromosomes were found to explain a proportion of the phenotypic variation for both the VL and NVL phenotype. By grouping the M. bovis outcomes (VLs and NVLs) variance was attributed to nine chromosomes. When contrasting the two M. bovis infection outcomes (VLs vs NVLs) nine chromosomes were found to harbour heritable variation. Regardless of the case phenotype under investigation, chromosome heritability did not exceed 8% indicating that the genetic control of bTB resistance consists of variants of small to moderate effect situated across many chromosomes of the bovine genome.

CONCLUSIONS

These findings suggest the host genetics of M. bovis infection outcomes is governed by distinct and overlapping genetic variants. Thus, variation in the pathology of M. bovis infected cattle may be partly genetically determined and indicative of different host responses or pathogen handling. There may be at least three distinct outcomes following M. bovis exposure in dairy cattle: resistance to infection, infection resulting in pathology or no detectable pathology.

The support needs of patients waiting for publicly funded bariatric surgery - implications for health service planners

The objective of this study was to investigate the experience of waiting for publicly funded bariatric surgery in an Australian tertiary healthcare setting. Focus groups and individual interviews involving people waiting for or who had undergone publicly funded bariatric surgery were audio-recorded, transcribed and analysed thematically. A total of 11 women and 6 men engaged in one of six focus groups in 2014, and an additional 10 women and 9 men were interviewed in 2015. Mean age was 53 years (range 23-66); mean waiting time was 6 years (range 0-12), and mean time since surgery was 4 years (range 0-11). Waiting was commonly reported as emotionally challenging (e.g. frustrating, depressing, stressful) and often associated with weight gain (despite weight-loss attempts) and deteriorating physical health (e.g. development of new or worsening obesity-related comorbidity or decline in mobility) or psychological health (e.g. development of or worsening depression). Peer support, health and mental health counselling, integrated care and better communication about waitlist position and management (e.g. patient prioritization) were identified support needs. Even if wait times cannot be reduced, better peer and health professional supports, together with better communication from health departments, may improve the experience or outcomes of waiting and confer quality-of-life gains irrespective of weight loss.

Key Points to Facilitate the Adoption of Computer-Based Assessments

There are strong pedagogical arguments in favor of adopting computer-based assessment. The risks of technical failure can be managed and are offset by improvements in cost-effectiveness and quality assurance capability. Academic, administrative, and technical leads at an appropriately senior level within an institution need to be identified, so that they can act as effective advocates. All stakeholder groups need to be represented in undertaking a detailed appraisal of requirements and shortlisting software based on core functionality, summative assessment life cycle needs, external compatibility, security, and usability. Any software that is a candidate for adoption should be trialed under simulated summative conditions, with all stakeholders having a voice in agreeing the optimum solution. Transfer to a new system should be carefully planned and communicated, with a programme of training established to maximize the success of adoption.

N-fixation in legumes--An assessment of the potential threat posed by ozone pollution

The growth, development and functioning of legumes are often significantly affected by exposure to tropospheric ozone (O3) pollution. However, surprisingly little is known about how leguminous Nitrogen (N) fixation responds to ozone, with a scarcity of studies addressing this question in detail. In the last decade, ozone impacts on N-fixation in soybean, cowpea, mung bean, peanut and clover have been shown for concentrations which are now commonly recorded in ambient air or are likely to occur in the near future. We provide a synthesis of the existing literature addressing this issue, and also explore the effects that may occur on an agroecosystem scale by predicting reductions in Trifolium (clovers) root nodule biomass in United Kingdom (UK) pasture based on ozone concentration data for a "high" (2006) and "average" ozone year (2008). Median 8% and 5% reductions in clover root nodule biomass in pasture across the UK were predicted for 2006 and 2008 respectively. Seasonal exposure to elevated ozone, or short-term acute concentrations >100 ppb, are sufficient to reduce N-fixation and/or impact nodulation, in a range of globally-important legumes. However, an increasing global burden of CO2, the use of artificial fertiliser, and reactive N-pollution may partially mitigate impacts of ozone on N-fixation.

Integrated allelic, transcriptional, and phenomic dissection of the cardiac effects of titin truncations in health and disease

The recent discovery of heterozygous human mutations that truncate full-length titin (TTN, an abundant structural, sensory, and signaling filament in muscle) as a common cause of end-stage dilated cardiomyopathy (DCM) promises new prospects for improving heart failure management. However, realization of this opportunity has been hindered by the burden of TTN-truncating variants (TTNtv) in the general population and uncertainty about their consequences in health or disease. To elucidate the effects of TTNtv, we coupled TTN gene sequencing with cardiac phenotyping in 5267 individuals across the spectrum of cardiac physiology and integrated these data with RNA and protein analyses of human heart tissues. We report diversity of TTN isoform expression in the heart, define the relative inclusion of TTN exons in different isoforms (using the TTN transcript annotations available at http://cardiodb.org/titin), and demonstrate that these data, coupled with the position of the TTNtv, provide a robust strategy to discriminate pathogenic from benign TTNtv. We show that TTNtv is the most common genetic cause of DCM in ambulant patients in the community, identify clinically important manifestations of TTNtv-positive DCM, and define the penetrance and outcomes of TTNtv in the general population. By integrating genetic, transcriptome, and protein analyses, we provide evidence for a length-dependent mechanism of disease. These data inform diagnostic criteria and management strategies for TTNtv-positive DCM patients and for TTNtv that are identified as incidental findings.

Diffusion-weighted imaging and magnetic resonance proton spectroscopy following preterm birth

AIM

To study the associations between magnetic resonance proton spectroscopy (MRS) data and apparent diffusion coefficients (ADC) from the preterm brain with developmental outcome at 18 months corrected age and clinical variables.

MATERIALS AND METHODS

A prospective observational cohort study of 67 infants born before 35 weeks gestational age who received both magnetic resonance imaging of the brain between 37 and 44 weeks corrected gestational age and developmental assessment around 18 months corrected age.

RESULTS

No relationships were found between ADC values and MRS results or outcome. MRS ratios involving N-acetyl aspartate (NAA) from the posterior white matter were associated with "severe" and "moderate to severe" difficulties, and fine motor scores were significantly lower in participants with a visible lactate doublet in the posterior white matter. The presence of a patent ductus arteriosus (PDA) was the only clinical factor related to NAA ratios.

CONCLUSION

Altered NAA levels in the posterior white matter may reflect subtle white matter injury associated with neuro-developmental difficulties, which may be related to a PDA. Further work is needed to assess the longer-term neuro-developmental implications of these findings, and to study the effect of PDAs on developmental outcome in later childhood/adolescence.

Highlighting the threat from current and near-future ozone pollution to clover in pasture

Globally, the legume-rhizobia symbiosis, contained within specialised organs called root nodules, is thought to add at least 30 Tg N annually to agricultural land. The growth and functioning of a modern white clover (Trifolium repens cv. Crusader) and red clover (T. pratense cv. Merviot) cultivar were investigated in current and future ozone scenarios in solardomes. Both cultivars developed leaf injury and had significant reductions in root biomass and root nodule number in response to ozone, with Crusader also displaying a reduced size and mass of nodules. In-situ measurements of N-fixation in Crusader by acetylene reduction assay revealed reduced N-fixation rates in a future scenario with an increased background and moderate peaks of ozone. The implications for the sustainability of temperate pasture are discussed.