Estimating the Rates of Undiagnosed Prediabetes and Diabetes Among People Experiencing Homelessness

OBJECTIVES

The rising prevalence of type 2 diabetes (T2D) in Canada poses a significant health challenge. Despite the convenience of screening for diabetes with glycated hemoglobin concentration, people experiencing homelessness (PEH) often face barriers to accessing diabetes screening, potentially leading to underdiagnosis. In this study, we aim to assess the prevalence of undiagnosed diabetes among PEH in Calgary, Alberta, and contribute insights for planning healthcare services and public health initiatives.

METHODS

Four screening clinics were held, and participants were recruited through posters and word of mouth. Participants underwent point-of-care glycated hemoglobin (A1C) testing using the Siemens DCA Vantage point-of-care analyzer. Descriptive statistics were used to identify the proportions of prediabetes and diabetes, whereas CanRisk survey scores were used to identify the pre-test probability of diabetes.

RESULTS

The mean age of participants (n=102) was 47.6 years, and the self-reported causes of homelessness among the participants were diverse, including: housing and financial issues (n=53), interpersonal and family issues (n=35), and health or corrections-related factors (n=27). The average A1C was 5.60% (standard deviation 0.57%), with 5 values in the diabetes range and 12 in the prediabetes range, for a total of 17 participants found to have previously undiagnosed dysglycemia.

CONCLUSIONS

The high rate of undiagnosed prediabetes and diabetes among people experiencing homelessness reflects at least what is already seen in the general population in Canada. More resources are required to reduce the barriers to screening for diabetes among this population.

Utilizing Nurse Practitioners and Physician Assistants in Academic Emergency Departments Does Not Reduce Residents' Exposure to More Complex Patients

BACKGROUND

Whether integration of nurse practitioners (NPs) and physician assistants (PAs) into academic emergency departments (EDs) affects emergency medicine (EM) resident clinical learning opportunities is unclear.

OBJECTIVE

We sought to compare EM resident exposure to more-complex patients, as well as patients undergoing Accreditation Council for Graduate Medical Education (ACGME)-required procedures, at nonpediatric academic EDs with lower, moderate, and higher levels of NP/PA utilization.

METHODS

In this cross-sectional study of National Hospital Ambulatory Medical Care Survey (NHAMCS) data for 2016-2020, nonpediatric academic EDs were classified into the following three groups based on the percentage of patients seen by an NP or PA: lower (≤ 10%), moderate (10.1-30%), and higher (> 30%) NP/PA utilization. The proportion of EM resident-seen patients meeting previously established complex patient criteria was then determined for EDs at each level of NP/PA utilization. The proportion of EM resident-seen patients receiving certain ACGME-required procedures was also determined. Survey analytic procedures and weighting as recommended by NHAMCS were used to calculate and compare proportions using 95% CIs.

RESULTS

The weighted 2016-2020 NHAMCS data sets represent 44,130,996 adult resident-seen patients presenting to nonpediatric academic EDs. The proportion of resident-seen patients meeting complex patient criteria did not significantly differ for lower (43.2%; 95% CI 30.6-56.8%), moderate (41.7%; 95% CI 33.0-50.9%), or higher (38.9%; 95% CI 29.3-49.4%) NP/PA utilization EDs. The proportion of patients undergoing an ACGME-required procedure also did not significantly differ across level of NP/PA utilization.

CONCLUSIONS

Higher levels of NP/PA utilization in nonpediatric academic EDs do not appear to reduce EM resident exposure to more-complex patients or ACGME-required procedures.

"I'll meet you at our bench": adaptation, innovation and resilience among VCSE organisations who supported marginalised and minoritised communities during the Covid-19 pandemic in Northern England - a qualitative focus group study

BACKGROUND

The Covid-19 pandemic has exacerbated pre-existing inequalities and increased adversity and challenges for vulnerable and marginalised communities worldwide. In the UK, the Voluntary Community and Social Enterprise (VCSE) sector play a vital role in supporting the health and wellbeing of people who are marginalised or experiencing multiple complex needs. However, only a small number of studies have focused on the impact that Covid-19 had on the VCSE sector.

METHODS

As part of a Health Inequalities Impact Assessment (HIIA), we conducted qualitative focus groups with staff and volunteers from five organisations to examine short, medium and longer-term impacts of Covid-19 upon the VCSE sector in Northern England. Nine online focus groups were conducted between March and July 2021.

FINDINGS

Focus group transcripts were analysed using Framework Analysis and yielded three central themes: (1) exacerbation of pre-existing inequalities, adversity and challenges for vulnerable and marginalised populations; (2) the 'price' of being flexible, innovative and agile for VCSE staff and volunteers; and (3) the voluntary sector as a 'lifeline' - organisational pride and resilience.

CONCLUSIONS

While the voluntary sector 'adapted at pace' to provide support during Covid-19 and in its continued aftermath, this resilience has potentially come at the cost of workforce and volunteer wellbeing, compounded by political obstacles and chronic shortage in funding and support. The VCSE sector has a vital role to play in the post-lockdown 'levelling up' agenda. The expertise, capacity and resilience of VCSE organisations, and their ability to respond to Covid-19, should be celebrated, recognised and supported adequately to maintain its resilience. To not do so threatens the sector's sustainability and risks jeopardising attempts to involve the sector in addressing the social determinants of health.

Receiving threatening or obscene messages from a partner and mental health, self-harm and suicidality: results from the Adult Psychiatric Morbidity Survey

PURPOSE

Threatening or obscene messaging is repeated, unwanted texts, emails, letters or cards experienced by the recipient as threatening or obscene, and causing fear, alarm or distress. It is rarely examined as an aspect of intimate partner violence. We describe the prevalence of exposure to threatening/obscene messaging from a current or ex-partner; characteristics of victims; and associations with other forms of violence and abuse, mental disorder, self-harm, and suicidality.

METHODS

Cross-sectional probability-sample survey of the general population in England aged 16 + . Multivariable regression modelling tested associations between receipt of threatening/obscene messaging and current common mental disorder, past-year self-harm and suicidality.

RESULTS

Threatening/obscene messages were received from a current/ex-partner by 6.6% (95%CI: 5.9-7.3) of adults who had been in a relationship; 1.7% received these in the past year. Victims were more likely to be female, under 35, single or divorced, socioeconomically disadvantaged, and to have experienced other forms of sexual and partner violence and abuse. Those who received threatening/obscene messages in the past year were more likely to experience common mental disorder (adjusted odds ratio 1.89; 1.01-3.55), self-harm (2.31; 1.00-5.33), and suicidal thoughts (2.00; 1.06-3.78).

CONCLUSION

Threatening/obscene messaging commonly occurs in the context of intimate partner violence. While often occurring alongside sexual and physical violence, messaging has an additional association with mental disorder and suicidality. Routine enquiry in service settings concerning safety, including those working with people who have escaped domestic violence, should ask about ongoing contact from previous as well as current partners. This should include asking about messaging, as well as other forms of potentially technology-enabled abuse which may become increasingly common.

Patient Perspectives on a Tailored Self-Management Education and Support Intervention for Low-Income Seniors With Chronic Health Conditions

Background

The Assessing Outcomes of Enhanced Chronic Disease Care Through Patient Education and a Value-based Formulary Study (ACCESS) was a 2 x 2 factorial randomized trial that tested the impact of a tailored self-management education support (SMES) program, which demonstrated a 22% reduction in adverse clinical events. We sought to qualitatively explore participants' perspectives on the SMES intervention, and the ways in which it may have improved self-management skills.

Methods

We used a qualitative descriptive approach and conducted individual semistructured interviews. We conducted inductive and deductive thematic analysis using NVivo 12 (QSR International, Burlington, MA).

Results

We interviewed 20 participants who had recently completed the 3-year SMES intervention. The following 3 main themes emerged from the data: (i) empowerment; (ii) intervention acceptability; and (iii) suggestions for improvement. Regarding empowerment, we identified subthemes of health literacy, self-efficacy, self-management, and active role in health. Several participants reported that empowerment promoted health behaviour change or improved confidence in self-management. Regarding acceptability, we identified subthemes of ease of use and presentation style. Most participants expressed positive feelings toward the intervention and felt that it was easy to understand. Finally, we identified subthemes of learning style, content, and engagement strategies, within the theme of suggestions for improvement. Some participants said that the messages were too general and did not fully address the complex health concerns they had.

Conclusions

Our results highlighted key strategies to promote patient engagement and self-management behaviours and demonstrated how they may have been used to improve clinical endpoints. Additionally, we demonstrated the novel use of marketing principles in SMES interventions.

Critically examining health complexity experienced by urban Indigenous peoples in Canada by exploring the factors that allow health complexity to persist: a qualitative study of Indigenous patients in Calgary, Alberta

OBJECTIVES

This study aims to identify and critically examine the components of health complexity, and explore the factors that allow it to exist, among urban Indigenous peoples in Canada.

DESIGN

Qualitative exploration with relational conversations.

SETTING

Calgary, Alberta, Canada.

PARTICIPANTS

A total of nine urban Indigenous patients were recruited from a multidisciplinary primary healthcare clinic that serves First Nations, Métis and Inuit peoples. Recruitment and data collection took place between September and November 2021.

RESULTS

Thematic analysis revealed three main themes, namely: sources of health complexity, psychological responses to adversity, and resilience, strengths, and protective factors. Key sources of health complexity arose from material resource disparities and adverse interpersonal interactions within the healthcare environment, which manifest into psychological distress while strengths and resilience emerged as protective factors.

CONCLUSION

The healthcare system remains inapt to address complexity among urban Indigenous peoples in Canada. Healthcare violence experienced by Indigenous peoples only further perpetuates health complexity. Future clinical tools to collect information about health complexity among urban Indigenous patients should include questions about the factors defined in this study.

Evidencing general acceptability of open-label placebo use for tackling overtreatment in primary care: a mixed methods study

BACKGROUND

Overtreatment poses a challenge to healthcare systems due to harmful consequences of avoidable side-effects and costs. This study presents the first account for examining the feasibility of placebo use for reducing overtreatment in primary care, including whether public attitudes support the use of different placebo types in place of inappropriate prescriptions of antibiotics, antidepressants, or analgesics.

METHODS

We used a multi-study, mixed-methods design, including patient and public (PPI) consultations, focus groups (Study 1) and two pre-registered online experiments (Studies 2 and 3).

RESULTS

Study 1 (N = 16) explored everyday conceptions and practicalities of potential placebo use in the context of respiratory infections. Findings highlighted the importance of trusting doctor-patient relationships and safety-netting. Study 2 employed a randomised experiment with a representative UK sample (N = 980), investigating attitudes towards 5 different treatment options for respiratory infections: (1) blinded + pure placebo, (2) open-label + pure placebo, (3) open-label + impure placebo, (4) antibiotic treatment, and (5) no treatment. Study 2 also examined how attitudes varied based on wording and individual differences. Findings indicated general support (ηp2 = .149, large effect size) for replacing inappropriate antibiotics with open-label + impure placebos, although personal placebo acceptability was lower. Also, older people, individuals suffering from chronic illness or those showing higher levels of health anxiety appeared less amenable to placebo use. Study 3 (N = 1177) compared attitudes towards treatment options across three clinical scenarios: respiratory infection, depression and pain. Findings suggested significant differences in the acceptability of placebo options based on the clinical context. In the infection scenario, options for open-label + pure placebos, open-label + impure placebos and no treatment were rated significantly more acceptable (ηp2 = .116, medium effect size) compared to the depression and pain scenarios. Again, general support for placebos was higher than placebo acceptability for personal use.

CONCLUSIONS

Findings from PPI and three studies indicate general support for combatting overprescribing in primary care through clinical placebo use. This is an indicator for wider UK public support for a novel, behavioural strategy to target a long-standing healthcare challenge. General acceptability appears to be highest for the use of open-label + impure placebos in the context of antibiotic overprescribing.

Applying National Diabetic Care Standards for the Management of a Hispanic Population Attending a Free Clinic

BACKGROUND

National quality measures set goals for diabetes management. Hispanic populations are higher risk for diabetes and associated complications, especially low-income communities. Research suggests free clinics provide suboptimal diabetes management. Our quality improvement project aims to improve diabetes management in the Hispanic free clinic population.

METHODS

Clínica Latina's volunteer medical students and physicians serve predominantly uninsured Spanish-speaking patients. Established diabetes patients that attended clinic during the study were included. Data was collected regarding patients' diabetes care for two months, then analyzed compared to quality metrics. We implemented paper checklists and electronic medical record (EMR) smart phrases for volunteers to utilize in managing diabetes.

RESULTS

32 patients were included in the study. At baseline, 78% had an A1C check in the past 3 months, 81% were on a statin. In the past year, 81% had a lipid panel, 19% had an eye exam, 63% had a diabetic foot exam, 53% had a urine microalbumin-creatinine screening. After interventions, 97% had an A1C check, 93% were on a statin, 91% had a lipid panel, 31% had an eye exam, 75% had a foot exam, 63% had a urine microalbumin-creatinine. Patients with an LDL < 100 increased from 62 to 66%. The mean A1C did not statistically significantly change. Volunteer smart phrase utilization increased from 37 to 59.1%.

CONCLUSION

We implemented a checklist and EMR smart phrase to optimize diabetes management in a student-run Hispanic free clinic, which improved quality metrics. Low-resource clinics serving Spanish-speaking populations may benefit from similar interventions to improve diabetic care.

The community engagement course and action network: strengthening community and academic research partnerships to advance health equity

Background

Historically Black Colleges and Universities and Minority Serving Institutions are uniquely positioned to implement community-campus research partnerships based on a history of service, the pursuit of community trustworthiness and student demographics often similar to surrounding marginalized communities. The Morehouse School of Medicine Prevention Research Center collaborates with members of Historically Black Colleges and Universities, Minority Serving Institutes, and community organizations on the Community Engaged Course and Action Network. This network is the first of its kind and aims to strengthen members' ability to implement Community-Based Participatory Research (CBPR) principles and partnerships. Projects address public health priorities including mental health among communities of color, zoonotic disease prevention, and urban food deserts.

Materials and methods

To assess the effectiveness of the network, a Participatory Evaluation framework was implemented to conduct process evaluation which included review of partnership structures, operations, project implementation processes, and preliminary outcomes of the research collaborations. A focus group of Community Engagement Course and Action Network members (community and academic) was also conducted to identify benefits and challenges of the network with emphasis on key areas for improvement to further enhance the relationships between partners and to facilitate their subsequent community-campus research.

Results

Network improvements were tied to themes strengthening community-academic partnerships including sharing and fellowship, coalition building and collaboration, and greater connections and awareness of community needs through their current community-academic partnerships. The need to conduct ongoing evaluation during and after implementation, for determining the early adoption of CBPR approaches was also identified.

Conclusion

Evaluation of the network's processes, infrastructure, and operation provides early lessons learned to strengthen the network. Ongoing assessment is also essential for ensuring continuous quality improvement across partnerships such as determining CBPR fidelity, assessing partnership synergy, and dynamics, and for quality improvement of research protocol. The implications and potential for advancing implementation science through this and similar networks are great towards advancing leadership in modeling how foundations in community service can advance to CBPR partnership formation and ultimately, health equity approaches, that are local defined and assessed.

'How I'm feeling today, I probably won't be feeling tomorrow'. Using I-Poems to explore young people's changing emotions during the Covid-19 pandemic - A qualitative, longitudinal study

Background

Relatively little published qualitative research has explored children and young people's (CYP) prolonged or longitudinal experiences of the pandemic, and their emotional responses to such unreserved change to everyday life. As part of a broader, qualitative longitudinal study, this paper explores change and continuity in young people's emotions over time during the Covid-19 pandemic in North East England.

Methods

I-Poems were curated for each of the 26 young people in this study from serial interview transcripts and diary entries, collected over the course of 16 months. Creation of I-Poems require researchers to focus on sentences made by the interviewee that include the word "I," and without changing the order of those sentences, to present them in poetic stanzas.

Findings

Young people's voices and experiences became more poignant and powerful when their 'I' narrative was centralised, silencing the presence of the researcher. Further, presenting the data in this way allowed us to see how the following emotions shifted over time: grief, sadness, frustration, anger, anxiety, joy, pleasure, excitement. We contend that young people experienced significant rupture and change over the course of our 16 month project, with both positive and negative repercussions for their emotional wellbeing.

Conclusions

Large scale (quantitative and qualitative) studies remain much needed to focus on the long-term impacts of the pandemic on young people's social, emotional and cultural lives. Longitudinal and creative qualitative approaches (such as I-Poems) have the potential to centralise participant voice, break down power dynamics, and allow exploration of shifting experiences and emotions over time.

The role of hospital antimicrobial and infectious diseases pharmacists in the UK: a theoretically underpinned exploration

Objectives

We sought to characterise the role of hospital infection pharmacists in the UK and to understand the core challenges being faced, future role development desires and the required support to address these.

Methods

We developed a questionnaire underpinned by the theoretical domains framework exploring the barriers and enablers to pharmacists fulfilling their perceived roles and responsibilities. Any pharmacist whose role included 'specialist antimicrobial' or 'infectious diseases' was invited to complete a questionnaire sent via national infection and pharmacy groups/networks. Descriptive statistics were used to report responses to each item, and a content analysis was undertaken to summarize the key messages from an extended response option.

Results

Of the 102 respondents, 91 (89.2%) were from English hospitals. Fifty-three (52%) were from district general hospitals and 45 (45.1%) from teaching hospitals. Most (97, 95%) respondents were of a senior grade. The need for a comprehensive educational programme, recognition of research as core to the role and integration with infection/microbiology departments were key requirements along with protected time to engage with the activities. Highlights of the role were opportunities to teach, making a significant contribution to patient care and scope to contribute to strategy and vision. The COVID-19 pandemic negatively impacted on respondents' capacity to undertake their perceived roles and responsibilities.

Conclusions

Our study delineates the need for UK infection and pharmacy policy makers to review hospital infection pharmacist developmental pathways and roles. Joint learning, and closer working, with infection/microbiology departments may be an efficient strategy to address the issues raised.

COVID-19 Vaccination Rates and Vaccine Hesitancy Among Spanish-Speaking Free Clinic Patients

We sought to assess COVID-19 vaccination rates, as well as attitudes and beliefs towards the vaccine, of patients in a Spanish-speaking student-run free clinic in Columbus, Ohio. A cross-sectional study was performed. Surveys were distributed to all individuals over 18 years who presented to La Clínica Latina between July, 2022 and September, 2022. A convenience sample was used: patients in the waiting room and their accompanying family members or friends were invited to participate. Subjects were excluded if under the age of 18 or over the age of 75, or if non-Spanish speaking. Of the 158 individuals who agreed to participate in our study, 146 responded to the question regarding vaccination status, revealing 90.4% of respondents had received a COVID-19 vaccination. Most respondents learned about the vaccine from social media (26.4%) or television (22.7%). The majority of participants sought answers to questions surrounding the vaccine by asking their doctor (49.1%). The most common reason among unvaccinated participants for not undergoing vaccination was fear of an adverse reaction to the vaccine (n = 11). We found that a large proportion (90.4%) of individuals seeking care at a Spanish-speaking free clinic were vaccinated against COVID-19. Our study also provides perspective on the means of health knowledge acquisition and behaviors in this predominantly Latinx patient population in central Ohio. We can utilize our results to optimize and tailor clinic services and initiatives for COVID-19 boosters to meet the needs of this community.

Letter to the Editor Regarding: Evolving Business Models in Orthotics by Schneider, N

The purpose of this letter is to continue the dialogue regarding the paper "Evolving business models in Orthotics" in the Canadian Prosthetics & Orthotics Journal Volume 4, Issue2, No.3, 2021. In it we present the perspective of the current Alberta Association of Orthotists and Prosthetists (AAOP) and provide additional context and information on historical events. Finally, we provide additional clarity on how costing is approached in the Province of Alberta (Canada) and the purported inequity in compensation between the two disciplines.

A good investment: longer-term cost savings of sensitive parenting in childhood

Introduction

Good quality parenting in early childhood is reliably associated with positive mental and physical health over the lifespan.

Objectives

The hypothesis that early parenting quality has significant long-term financial benefits has not been previously tested.

Methods

Design: Longitudinal study with follow-up from 2012 to 2016; UK multicentre study cohort. Participants: 174 young people drawn from 2 samples, one at moderate risk of poor outcomes and one at high risk, assessed aged 4–6 years then followed up in early adolescence (mean age 12.1 years). Measures: The primary outcome was total costs: health, social care, extra school support, out-of-home placements and family-born expenditure, determined through semistructured economic interviews. Early parenting quality was independently assessed through direct observation of parent–child interaction.

Results

Costs were lower for youths exposed to more sensitive parenting (most sensitive quartile mean £1,619, least sensitive quartile mean £21,763; p < .001). Costs were spread across personal family expenditure and education, health, social and justice services. The cost difference remained significant after controlling for several potential confounders. These included demographic variables (family poverty, parental education); exposure to child abuse; and child/young person variables including level of antisocial behaviour in both childhood and adolescence, IQ and attachment security.

Conclusions

This study is the first showing that more sensitive early parental care predicts lower costs to society many years later, independent of poverty, child and youth antisocial behaviour levels and IQ. The findings provide novel evidence for the public health impact of early caregiving quality and likely financial benefits of improving it.

Disclosure

No significant relationships.

Language used to describe medication review activities: does it require standardisation? A narrative synthesis

Introduction

Medication review (MR) is a health care professional’s systematic assessment of a patient’s medications with recommendations for improvement (1). To enable comparison between different evaluations of medication review-based interventions to determine whether the nature of activity differs, it is important that standardised language is used. Currently, there is no accepted international taxonomy for describing medication review activities. Therefore, we undertook a systematic review of literature with narrative synthesis to determine whether standardisation may be appropriate.

Aim

To determine the range of terms used to describe medication review activities.

Method

A PROSPERO registered systematic review (CRD 42020215992) was performed using search terms according to the Population, Intervention, Comparison and Outcome (PICO) framework. ‘Population’ & ‘Comparison’ were not used. Synonyms for medication review activities were used for both ‘Intervention’ and ‘Outcomes’, e.g., stop, start, change, alter. We included all papers reporting medication review activities in English with empirical data. Papers not using language to describe medication review activities were excluded. Two researchers reviewed all titles, abstracts, and full-text papers independently; discussion resolved any disagreement. Data extraction was carried out independently as per Cochrane Effective Practice and Organisation of Care (EPOC) as follows:

The papers were assessed using the Mixed Method Appraisal Tool (MMAT). The research team themed the extracted terms.

Results

After deleting duplicates, 9746 titles were screened. Twenty-one studies were included: eight quantitative non-randomised trials, eight randomised controlled trials, and five quantitative descriptive studies. The studies covered the UK, Netherlands, Australia, Sweden, Norway, Belgium, Canada, and Jordan. The table summarises the medication review activities reported in these papers.

Conclusion

Various authors reported medication review activities. ‘Alter’ and ‘adaptation’ are examples of ambiguous terms. Determining whether actions are related with activities to reduce or increase doses is difficult due to such terminology. As a result, comparing medication review approaches may be difficult. Limiting the search strategy to English-language only may have missed some studies. A taxonomy to describe and define medication review activities, thereby standardising MR reporting, should improve the presentation of data from process evaluations and the ability to compare activity between studies.

Reference

(1) Christensen M, Lundh A. Medication review in hospitalised patients to reduce morbidity and mortality. Cochrane Database Syst Rev [Internet]. 2016 Feb 20; Available from: https://doi.wiley.com/10.1002/14651858.CD008986.pub3

Healthy food prescription incentive programme for adults with type 2 diabetes who are experiencing food insecurity: protocol for a randomised controlled trial, modelling and implementation studies

INTRODUCTION

The high cost of many healthy foods poses a challenge to maintaining optimal blood glucose levels for adults with type 2 diabetes mellitus who are experiencing food insecurity, leading to diabetes complications and excess acute care usage and costs. Healthy food prescription programmes may reduce food insecurity and support patients to improve their diet quality, prevent diabetes complications and avoid acute care use. We will use a type 2 hybrid-effectiveness design to examine the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of a healthy food prescription incentive programme for adults experiencing food insecurity and persistent hyperglycaemia. A randomised controlled trial (RCT) will investigate programme effectiveness via impact on glycosylated haemoglobin (primary outcome), food insecurity, diet quality and other clinical and patient-reported outcomes. A modelling study will estimate longer-term programme effectiveness in reducing diabetes-related complications, resource use and costs. An implementation study will examine all RE-AIM domains to understand determinants of effective implementation and reasons behind programme successes and failures.

METHODS AND ANALYSIS

594 adults who are experiencing food insecurity and persistent hyperglycaemia will be randomised to a healthy food prescription incentive (n=297) or a healthy food prescription comparison group (n=297). Both groups will receive a healthy food prescription. The incentive group will additionally receive a weekly incentive (CDN$10.50/household member) to purchase healthy foods in supermarkets for 6 months. Outcomes will be assessed at baseline and follow-up (6 months) in the RCT and analysed using mixed-effects regression. Longer-term outcomes will be modelled using the UK Prospective Diabetes Study outcomes simulation model-2. Implementation processes and outcomes will be continuously measured via quantitative and qualitative data.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Calgary and the University of Alberta. Findings will be disseminated through reports, lay summaries, policy briefs, academic publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04725630.

PROTOCOL VERSION

Version 1.1; February 2022.

Exploring young people's perspectives of inequalities in health: a qualitative study

Background

Reducing inequalities in health is an enduring global public health challenge. Worryingly in England, inequalities across some groups and places are worsening, highlighted and exacerbated by the Covid-19 pandemic. While there has been growing interest in exploring public understandings of health inequalities, few studies have explored the views of young people. Our study seeks to redress this by exploring young people's perspectives of inequalities in health.

Methods

Working with existing youth organisations, we recruited young people (aged 13-21) from six youth groups in areas of high deprivation across three geographical locations in England. Each group took part in three interlinked focus groups (n = 18), the majority of which were run online using video conferencing platforms. Focus groups were co-delivered with partnering youth organisations during 2021. They involved participatory concept mapping activities, and the discussion of health related news articles.

Results

Key themes emerged around young people's perspectives of: i) factors influencing health within their local area; ii) understandings of inequalities in health; and iii) key messages to convey to those with a role in addressing health inequalities at a place level.

Conclusions

Our study highlights the importance of exploring and understanding young people's perspectives of inequalities in order to better shape policies which are supported by the communities and people they impact.

Key messages

Young people have a nuanced, experiential understanding of key factors influencing their health and inequalities in health within their local areas. Building upon young people’s understandings of inequalities in health provides opportunities to mobilise support for policies seeking to change the distribution of key social determinants.

A Subsidized Healthy Food Prescription Program for Adults With Type 2 Diabetes Who Are Experiencing Food Insecurity: Protocol for a Randomized Controlled Trial

Objectives

It is vital for individuals with type 2 diabetes (T2DM) to adhere to a healthy dietary pattern to maintain optimal blood glucose levels and overall health. Increasing costs of healthy foods, however, are a barrier to maintaining healthful dietary patterns, particularly for individuals with T2DM who are experiencing food insecurity. Poor diet quality may result in difficulties maintaining optimal blood glucose levels, leading to higher rates of diabetes complications, and increased acute care usage and costs. Although the adverse impacts of food insecurity on maintaining optimal blood glucose levels are well documented, effective strategies to this among individuals with T2DM are lacking. One approach is providing subsidies to purchase healthy foods through subsidized healthy food prescription programs. These programs may help reduce food insecurity and improve diet quality, thereby improving blood glucose levels and reducing diabetes complications over time.

Methods

A parallel group randomized controlled trial will examine the effectiveness of a subsidized healthy food prescription program compared to a healthy food prescription alone in improving average blood glucose levels (primary outcome), and other secondary outcomes among 404 adults who are experiencing food insecurity and persistent hyperglycemia. The subsidized healthy food prescription program consists of two core elements: 1) A one-time healthy food prescription pamphlet that outlines an evidence-based healthy dietary pattern; 2) A healthy food subsidy of $1.50/day/household member to purchase healthy foods in participating supermarkets for 6 months. At baseline and 6-month follow-up, participants will provide responses to sociodemographic and health-related items, and a variety of patient-reported outcomes. Biochemical and physical measurements will also be obtained.

Results

The study's theory of change posits that reducing food insecurity and improving diet quality will be key mediators in improving blood glucose levels, which may reduce diabetes complications, and healthcare usage and costs over time.

Conclusions

The results of this study will demonstrate if a subsidized healthy food prescription program results in meaningful changes in average blood glucose levels and other clinically relevant outcomes.

Funding Sources

Alberta Innovates, Alberta Health Services.

'Well-leg' compartment syndrome associated with gynaecological surgery: a perioperative risk-reduction protocol and checklist

'Well-leg' compartment syndrome (WLCS) is an uncommon, but potentially devastating, complication associated with prolonged patient positioning for abdomino-pelvic surgery. Gynaecologists, anaesthetists and the wider theatre team share a responsibility to minimise the risk of this highly morbid, and even fatal, postoperative complication. This article provides an overview of WLCS related to gynaecological surgery - raising awareness amongst gynaecologists and highlighting the time-critical nature of diagnosis and management. Given the potential litiginous nature of this complication, we also present a perioperative checklist and risk-reduction protocol to suggest a standardised approach to prevention and relevant documentation. TWEETABLE ABSTRACT: Gynaecologists share a responsibility to minimise the risk of postoperative 'well-leg' compartment syndrome.

Vulvar Aphthous Ulcer in an Adolescent With COVID-19

BACKGROUND

Vulvar aphthous ulcers have been associated with various prodromal viral illnesses. We describe the case of an adolescent girl who developed vulvar aphthous ulcers during infection with Coronavirus, SARS-CoV-2.

CASE

A 19-year-old girl presented to the emergency department with cough, sore throat, fevers, and rash, and tested positive for COVID-19. She re-presented 2 days later with vulvar pain and was found to have a vulvar aphthous ulcer. She was admitted for pain control and treated with oral steroids. Improvement in her vulvar pain was noted, along with resolution of fevers, cough, and rash.

SUMMARY AND CONCLUSION

This case illustrates the novel association of COVID-19 with vulvar aphthous ulcers in adolescents. Use of oral steroids for symptomatic management of COVID-19 led to rapid clinical improvement.

6 Improving Patient Flow in a Multi-Specialty Assessment Area by Introducing Referral Pathways for Orthopaedics and Plastic Surgery during the COVID-19 Pandemic

Introduction

The COVID-19 pandemic has seen fundamental organisational changes to emergency departments internationally. Specialties throughout the hospital setting have been asked to change their working practice, often with the aim of adapting to new processes in emergency departments. Early in the pandemic, the orthopaedic team at one district general hospital were required to provide 24/7 onsite cover in a multi-specialty area. Confusion over the referral pathways of two specialties (orthopaedics and plastic surgery) led to increase waiting times, constrained patient flow and poor patient and staff satisfaction.

Method

This quality improvement project occurred over three cycles of data collection and intervention over a two-month period. A novel referral pathway was developed and implemented after discussion with consultants in orthopaedics, plastics, and emergency medicine. Interventions included staff teaching, clarifying of roles at morning meetings and the deployment of posters.

Results

In cycle 1, 39% of orthopaedic referrals were inappropriately referred. By cycle 3, 0% of orthopaedic patients were inappropriately referred. Average time in department for patients referred to orthopaedics improved from 124 minutes to 88 minutes. Staff reported increased satisfaction, with appreciation for the clarification on referral criteria.

Conclusions

This QUIP demonstrates how simple interventions during times of crisis can solve complex organisational issues.

Functional mutants of Azospirillum brasilense elicit beneficial physiological and metabolic responses in Zea mays contributing to increased host iron assimilation

Iron (Fe), an essential element for plant growth, is abundant in soil but with low bioavailability. Thus, plants developed specialized mechanisms to sequester the element. Beneficial microbes have recently become a favored method to promote plant growth through increased uptake of essential micronutrients, like Fe, yet little is known of their mechanisms of action. Functional mutants of the epiphytic bacterium Azospirillum brasilense, a prolific grass-root colonizer, were used to examine mechanisms for promoting iron uptake in Zea mays. Mutants included HM053, FP10, and ipdC, which have varying capacities for biological nitrogen fixation and production of the plant hormone auxin. Using radioactive iron-59 tracing and inductively coupled plasma mass spectrometry, we documented significant differences in host uptake of Fe2+/3+ correlating with mutant biological function. Radioactive carbon-11, administered to plants as 11CO2, provided insights into shifts in host usage of 'new' carbon resources in the presence of these beneficial microbes. Of the mutants examined, HM053 exhibited the greatest influence on host Fe uptake with increased plant allocation of 11C-resources to roots where they were transformed and exuded as 11C-acidic substrates to aid in Fe-chelation, and increased C-11 partitioning into citric acid, nicotianamine and histidine to aid in the in situ translocation of Fe once assimilated.

A comparison of gastric gas volumes measured by computed tomography after high-flow nasal oxygen therapy or conventional facemask ventilation. Anaesthesia 2021;76:1184-1189. [PMID: 33651914 DOI: 10.1111/anae.15433]

High-flow nasal oxygen therapy is increasingly used to improve peri-intubation oxygenation. However, it is unknown whether it may cause or exacerbate insufflation of gas into the stomach. High-flow nasal oxygen therapy is now standard practice in our hospital for adult patients undergoing percutaneous thermal ablation of liver cancer under general anaesthesia with tracheal intubation. We compared gastric gas volumes measured from computed tomography images that had been acquired immediately after intubation in two series of patients: 50 received peri-intubation high-flow nasal oxygen therapy and another 50 received conventional facemask pre-oxygenation and ventilation before intubation and before high-flow nasal oxygen therapy became standard practice in our unit. Median (IQR [range]) gastric gas volume was 24.0 (14.2-59.9 [3-167]) cm³ in the high-flow nasal oxygen therapy group and 23.8 (12.6-38.8 [0-185]) cm³ in the facemask group. There was no difference between the two groups in the volume of gastric gas measured by computed tomography imaging (Mann-Whitney U-test, U = 1136, p = 0.432, n₁  = n₂  = 50). Our results demonstrate that a small volume of gastric gas is commonly present after induction of anaesthesia, but that the use of peri-intubation high-flow nasal oxygen therapy for pre-oxygenation and during apnoea does not increase this volume compared with conventional facemask pre-oxygenation and ventilation. This is clinically relevant, as high-flow nasal oxygen therapy is increasingly being used in a peri-intubation context and in patients at higher risk of aspiration.

[Recommendations for the Protocol of functional examination of the anorectal zone and disorders classification: the International Anorectal Physiology Working Group consensus and Russian real-world practice]

This manuscript summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance, terminology used, and interpretation of anorectal function testing including anorectal manometry (focused on high-resolution manometry), the rectal sensory test, and the balloon expulsion test. Based on these measurements, a classification system for disorders of anorectal function is proposed. Aim to provide information about methods of diagnosis and new classification of functional anorectal disorders to a wide range of specialists general practitioners, therapists, gastroenterologists, coloproctologists all who face the manifestations of these diseases in everyday practice and determine the diagnostic and therapeutic algorithm. Current paper provides agreed statements of IAPWG Consensus and comments (in italics) of Russian experts on real-world practice, mainly on methodology of examination. These comments in no way intended to detract from the provisions agreed by the international group of experts. We hope that these comments will help to improve the quality of examination based on the systematization of local experience with the use of the methods discussed and the results obtained. Key recommendations: the International Anorectal Physiology Working Group protocol for the performance of anorectal function testing recommends a standardized sequence of maneuvers to test rectoanal reflexes, anal tone and contractility, rectoanal coordination, and rectal sensation. Major findings not seen in healthy controls defined by the classification are as follows: rectoanal areflexia, anal hypotension and hypocontractility, rectal hyposensitivity, and hypersensitivity. Minor and inconclusive findings that can be present in health and require additional information prior to diagnosis include anal hypertension and dyssynergia.

Collateral damage: the impact on outcomes from cancer surgery of the COVID-19 pandemic

BACKGROUND

Cancer diagnostics and surgery have been disrupted by the response of health care services to the coronavirus disease 2019 (COVID-19) pandemic. Progression of cancers during delay will impact on patients' long-term survival.

PATIENTS AND METHODS

We generated per-day hazard ratios of cancer progression from observational studies and applied these to age-specific, stage-specific cancer survival for England 2013-2017. We modelled per-patient delay of 3 and 6 months and periods of disruption of 1 and 2 years. Using health care resource costing, we contextualise attributable lives saved and life-years gained (LYGs) from cancer surgery to equivalent volumes of COVID-19 hospitalisations.

RESULTS

Per year, 94 912 resections for major cancers result in 80 406 long-term survivors and 1 717 051 LYGs. Per-patient delay of 3/6 months would cause attributable death of 4755/10 760 of these individuals with loss of 92 214/208 275 life-years, respectively. For cancer surgery, average LYGs per patient are 18.1 under standard conditions and 17.1/15.9 with a delay of 3/6 months (an average loss of 0.97/2.19 LYGs per patient), respectively. Taking into account health care resource units (HCRUs), surgery results on average per patient in 2.25 resource-adjusted life-years gained (RALYGs) under standard conditions and 2.12/1.97 RALYGs following delay of 3/6 months. For 94 912 hospital COVID-19 admissions, there are 482 022 LYGs requiring 1 052 949 HCRUs. Hospitalisation of community-acquired COVID-19 patients yields on average per patient 5.08 LYG and 0.46 RALYGs.

CONCLUSIONS

Modest delays in surgery for cancer incur significant impact on survival. Delay of 3/6 months in surgery for incident cancers would mitigate 19%/43% of LYGs, respectively, by hospitalisation of an equivalent volume of admissions for community-acquired COVID-19. This rises to 26%/59%, respectively, when considering RALYGs. To avoid a downstream public health crisis of avoidable cancer deaths, cancer diagnostic and surgical pathways must be maintained at normal throughput, with rapid attention to any backlog already accrued.

A qualitative exploration of school-based staff's experiences of delivering an alcohol screening and brief intervention in the high school setting: findings from the SIPS JR-HIGH trial

BACKGROUND

Whilst underage drinking in the UK has been declining in recent years, prevalence is still higher than in most other Western European countries. Therefore, it is important to deliver effective interventions to reduce risk of harm.

METHODS

Semi-structured interviews with staff delivering an alcohol screening and brief intervention in the high-school setting. The analysis was informed by normalization process theory (NPT), interviews were open coded and then a framework applied based on the four components of NPT.

RESULTS

Five major themes emerged from the analysis. The majority of participants felt that the intervention could be useful, and that learning mentors were ideally suited to deliver it. However, there was a feeling that the intervention should have been targeted at young people who drink the most.

CONCLUSIONS

The intervention was generally well received in schools and seen as an effective tool for engaging young people in a discussion around alcohol. However, in the future schools need to consider the level of staffing in place to deliver the intervention. Furthermore, the intervention could focus more on the long-term risks of initiating alcohol consumption at a young age.

Power series method for solving TASEP-based models of mRNA translation

We develop a method for solving mathematical models of messenger RNA (mRNA) translation based on the totally asymmetric simple exclusion process (TASEP). Our main goal is to demonstrate that the method is versatile and applicable to realistic models of translation. To this end we consider the TASEP with codon-dependent elongation rates, premature termination due to ribosome drop-off and translation reinitiation due to circularisation of the mRNA. We apply the method to the model organism Saccharomyces cerevisiae under physiological conditions and find an excellent agreement with the results of stochastic simulations. Our findings suggest that the common view on translation as being rate-limited by initiation is oversimplistic. Instead we find theoretical evidence for ribosome interference and also theoretical support for the ramp hypothesis which argues that codons at the beginning of genes have slower elongation rates in order to reduce ribosome density and jamming.

Marijuana use in young mothers and adverse pregnancy outcomes: a retrospective cohort study

OBJECTIVE

To evaluate the association between marijuana use and a composite adverse pregnancy outcome using biological sampling.

DESIGN

Retrospective cohort study.

SETTING

Single tertiary center.

POPULATION

Young women (13-22 years old) with singleton, non-anomalous pregnancies delivered from September 2011 to May 2017.

METHODS

Exposure was defined as marijuana detected on universal urine toxicology testing or by self-report. Multivariable logistic regression modelling was used to estimate the effect of any marijuana use on the primary composite outcome. The effect of marijuana exposure was also estimated for self-reported use, toxicology-detected use, and multiple use detected by toxicology.

MAIN OUTCOME MEASURE

The primary composite outcome included spontaneous preterm birth, hypertensive disorders of pregnancy, stillbirth, or small for gestational age.

RESULTS

Of 1206 pregnant young women, 17.5% (n = 211) used marijuana. Among the women who used marijuana, 8.5% (n = 18) were identified by self-report alone, 63% (n = 133) by urine toxicology alone, and 28.4% (n = 60) by both. Urine toxicology testing results were available for 1092 (90.5%) births. The composite outcome occurred more frequently in pregnancies exposed to marijuana (46 versus 34%, P < 0.001). This remained significant after adjusting for race/ethnicity and tobacco in the multivariable model (adjusted OR 1.50, 95% CI 1.09-2.05). When marijuana exposure was defined by self-report only, the association with adverse pregnancy outcome became non-significant (adjusted OR 1.01, 95% CI 0.62-1.64).

CONCLUSION

In a population of young women with nearly universal biological sampling, marijuana exposure was associated with adverse pregnancy outcomes. The heterogeneity of findings in existing studies evaluating the impact of marijuana on mothers and neonates may result from the incomplete ascertainment of exposure.

TWEETABLE ABSTRACT

Marijuana use, as detected by universal urine testing, was associated with a composite adverse pregnancy outcome among young mothers.

Variation in uptake of Healthy Start Food Vouchers in the Six Health and Social Care Partnerships

Background

The primary aim of this study was to assess the difference in uptake levels of Healthy Start Food Vouchers, a means tested benefit to afford nutritious food, between 6 Health and Community Partnerships (HSCP) in Greater Glasgow and Clyde (GGC). Our secondary aim was to explore possible reasons for the observed variation.

Methods

Routinely collected Healthy Start data for the months of August to September 2017 were obtained from the UK Department of Health. Postcode sectors were matched up with their corresponding HSCPs in GGC. Analysis looked for associations between uptake rates and various HSCP area-based characteristics.

Results

Large variations were observed within GGC. Chi-square test showed a significant association between uptake and HSCP area (P &lt; 0.0005). Trend analysis of uptake with area deprivation (P = 0.001) and resource allocation (P &lt; 0.001) was also significant. Subjective analysis of trend direction suggested that uptake increased with deprivation and resource allocation of the HSCP.

Conclusions

Significant trends were found and the observed patterns suggested that the relationship between uptake rates and HSCP area is more complex than the geographical characteristics alone. Future studies need to look at the difference in management and awareness of the voucher scheme between Maternity teams in HSCPs.

Key messages

There is significant variation in the uptake of means tested benefits with some areas having a nearly forty percent of eligible individuals not receiving available support. A qualitative approach is required to determine the causes of low uptake rates of benefits and improve the effectiveness of maternity teams in different areas.

Influenza and vaccination: beliefs and practices of local authority staff

BACKGROUND

Influenza causes large outbreaks every year. Professionals outside healthcare, including social care staff and non-care giving roles, have a key role in protecting their clients and sustaining operational productivity through influenza vaccination. There has been little research on non-healthcare staff working with vulnerable people and those working in non-caregiving settings regarding influenza and influenza vaccination.

AIMS

To understand the practices, experiences, perceptions and motivations of local authority staff regarding influenza and influenza vaccination.

METHODS

Semi-structured focus groups were carried out with local authority staff in Gloucestershire. Transcripts were thematically analysed.

RESULTS

Participants tended to perceive influenza as a serious illness, where a person had a specific risk factor or during pandemics. They did not feel vulnerable unless they had previous experience of infection or had an underlying health condition. Motivation to vaccinate was based on previous experience of influenza, where they had a close family member at risk or when working directly with vulnerable clients. Beliefs about negative side effects of the vaccine were the strongest reason for vaccine refusal. Ease of access to vaccination through on-site clinics is key to uptake. Management are perceived as key motivators or blockers to vaccine uptake.

CONCLUSIONS

Workers outside healthcare settings do not feel vulnerable to influenza and have low motivation to vaccinate, unless they have previous experience of infection or an underlying health condition. Vaccination programmes must proactively address workers' beliefs and motivations to ensure their participation in flu vaccination programmes.

B-78 Social Skills Training for Verbal Aggression in Conserved Adults with Traumatic Brain Injury, Schizophrenia, and Schizoaffective Disorder

Objective

This pilot study examined the effectiveness of a social skills training (SST) program aimed to decrease verbal aggressive behavior and increase prosocial skills of conserved adults.

Method

Conserved adults (N = 10) with traumatic brain injury, schizophrenia, and schizoaffective disorder received SST for six weeks, an hour weekly, and they were assessed pre- and post-intervention. The Overt Aggression Scale-Modified for Neurorehabilitation-Extended was used to measure aggressive behaviors. Aggressive behavior to self, objects, and others was rated by facility staff that were not involved in the SST. Acquisition of social skills was rated by facility staff on the number of observed prosocial behavior (self-initiates greeting, responds to greeting, expresses gratitude). Only verbal aggression and prosocial scores were used given SST’s content. A paired samples t-test was conducted to evaluate the pre-post effectiveness and effect sizes.

Results

Aggression improved from M = 2.83 (SD = 3.39) to M = 1.00 (SD = 1.98), an improvement of 1.83, but was not statistically significant (t[8] = 2.28, p = .052; Cohen’s d = .76). 95% confidence interval ranged from -0.02 to 3.67. Prosocial behaviors improved from M = 8.67 (SD = 2.35) to M = 9.83 (SD = 2.41), an improvement of 1.17, but was not statistically significant (t[8] = -1.56, p = .158; Cohen’s d = .52). 95% confidence interval ranged from -2.90 to .56.

Conclusions

Effect sizes showed a decrease in aggression and social skills improvement of the participants. This SST is promising and should be examined with randomized controlled trial studies with larger sample sizes.

Mental Health Services for ‘Difficult’ Women: Reflections on Some Recent Developments

The provision of mental health services to women has come sharply into focus for providers of secure psychiatric services in the UK. Women's services are being developed in response to the known risks of mixed-sex provision, and a growing appreciation of the ways that women in secure services can be further disadvantaged by their minority status. Our intention here is to present evidence and reflections to help inform this development. The evidence is drawn from our recent work in this field, which includes carrying out a review of local mental health services for ‘difficult’ women, and developing and piloting a national training programme for staff working with women in secure services. The reflections we offer are informed by the conviction that taking social inequalities into account is central to making sense of women's mental health difficulties, and improving service responses to women's needs. While there are signs that many mental health workers in secure services are beginning to share these convictions, the challenge now is to provide the necessary authorization, training and support that will enable them to translate these understandings into empowerment practice with women.

Abstract P1-13-04: Efficacy of adjuvant 5-Fluorouracil in residual HER2-negative breast cancer following neoadjuvant chemotherapy

Background: Patients with residual disease following neoadjuvant chemotherapy have an increased risk of relapse. Recently the CREATE-X trial demonstrated that adjuvant capecitabine (oral prodrug of 5'deoxy-5-fluorouridine), prolonged disease-free survival and overall survival among patients with HER2-negative breast cancer who had residual invasive disease after neoadjuvant chemotherapy containing anthracycline, taxane, or both. Therefore, we sought to evaluate the antitumor efficacy of 5-fluorouracil (5-FU) in patient-derived xenografts (PDXs) from residual tumors resistant to neoadjuvant chemotherapy.

Methods: Antitumor efficacy of 5-FU was assessed in vivo in three PDXs varying in hormone receptor status (0, 4% and 11% respectively), generated from residual tumors of primary breast cancer patients treated with neoadjuvant chemotherapy containing anthracycline, and taxanes. In addition, significance of timing of therapy was also assessed, comparing efficacy of initiating treatment upon implantation (immediate start cohort; mimicking treating residual disease with adjuvant therapy), with initiating treatment upon establishment of PDX (standard start cohort).

Results: 5-FU was efficacious in established PDX models that are triple negative (0% ER; p&lt; 0.0001), low ER positive (4% ER, p=0.0213) and ER-positive (11% ER; p= 0.0390), decreasing growth compared to the cohort. However, there was no statistically significant difference between the immediate start cohort and standard start cohort. Western blot analysis of the treatment-naïve derived mouse tumors recognized RB as a predictive biomarker for 5-FU response.

Conclusion: 5-FU has anti-tumor activity in residual HER2-negative PDX models resistant to taxanes, and anthracyclines in the neoadjuvant setting.

Citation Format: Owusu-Brackett N, Scott S, Yuca E, Evans KW, Tapia C, Meric-Bernstam F. Efficacy of adjuvant 5-Fluorouracil in residual HER2-negative breast cancer following neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-13-04.

Video-tube thoracostomy in trauma resuscitation: A pilot study

BACKGROUND

Complications related to incorrect positioning of tube thoracostomy (TT) have been reported to be as high as 30%. The aim of this study was to assess the feasibility of flexible videoscope guided placement of a pre-loaded chest tube, permitting direct intrapleural visualization and placement (Video-Tube Thoracostomy [V-TT]).

METHODS

A prospective, single centre, phase 1 pilot study with a parallel control group was undertaken. The population studied were adult thoracic trauma patients requiring emergency TT who were haemodynamically stable. The intervention performed was VTT. Patients in the control group underwent conventional TT. The primary outcome was tube position as defined by a consultant radiologist's interpretation of chest x-ray (CXR) or CT. The trial was registered with ANZCTR.org.au (ACTRN: 12,615,000,870,550).

RESULTS

There were 37 patients enrolled in the study - 12 patients allocated to the VTT intervention group and 25 patients allocated to conventional TT. Mean age of participants was 48 years (SD 15) in intervention group and 46 years (SD 15) years in the control group. In the VTT group all patients were male; the indications were pneumothorax (83%), haemothorax (8%) and haemopneumothorax (8%). The median injury severity score was 23 (16-28). There were 1 positional and 1 insertional complications. In the control group 72% of patients were male, the indications were pneumothorax (56%), haemothorax (4%) and haemopneumothorax (40%). The median injury severity score was 24 (14-36). There were 8 (32%) positional complications and no insertional complications.

CONCLUSION

V-TT was demonstrated to be a feasible alternative to conventional thoracostomy and merits further investigation.

Decreasing Blood Culture Contaminants in a Pediatric Emergency Department: An Interrupted Time Series Analysis

INTRODUCTION

High peripheral blood culture contamination rates (BCCR) in the emergency department (ED) contribute to overuse and harm. This study describes 2 years of quality improvement (QI) interventions that aimed to decrease a high BCCR in a pediatric ED.

METHODS

The QI team created a Key Driver Diagram with multiple Plan-Do-Study-Act (PDSA) cycles. PDSA interventions included a venipuncture sterility checklist (PDSA1), phlebotomist feedback system (PDSA2), and physician ordering guidelines (PDSA3). The specific aim was to decrease the BCCR by 50% within 24 months. The secondary aim was to decrease the peripheral blood culture ordering rate (BCOR) by 10% within 24 months. The balancing measure was the proportion of pathogenic bacteremia cases at ED return visits before and after PDSA3 implementation. A financial measure estimated the savings in charges between the observed and expected contaminants in PDSA3. An interrupted time series design applied statistical process control methodology to detect special cause variations.

RESULTS

The BCCR in the baseline, PDSA1, PDSA2, and PDSA3 periods were 3.02%, 2.30%, 1.58%, and 1.17%, respectively. The BCOR in the baseline, PDSA1, PDSA2, and PDSA3 periods was 4.80%, 4.26%, 3.82%, and 3.49%, respectively. Special cause variations occurred after PDSA cycle implementations for both BCCR and BCOR. There was no change in the balancing measure. The interventions were associated with an annual prevention of 95 contaminants and savings of $300,070.

CONCLUSIONS

Interventions that focused on improving venipuncture technique and limiting unnecessary blood cultures were associated with fewer contaminants and the achievement of the QI team's project aims.

Contingency Training Alters Neurobiological Components of Emotional Resilience in Male and Female Rats

Prior research with a rat model of behavioral therapy [i.e., effort-based reward (EBR) contingency training] suggests that strengthened associations between physical effort and desired outcomes enhance neurobiological indices of resilience. In the current study, male and female Long-Evans rats were exposed to either six weeks of EBR training or noncontingent training prior to 10 days of exposure to chronic unpredictable stress (CUS). Subsequently, all animals were exposed to a problem-solving task and then trained in a spatial learning/foraging task, the Dry Land Maze (DLM). Following habituation training and test trials, rats were assessed in a probe trial that generated a prediction error (cognitive uncertainty). Results indicated that, during CUS exposure, contingency-training enhanced dehydroepiandrosterone/corticosterone ratios (consistent with healthier stress responses), especially in male rats. Additionally, contingency training increased exploratory behaviors in the probe trial as well as differentially influenced on-task problem-solving performance in males and females. Following the probe trial, brains were exposed to histological analyses to determine the effects of sex and contingency training on various neurobiological markers. Contingency training decreased BDNF-immunoreactivity (ir) in the hippocampus CA1 and lateral habenula, implicating differential neuroplasticity responses in the training groups. Further, coordinated fos-ir activation in areas associated with emotional resilience (i.e., motivation-regulation) was observed in contingent-trained animals. In sum, the current findings confirm that behavioral training is associated with neurobiological markers of emotional resilience; however, further assessments are necessary to more accurately determine the therapeutic potential for the EBR contingency training model.