Can freshwater plants and algae act as an effective feed supplement to reduce methane emissions from ruminant livestock?

Methane production by livestock is a substantial component of greenhouse gas emissions worldwide. The marine red algae, Asparagopsis taxiformis, has been identified as a possible supplement in livestock feeds due to its potent inhibition of methane production but currently is unable to be produced at scale. Finding additional taxa that inhibit methane production is therefore desirable. Here we provide foundational evidence of methanogenesis-inhibiting properties in Australian freshwater plants and algae, reviewing candidate species and testing species' chemical composition and efficacy in vitro. Candidate plant species and naturally-occurring algal mixes were collected and assessed for ability to reduce methane in batch testing and characterised for biochemical composition, lipids and fatty acids, minerals and DNA. We identified three algal mixes and one plant (Montia australasica) with potential to reduce methane yield in in vitro batch assay trials. All three algal mixes contained Spirogyra, although additional testing would be needed to confirm this alga was responsible for the observed activity. For the two samples that underwent multiple dose testing, Algal mix 1 (predominantly Spirogyra maxima) and M. australasica, there seems to be an optimum dose but sources, harvesting and storage conditions potentially determine their methanogenesis-inhibiting activity. Based on their compositions, fatty acids are likely to be acting to reduce methane in Algal mix 1 while M. australasica likely contains substantial amounts of the flavonoids apigenin and kaempferol, which are associated with methane reduction. Based on their mineral composition, the samples tested would be safe for livestock consumption at an inclusion rate of 20%. Thus, we identified multiple Australian species that have potential to be used as a feed supplement to reduce methane yield in livestock which may be suitable for individual farmers to grow and feed, reducing complexities of supply associated with marine alternatives and suggesting avenues for investigation for similar species elsewhere.

Deep learning to extract the meteorological by-catch of wildlife cameras

Microclimate-proximal climatic variation at scales of metres and minutes-can exacerbate or mitigate the impacts of climate change on biodiversity. However, most microclimate studies are temperature centric, and do not consider meteorological factors such as sunshine, hail and snow. Meanwhile, remote cameras have become a primary tool to monitor wild plants and animals, even at micro-scales, and deep learning tools rapidly convert images into ecological data. However, deep learning applications for wildlife imagery have focused exclusively on living subjects. Here, we identify an overlooked opportunity to extract latent, ecologically relevant meteorological information. We produce an annotated image dataset of micrometeorological conditions across 49 wildlife cameras in South Africa's Maloti-Drakensberg and the Swiss Alps. We train ensemble deep learning models to classify conditions as overcast, sunshine, hail or snow. We achieve 91.7% accuracy on test cameras not seen during training. Furthermore, we show how effective accuracy is raised to 96% by disregarding 14.1% of classifications where ensemble member models did not reach a consensus. For two-class weather classification (overcast vs. sunshine) in a novel location in Svalbard, Norway, we achieve 79.3% accuracy (93.9% consensus accuracy), outperforming a benchmark model from the computer vision literature (75.5% accuracy). Our model rapidly classifies sunshine, snow and hail in almost 2 million unlabelled images. Resulting micrometeorological data illustrated common seasonal patterns of summer hailstorms and autumn snowfalls across mountains in the northern and southern hemispheres. However, daily patterns of sunshine and shade diverged between sites, impacting daily temperature cycles. Crucially, we leverage micrometeorological data to demonstrate that (1) experimental warming using open-top chambers shortens early snow events in autumn, and (2) image-derived sunshine marginally outperforms sensor-derived temperature when predicting bumblebee foraging. These methods generate novel micrometeorological variables in synchrony with biological recordings, enabling new insights from an increasingly global network of wildlife cameras.

A multicentre randomised controlled trial of the McGrath Mac videolaryngoscope versus conventional laryngoscopy

Before completion of this study, there was insufficient evidence demonstrating the superiority of videolaryngoscopy compared with direct laryngoscopy for elective tracheal intubation. We hypothesised that using videolaryngoscopy for routine tracheal intubation would result in higher first-pass tracheal intubation success compared with direct laryngoscopy. In this multicentre randomised trial, 2092 adult patients without predicted difficult airway requiring tracheal intubation for elective surgery were allocated randomly to either videolaryngoscopy with a Macintosh blade (McGrath) or direct laryngoscopy. First-pass tracheal intubation success was higher with the McGrath (987/1053, 94%), compared with direct laryngoscopy (848/1039, 82%); absolute risk reduction (95%CI) was 12.1% (10.9-13.6%). This resulted in a relative risk (95%CI) of unsuccessful tracheal intubation at first attempt of 0.34 (0.26-0.45; p < 0.001) for McGrath compared with direct laryngoscopy. Cormack and Lehane grade ≥ 3 was observed more frequently with direct laryngoscopy (84/1039, 8%) compared with McGrath (8/1053, 0.7%; p < 0.001) No significant difference in tracheal intubation-associated adverse events was observed between groups. This study demonstrates that using McGrath videolaryngoscopy compared with direct laryngoscopy improves first-pass tracheal intubation success in patients having elective surgery. Practitioners may consider using this device as first choice for tracheal intubation.

Building a Covid-19 secure intensive care unit: A human-centred design approach

Background

The Covid-19 pandemic has highlighted weaknesses in the National Health Service critical care provision including both capacity and infrastructure. Traditionally, healthcare workspaces have failed to fully incorporate Human-Centred Design principles resulting in environments that negatively affect the efficacy of task completion, patient safety and staff wellbeing. In the summer of 2020, we received funds for the urgent construction of a Covid-19 secure critical care facility. The aim of this project was to design a pandemic resilient facility centred around both staff and patient requirements and safety, within the available footprint.

Methods

We developed a simulation exercise, underpinned by Human-Centred Design principles, to evaluate intensive care designs through Build Mapping, Tasks Analysis and Qualitative data. Build Mapping involved taping out sections of the design and mocking up with equipment. Task Analysis and qualitative data were collected following task completion.

Results

56 participants completed the build simulation exercise generating 141 design suggestions (69 task related, 56 patient and relative related, 16 staff related). Suggestions translated to 18 multilevel design improvements; five significant structural changes (Macro level) including wall moves and lift size change. Minor improvements were made at a Meso and Micro design level. Critical care design drivers identified included functional drivers (visibility, Covid-19 secure environment, workflow, and task efficiency) and behavioural drivers (learning and development, light, humanising intensive care and design consistency).

Conclusion

Success of clinical tasks, infection control, patient safety and staff/patient wellbeing are highly dependent on clinical environments. Primarily, we have improved clinical design by focusing on user requirements. Secondly, we developed a replicable approach to exploring healthcare build plans revealing significant design changes, that may have only been identified once built.

Strategies and checklist for designing and conducting palliative care research with family carers: EAPC international expert elicitation study

BACKGROUND

Palliative care services seek to improve the wellbeing of family carers of people living with serious and life-limiting illness. To help achieve this goal, systematic reviews have recommended priority areas for family carer research and the need to improve the quality of study design. Policy makers have also advocated for enhanced family carer support. However, there are specific methodological considerations and challenges in designing and conducting carer research conducted during the course of the serious illness trajectory and in bereavement.

AIM

To develop strategies to improve the design and conduct of research with family carers.

DESIGN

Expert elicitation study using an adapted version of the 'Identify, Discuss, Estimate and Aggregate' elicitation protocol, supplemented with strategies from peer-reviewed literature.

SETTING/PARTICIPANTS

Nine members of the management committee of the European Association for Palliative Care's Reference group on family carer research, comprising international senior research academics in family caregiving.

RESULTS

A compilation of recommended strategies and checklist was created to: (a) help researchers plan research involving family carers focussing on: preparation, conduct and dissemination and (b) assist ethics committees and funding bodies to evaluate proposals.

CONCLUSIONS

The strategies and checklist for conducting research with family carers may enhance methodologically rigorous research. Consequently, researchers, practitioners and policy makers will not only gain a more comprehensive understanding of the unmet needs of family carers but also promote the development of empirically sound interventions.

An analysis of the experiences of bereaved relatives and health care providers following palliative sedation: a study protocol for a qualitative international multicenter case study

BACKGROUND

Patients at the end-of-life may experience refractory symptoms of which pain, delirium, vomiting and dyspnea are the most frequent. Palliative sedation can be considered a last resort option to alleviate one or more refractory symptoms. There are only a limited number of (qualitative) studies exploring the experiences of relatives of sedated patients and their health care professionals (HCPs). The aims of this study protocol are: 1) to elicit the experiences of bereaved relatives and health care professionals of patients treated with palliative sedation and 2) to explore the understanding of the decision-making process to start palliative sedation across care settings in 5 European countries.

METHODS

This study protocol is part of the larger HORIZON 2020 Palliative Sedation project. Organisational case study methodology will be used to guide the study design. In total, 50 cases will be conducted in five European countries (10 per country). A case involves a semi-structured interview with a relative and an HCP closely involved in the care of a deceased patient who received some type of palliative sedation at the end-of-life. Relatives and health care professionals of deceased patients participating in a linked observational cohort study of sedated patients cared for in hospital wards, palliative care units and hospices will be recruited. The data will be analyzed using a framework analysis approach. The first full case will be analyzed by all researchers after being translated into English using a pre-prepared code book. Afterwards, bimonthly meetings will be organized to coordinate the data analysis.

DISCUSSION

The study aims to have a better understanding of the experiences of relatives and professional caregivers regarding palliative sedation and this within different settings and countries. Some limitations are: 1) the sensitivity of the topic may deter some relatives from participation, 2) since the data collection and analysis will be performed by at least 5 different researchers in 5 countries, some differences may occur which possibly makes it difficult to compare cases, but using a rigorous methodology will minimize this risk.

How well do polygenic risk scores identify men at high risk for prostate cancer? Systematic review and meta-analysis

OBJECTIVES

Genome-wide association studies have revealed over 200 genetic susceptibility loci for prostate cancer (PCa). By combining them, polygenic risk scores (PRS) can be generated to predict risk of PCa. We summarize the published evidence and conduct meta-analyses of PRS as a predictor of PCa risk in Caucasian men.

PATIENTS AND METHODS

Data were extracted from 59 studies, with 16 studies including 17 separate analyses used in the main meta-analysis with a total of 20,786 cases and 69,106 controls identified through a systematic search of ten databases. Random effects meta-analysis was used to obtain pooled estimates of area under the receiver-operating characteristic curve (AUC). Meta-regression was used to assess the impact of number of single-nucleotide polymorphisms (SNPs) incorporated in PRS on AUC. Heterogeneity is expressed as I² scores. Publication bias was evaluated using funnel plots and Egger tests.

RESULTS

The ability of PRS to identify men with PCa was modest (pooled AUC 0.63, 95% CI 0.62-0.64) with moderate consistency (I² 64%). Combining PRS with clinical variables increased the pooled AUC to 0.74 (0.68-0.81). Meta-regression showed only negligible increase in AUC for adding incremental SNPs. Despite moderate heterogeneity, publication bias was not evident.

CONCLUSION

Typically, PRS accuracy is comparable to PSA or family history with a pooled AUC value 0.63 indicating mediocre performance for PRS alone.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

UK Research and Innovation and National Institute for Health Research.

Large differences in the organization of palliative care in nursing homes in six European countries: findings from the PACE cross-sectional study

Background

To be able to provide high-quality palliative care, there need to be a number of organizational structures available in the nursing homes. It is unclear to what extent such structures are actually present in nursing homes in Europe. We aim to examine structural indicators for quality of palliative care in nursing homes in Europe and to evaluate the differences in terms of availability of and access to palliative care, infrastructure for residents and families, multidisciplinary meetings and quality improvement initiatives.

Methods

A PACE cross-sectional study (2015) of nursing homes in Belgium, England, Finland, Italy, the Netherlands and Poland. Nursing homes (N = 322) were selected in each country via proportional stratified random sampling. Nursing home administrators (N = 305) filled in structured questionnaires on nursing home characteristics. Organization of palliative care was measured using 13 of the previously defined IMPACT structural indicators for quality of palliative care covering four domains: availability of and access to palliative care, infrastructure for residents and families, multidisciplinary meetings and quality improvement initiatives. We calculated structural indicator scores for each country and computed differences in indicator scores between the six countries. Pearson’s Chi-square test was used to compute the p-value of each difference.

Results

The availability of specialist palliative care teams in nursing homes was limited (6.1–48.7%). In Finland, Poland and Italy, specialist advice was also less often available (35.6–46.9%). Up to 49% of the nursing homes did not provide a dedicated contact person who maintained regular contact with the resident and relatives. The 24/7 availability of opioids for all nursing home residents was low in Poland (37.5%).

Conclusions

This study found a large heterogeneity between countries in the organization of palliative care in nursing homes, although a common challenge is ensuring sufficient structural access to specialist palliative care services. Policymakers and health and palliative care organizations can use these structural indicators to identify areas for improvement in the organization of palliative care.

Incidence and risk factors for prolonged postoperative opioid use following lumbar spine surgery: a cohort study

OBJECTIVE

Sustained postoperative opioid use after elective surgery is a matter of growing concern. Herein, the authors investigated incidence and predictors of long-term opioid use among patients undergoing elective lumbar spine surgery, especially as a function of opioid prescribing practices at postoperative discharge (dose in morphine milligram equivalents [MMEs] and type of opioid).

METHODS

The OptumLabs Data Warehouse (OLDW) was queried for postdischarge opioid prescriptions for patients undergoing elective lumbar decompression and discectomy (LDD) or posterior lumbar fusion (PLF) for degenerative spine disease. Only patients who received an opioid prescription at postoperative discharge and those who had a minimum of 180 days of insurance coverage prior to surgery and 180 days after surgery were included. Opioid-naive patients were defined as those who had no opioid fills in 180 days prior to surgery. The following patterns of long-term postoperative use were investigated: additional fills (at least one opioid fill 90-180 days after surgery), persistent fills (any span of opioid use starting in the 180 days after surgery and lasting at least 90 days), and Consortium to Study Opioid Risks and Trends (CONSORT) criteria for persistent use (episodes of opioid prescribing lasting longer than 90 days and 120 or more total days' supply or 10 or more prescriptions in 180 days after the index fill). Multivariable logistic regression was performed to identify predictors of long-term use.

RESULTS

A total of 25,587 patients were included, of whom 52.7% underwent PLF (n = 13,486) and 32.5% (n = 8312) were opioid-naive prior to surgery. The rates of additional fills, persistent fills, and CONSORT use were 47%, 30%, and 23%, respectively, after PLF and 35.4%, 19%, and 14.2%, respectively, after LDD. The rates among opioid-naive patients were 18.9%, 5.6%, and 2.5% respectively, after PLF and 13.3%, 2.0%, and 0.8%, respectively, after LDD. Using multivariable logistic regression, the following were identified to be significantly associated with higher risk of long-term opioid use following PLF: discharge opioid prescription ≥ 500 MMEs, prescription of a long-acting opioid, female sex, multilevel surgery, and comorbidities such as depression and drug abuse (all p < 0.05). Elderly (age ≥ 65 years) and opioid-naive patients were found to be at lower risk (all p < 0.05). Similar results were obtained on analysis for LDD with the following significant additional risk factors identified: discharge opioid prescription ≥ 400 MMEs, prescription of tramadol alone at discharge, and inpatient surgery (all p < 0.05).

CONCLUSIONS

In an analysis of pharmacy claims from a national insurance database, the authors identified incidence and predictors of long-term opioid use after elective lumbar spine surgery.

Variations in Postoperative Opioid Prescription Practices and Impact on Refill Prescriptions Following Lumbar Spine Surgery

OBJECTIVE

Understanding postsurgical prescribing patterns and their impact on persistent opioid use is important for establishing reasonable opioid prescribing protocols. We aimed to determine national variation in postoperative opioid prescription practices following elective lumbar spine surgery and their impact on short-term refill prescriptions.

METHODS

The OptumLabs Data Warehouse was queried from 2016 to 2017 for adults undergoing anterior lumbar fusion, posterior lumbar fusion, circumferential lumbar fusion, and lumbar decompression/discectomy for degenerative spine disease. Discharge opioid prescription fills were obtained and converted to morphine milligram equivalents (MMEs). Age- and sex-adjusted MMEs and frequency of discharge prescriptions >200 MMEs were determined for each U.S. census division and procedure type.

RESULTS

The study included 43,572 patients with 37,894 postdischarge opioid prescription fills. There was wide variation in mean filled MMEs across all census divisions (anterior lumbar fusion: 774-1147 MMEs; posterior lumbar fusion: 717-1280 MMEs; circumferential lumbar fusion: 817-1271 MMEs; lumbar decompression/discectomy: 619-787 MMEs). A significant proportion of cases were found to have filled discharge prescriptions >200 MMEs (posterior lumbar fusion: 78.6%-95%; anterior lumbar fusion: 87.5%-95.6%; circumferential lumbar fusion: 81.4%-96.5%; lumbar decompression/discectomy: 80.5%-91%). Multivariable logistic regression showed that female sex and inpatient surgery were associated with a top-quartile discharge prescription and a short-term second opioid prescription fill, while the opposite was noted for elderly and opioid-naïve patients (all P ≤ 0.05). Prescriptions with long-acting opioids were associated with higher odds of a second opioid prescription fill (reference: nontramadol short-acting opioid).

CONCLUSIONS

In analysis of filled opioid prescriptions, we observed a significant proportion of prescriptions >200 MMEs and wide regional variation in postdischarge opioid prescribing patterns following elective lumbar spine surgery.

New solid-state organic scintillators for fast and thermal neutron detection

Detection of special nuclear materials (SNM) requires instruments that can detect and characterize uranium and plutonium isotopes, having at the same time the ability to discriminate among different types of radiation. For many decades, neutron detection has been based on 3He proportional counters sensitive primarily to thermal neutrons. The most common methods for detection of fast neutrons have been based on liquid scintillators with pulse shape discrimination (PSD). The shortage of 3He and handling issues with liquid scintillators stimulated a search for efficient solid-state PSD materials. Recent studies conducted at LLNL led to development of new materials, among which are organic crystals with excellent PSD and first PSD plastics for fast neutron detection. More advantages are introduced by plastics doped with neutron capture agents, such as 10B and 6Li, that can be used without moderation for combined detection of both thermal and fast neutrons, offering, in addition, a unique “triple” PSD for signal separation between fast neutrons, thermal neutrons, and gamma-rays. More recent studies have been focused on development of deuterated scintillators that can be used for neutron spectroscopy without time-of-flight (ToF). Among commercially produced materials are large-scale (>10 cm) stilbene crystals grown by the inexpensive solution technique, and different types of PSD plastics that, due to the deployment advantages and ease of fabrication, create a basis for the widespread use of solid-state scintillators as large-volume and low-cost neutron detectors.

The logistical management of tertiary urethral disease in the United Kingdom: Implications from an online audit of male reconstructive urethral surgery

Objective:

To determine those patient groupings, based on volume and risk, whose optimal urethral reconstructive management might be provided by a reorganisation of UK reconstructive surgeons.

Methods:

Between 2010 and 2017, ~689 men/year were enrolled onto an online audit platform collecting data about urethral reconstruction in the UK; this accrual was compared against hospital episode statistics (HES). The available workforce, and where this was based, was collected. Individual and institutional incumbent patient volumes, pathology, surgical complexity and outcomes from treatment were collated to stratify volume/risk groups.

Results:

More than 90% of all HES-recorded data were accrued, being provided by 50 surgeons at 39 operative sites. Most reconstructive surgery was provided at 10 centres performing >20 procedures/year. More than 50% of all interventions were of a high-volume low-risk type. Of activity, 32.3% was intermediate volume or moderate risk, and 12.5% of men presented for lower-volume or higher-risk procedures.

Conclusion:

Correlation of detailed volume/outcome data allows the definition of patient populations presenting for urethral reconstruction. Stratification of each group’s management, to optimise the surgical outcome, may be applied to a hierarchical service delivery model based on the complexity of the patient’s presenting urethral pathology.

Level of evidence:

Level IV

Patterns of Use, Efficacy, and Safety of Treatment Options for Patients with Graves' Disease: A Nationwide Population-Based Study

Background: Considerable uncertainty remains about the pattern of use of treatment options for Graves' disease (GD) and their comparative effectiveness and safety. Methods: Between 2005 and 2013, we identified patients with GD who received antithyroid drugs (ATDs), radioactive iodine (RAI) or surgery, and were represented in a large administrative data set in the United States (OptumLabs^® Data Warehouse). Results: We identified 4661 patients with GD: mean age 48 (SD ±14) years, white (63%), and female (80%). Patients received ATD, n = 2817 (60%), RAI, n = 1549 (33%), or surgery, n = 295 (6%). Success rates were 50% for ATD, 93% for RAI, and 99% for surgery. Median time to treatment failure was 6.8 months for ATD and 3 months for RAI and surgery. When patients were required to be on ATD for at least one year before assessing failure, the failure rate decreased to 25%. Adverse effects occurred in 12% of patients receiving ATD, 6% with RAI, and 24% with surgery. Factors associated with treatment success were age >55 years (for ATD) and female sex (for RAI). About 12% of patients receiving ATD continued this treatment for >24 months as initial therapy. When patients failed ATD therapy, the most common second-line therapy was reinitiation of ATD (65%), RAI (26%), and surgery (9%). Overall, 26% of patients remain on ATD therapy (combined first or second line). Conclusions: ATD therapy was the most common GD therapy and demonstrated the lowest efficacy and infrequent significant adverse effect profile. With one fourth of patients remaining on ATD treatment (initial or second modality treatment), it becomes imperative to determine the long-term efficacy, safety, costs, and burdens of this modality of treatment.

INFOMATAS multi-center systematic review and meta-analysis individual patient data of dynamic cerebral autoregulation in ischemic stroke

Rationale

Disturbances in dynamic cerebral autoregulation after ischemic stroke may have important implications for prognosis. Recent meta-analyses have been hampered by heterogeneity and small samples.

Aim and/or hypothesis

The aim of study is to undertake an individual patient data meta-analysis (IPD-MA) of dynamic cerebral autoregulation changes post-ischemic stroke and to determine a predictive model for outcome in ischemic stroke using information combined from dynamic cerebral autoregulation, clinical history, and neuroimaging.

Sample size estimates

To detect a change of 2% between categories in modified Rankin scale requires a sample size of ∼1500 patients with moderate to severe stroke, and a change of 1 in autoregulation index requires a sample size of 45 healthy individuals (powered at 80%, α = 0.05). Pooled estimates of mean and standard deviation derived from this study will be used to inform sample size calculations for adequately powered future dynamic cerebral autoregulation studies in ischemic stroke.

Methods and design

This is an IPD-MA as part of an international, multi-center collaboration (INFOMATAS) with three phases. Firstly, univariate analyses will be constructed for primary (modified Rankin scale) and secondary outcomes, with key co-variates and dynamic cerebral autoregulation parameters. Participants clustering from within studies will be accounted for with random effects. Secondly, dynamic cerebral autoregulation variables will be validated for diagnostic and prognostic accuracy in ischemic stroke using summary receiver operating characteristic curve analysis. Finally, the prognostic accuracy will be determined for four different models combining clinical history, neuroimaging, and dynamic cerebral autoregulation parameters.

Study outcome(s)

The outcomes for this study are to determine the relationship between clinical outcome, dynamic cerebral autoregulation changes, and baseline patient demographics, to determine the diagnostic and prognostic accuracy of dynamic cerebral autoregulation parameters, and to develop a prognostic model using dynamic cerebral autoregulation in ischemic stroke.

Discussion

This is the first international collaboration to use IPD-MA to determine prognostic models of dynamic cerebral autoregulation for patients with ischemic stroke.

National Home Care Initiative in Jordan: A Demonstration Project

Background and context: The home healthcare market in Jordan is nascent with little service offered. It suffers from a highly fragmented and underregulated landscape. The limited access to qualified trustworthy home care services, lack of professional home care training, and lack of home health care insurance coverage have added to the heavy in-patient bed demand and delayed hospital discharges especially for disabled or terminally ill patients. Aim: To establish a comprehensive national home care program to improve the delivery of palliative and home care services in Jordan, and to conduct a situational analysis and generate policy recommendations. Strategy/Tactics: We used multiple strategies to reach our objectives. 1. Expansion of home care services at King Hussein Cancer Center (KHCC) to create a local demonstration project. 2. Building health care professional capacity by offering variety of educational programs. 3. Improving quality of service delivery by generating clinical practice guidelines, such as standards operating procedures and patient and family educational materials. 4. Use the pilot operational and financial data to generate an economic model to inform the development of similar home health care units in hospitals across Jordan. 5. National advocacy and building effective partnership with all related stakeholders to advance national policy. Program/Policy process: Between May 2016 and May 2017, 7818 home care visits were conducted by KHCC. For capacity building; 678 health care professionals were trained in palliative and home care, out of which 366 participants were females (54%). Palliative care was successfully recognized as a specialty by the Jordan Nursing Council and recognized as a subspecialty by the Jordan Medical Council. The palliative and home care standards of practice were included in the health care accreditation council. The analysis of economic evaluation data suggested that home care services decreased in-patient utilization and costs which is advantageous to a country with limited resources. As a result of the advocacy stream and a collaborative network, the national palliative and home care strategic framework was generated, and endorsed by the Ministry of Health. Outcomes: The NHCI resulted in a very successful pilot project and achieved specialty and subspecialty recognition. Furthermore, we were able to build the capacity of health care professionals and policy makers in the palliative and home care sector from public, private and academic institutions. In the advocacy and policy dimension, the Minister of Health officially approved and adapted the palliative and home care strategic framework that was developed by this initiative. What was learned: Cross-sector collaboration and effective partnership resulted in system change and policy advancement. Developing effective economic systems is essential in low resourced countries. The initiative was supported by a joint grant from the USAID and KHCC.

Thrifty phenotype versus cold adaptation: trade-offs in upper limb proportions of Himalayan populations of Nepal

The multi-stress environment of high altitude has been associated with growth deficits in humans, particularly in zeugopod elements (forearm and lower leg). This is consistent with the thrifty phenotype hypothesis, which has been observed in Andeans, but has yet to be tested in other high-altitude populations. In Himalayan populations, other factors, such as cold stress, may shape limb proportions. The current study investigated whether relative upper limb proportions of Himalayan adults (n = 254) differ between highland and lowland populations, and whether cold adaptation or a thrifty phenotype mechanism may be acting here. Height, weight, humerus length, ulna length, hand length and hand width were measured using standard methods. Relative to height, total upper limb and ulna lengths were significantly shorter in highlanders compared with lowlanders in both sexes, while hand and humerus length were not. Hand width did not significantly differ between populations. These results support the thrifty phenotype hypothesis, as hand and humerus proportions are conserved at the expense of the ulna. The reduction in relative ulna length could be attributed to cold adaptation, but the lack of difference between populations in both hand length and width indicates that cold adaptation is not shaping hand proportions in this case.

The influence of digit size and proportions on dexterity during cold exposure

OBJECTIVES

The current study investigated whether size and proportions of the hands and digits affect dexterity during severe cold exposure. As wide hands are known to lose less heat than narrow hands, and narrow digits are associated with greater dexterity, this study aimed to test whether there was a direct trade-off between dexterity and thermoregulation that shapes hand morphology.

METHODS

Participants (25 women, 15 men) carried out the Purdue Pegboard test before and after a 3-min ice-water immersion of the hand. Their hand length, hand width, digit lengths, and digit widths were measured using standard anthropometric methods.

RESULTS

Wide first and third digits associated with significantly reduced dexterity after immersion relative to individuals with narrower first and third digits. Second digit width positively correlated with average digit temperature after immersion. Hand length and hand width did not influence dexterity.

CONCLUSION

The current study suggests that digit width influences dexterity in cold conditions, reflecting patterns found at room temperature. Hand and digit morphology may be the product of two significant constraints on the hand: dexterity and thermoregulation. In cold conditions, hand morphology appears to be predominantly constrained by thermal stress, at the expense of dexterity. This may have important implications for interpreting the morphology of extinct and extant hominins.

The thermoregulatory function of the human hand: How do palm and digit proportions affect heat loss?

OBJECTIVES

The current study assessed whether ecogeographical patterns seen in hand proportions correlate with heat loss directly. Using a brief severe cold immersion experiment on the hand, the influence of hand and digit dimensions on heat loss was evaluated.

MATERIALS AND METHODS

A sample of 113 living individuals were tested. Two-dimensional and three-dimensional scanning techniques were used to assess hand and digit dimensions. Thermal imaging analysis was used to quantify heat loss during a 3-min ice-water immersion of the hands.

RESULTS

When body size was accounted for, hand width and digit length relative to total hand length were significant predictors of heat loss from the hand.

DISCUSSION

The current study provides empirical evidence to support the link between thermodynamic principles relating to surface area-to-volume ratio, and ecogeographical patterns associated with temperature.

Body size and body composition effects on heat loss from the hands during severe cold exposure

OBJECTIVES

This study investigated the influence of body size and composition on maintaining hand temperature during severe cold exposure. The hand's high surface area-to-volume ratio predisposes the hand to heat loss, increasing the risk of cold injury and even hypothermia, which are major selective pressures in cold environments. While vasoregulation may reduce heat loss from the hand, the effect of body form, tissue thermogenesis, and body insulation on heat loss is unknown.

MATERIALS AND METHODS

Thermal imaging was used to determine heat loss during a 3-min ice-water hand immersion test carried out on 114 volunteers (female = 63, male = 51). Established anthropometric measures were used to quantify body size, and bioelectrical impedance analysis determined skeletal muscle and fat mass.

RESULTS

Skeletal muscle mass relative to body mass was a highly significant predictor of heat loss, while body mass, fat mass, and stature were not. Body composition and body size had little to no significant influence during rewarming after immersion.

DISCUSSION

The thermogenic properties of muscle mass support maintenance of hand temperature during severe cold exposure. The findings here suggest that muscular individuals are less susceptible to heat loss and cold injury, and may be better at manual tasks in cold conditions than nonmuscular individuals.

Cancer-related pain management: A review of knowledge and attitudes of healthcare professionals

Cancer-related pain (CRP) is common and many patients continue to experience pain in spite of advances in pain management modalities. The lack of knowledge, inadequate assessment of CRP and/or organisational factors, such as lack of time due to heavy workload, can be a barrier to effective pain management of healthcare professionals. The purpose was to examine the evidence with regard to the knowledge and attitudes towards practice of healthcare professionals in relation to CRP management. A search of the literature (1999-2015) was conducted searching databases and journals including CINAHL, MEDLINE, PsycINFO, PubMed, Science Direct and Wiley-Blackwell. The initial search revealed a total of 99 articles and following removal of those that did not meet the inclusion criteria, 19 articles were included in the final review. Recognition of the widespread under treatment of CRP has prompted recent corrective efforts in terms of education from healthcare professionals, however, there is a continuing deficit in healthcare professionals' knowledge with regard to CRP management and indicated that healthcare professionals still have negative attitudes that hinder the delivery of quality care to patients suffering from CRP. Further research on how and where education on this topic should be delivered is required.

Integrated palliative care in Europe: a qualitative systematic literature review of empirically-tested models in cancer and chronic disease

BACKGROUND

Integrated Palliative Care (PC) strategies are often implemented following models, namely standardized designs that provide frameworks for the organization of care for people with a progressive life-threatening illness and/or for their (in)formal caregivers. The aim of this qualitative systematic review is to identify empirically-evaluated models of PC in cancer and chronic disease in Europe. Further, develop a generic framework that will consist of the basis for the design of future models for integrated PC in Europe.

METHODS

Cochrane, PubMed, EMBASE, CINAHL, AMED, BNI, Web of Science, NHS Evidence. Five journals and references from included studies were hand-searched. Two reviewers screened the search results. Studies with adult patients with advanced cancer/chronic disease from 1995 to 2013 in Europe, in English, French, German, Dutch, Hungarian or Spanish were included. A narrative synthesis was used.

RESULTS

14 studies were included, 7 models for chronic disease, 4 for integrated care in oncology, 2 for both cancer and chronic disease and 2 for end-of-life pathways. The results show a strong agreement on the benefits of the involvement of a PC multidisciplinary team: better symptom control, less caregiver burden, improvement in continuity and coordination of care, fewer admissions, cost effectiveness and patients dying in their preferred place.

CONCLUSION

Based on our findings, a generic framework for integrated PC in cancer and chronic disease is proposed. This framework fosters integration of PC in the disease trajectory concurrently with treatment and identifies the importance of employing a PC-trained multidisciplinary team with a threefold focus: treatment, consulting and training.

Parental decision-making on utilisation of out-of-home respite in children's palliative care: findings of qualitative case study research - a proposed new model

BACKGROUND

Respite in children's palliative care aims to provide a break for family's from the routine of caring. Parental decision-making regarding the utilisation of out-of-home respite is dependent on many interlinking factors including the child's age, diagnosis, geographical location and the family's capacity to meet their child's care needs. A proposed model for out-of-home respite has been developed based on the findings of qualitative case study research.

METHODS

Utilising multiple, longitudinal, qualitative case study design, the respite needs and experiences of parents caring for a child with a life-limiting condition were explored. Multiple, in-depth interviews were undertaken with the parents identified by a hospital-based children's palliative care team. Data were analysed using thematic analysis. Each individual case consists of a whole study. Cross-case comparison was also conducted.

RESULTS

Nine families were recruited and followed for two years. A total of 19 in-depth interviews were conducted with mothers and fathers (one or both) caring for a child with a life-limiting condition in Ireland. Each family reported vastly different needs and experiences of respite from their own unique perspective. Cross-case comparison showed that for all parents utilising respite care, regardless of their child's age and condition, home was the location of choice. Many interlinking factors influencing these decisions included: past experience of in-patient care, and trust and confidence in care providers. Issues were raised regarding the impact of care provision in the home on family life, siblings and the concept of home.

CONCLUSION

Respite is an essential element of children's palliative care. Utilisation of out-of-home respite is heavily dependent on a number of interlinked and intertwined factors. The proposed model of care offers an opportunity to identify how these decisions are made and may ultimately assist in identifying the elements of responsive and family-focused respite that are important to families of children with life-limiting conditions.

Large-scale discovery of novel genetic causes of developmental disorders

Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.

The prevalence of medical reasons for non-participation in the Scottish breast and bowel cancer screening programmes

Objective

Increasing uptake of cancer screening is a priority for health systems internationally, however, some patients may not attend because they are undergoing active treatment for the cancer of interest or have other medical reasons that mean participation would be inappropriate. This study aims to quantify the proportion of non-participants who have a medical reason for not attending cancer screening.

Methods

Medical reasons for not participating in breast and bowel screening were defined a priori on the basis of a literature review and expert opinion. The notes of 700 patients at two GP practices in Scotland were reviewed, to ascertain the prevalence of medical reasons amongst non-participants. Simple proportions and confidence intervals were calculated.

Results

17.4% of breast and 2.3% of bowel screening non-participants had a medical reason to not participate. The two most common reasons were previous breast cancer follow up (8.86%) and recent mammogram (6.57%).

Conclusion

These patients may not benefit from screening while also being distressed by receiving an invitation. This issue also makes accurate monitoring and target-setting for improving uptake difficult. Further work is needed to estimate robustly the extent to which medical reasons account for screening non-participation in a larger population.