Traditional crafting as a catalyst for Indigenous women's intergenerational cohesion and wellness: a Canadian perspective

Indigenous crafting practices are increasingly being recognised for their benefit to community connectedness, health, cultural identity, and individual wellbeing. This article explores published literature to determine the role of Indigenous crafting in transferring traditional and cultural teachings from female relatives and Elders to girls and younger women. We examine the effect of crafting on intergenerational cohesion and social connectedness within the Indigenous community. Does crafting serve as an effective conduit for physical, spiritual, emotional, and mental change in learners and teachers? Our review identifies 12 publications that describe Indigenous mostly girls and younger women's experiences as they acquire female Elders', teachers' and older family members' traditional and cultural teachings while participating in crafting activities. The papers identify an array of traditional and cultural activities including: basket weaving, beading, sewing, language acquisition, traditional songs, traditional dance, and storytelling. More contemporary forms of artistic expression such as photography, theatre and film production are also included. Research findings show that learning, teaching and practicing Indigenous crafting is associated with increased intergenerational cohesion, cultural connectedness, and wellbeing for both teachers and learners. Further, learning about Indigenous crafts and activities helps inspire pride in Indigenous identity and promotes healing from historical trauma.

Development and validation of a case definition for problematic menopause in primary care electronic medical records

BACKGROUND

Menopause is a normal transition in a woman's life. For some women, it is a stage without significant difficulties; for others, menopause symptoms can severely affect their quality of life. This study developed and validated a case definition for problematic menopause using Canadian primary care electronic medical records, which is an essential step in examining the condition and improving quality of care.

METHODS

We used data from the Canadian Primary Care Sentinel Surveillance Network including billing and diagnostic codes, diagnostic free-text, problem list entries, medications, and referrals. These data formed the basis of an expert-reviewed reference standard data set and contained the features that were used to train a machine learning model based on classification and regression trees. An ad hoc feature importance measure coupled with recursive feature elimination and clustering were applied to reduce our initial 86,000 element feature set to a few tens of the most relevant features in the data, while class balancing was accomplished with random under- and over-sampling. The final case definition was generated from the tree-based machine learning model output combined with a feature importance algorithm. Two independent samples were used: one for training / testing the machine learning algorithm and the other for case definition validation.

RESULTS

We randomly selected 2,776 women aged 45-60 for this analysis and created a case definition, consisting of two occurrences within 24 months of International Classification of Diseases, Ninth Revision, Clinical Modification code 627 (or any sub-codes) OR one occurrence of Anatomical Therapeutic Chemical classification code G03CA (or any sub-codes) within the patient chart, that was highly effective at detecting problematic menopause cases. This definition produced a sensitivity of 81.5% (95% CI: 76.3-85.9%), specificity of 93.5% (91.9-94.8%), positive predictive value of 73.8% (68.3-78.6%), and negative predictive value of 95.7% (94.4-96.8%).

CONCLUSION

Our case definition for problematic menopause demonstrated high validity metrics and so is expected to be useful for epidemiological study and surveillance. This case definition will enable future studies exploring the management of menopause in primary care settings.

Assessing young adults' menopause knowledge to increase understanding of symptoms and help improve quality of life for women going through menopause; a student survey

BACKGROUND

Due to menopause being a largely invisible and under-discussed topic in wider society, women often deal with menopause-related complications on their own. Social support and awareness have been shown to reduce negative menopausal experiences; however, lack of menopause knowledge, particularly among younger people, may deter support for women suffering from menopause symptoms. This study aims to assess the level of knowledge young adults have on menopause to be able to create interventions that target knowledge gaps and increase understanding of women's experiences and difficulties during their menopause transition.

METHODS

We created an electronic questionnaire based on menopause literature and guidelines from Menopause Societies. It was pilot-tested on young people in the target group age (n = 14; 7 male and 7 female), menopause clinicians (n = 5), and women experiencing menopause (n = 4). The final survey included questions on participant demographics, general menopause knowledge, and options to support menopause management and was distributed through university student newsletters. Responses over a two week period were collected anonymously. Descriptive statistics were applied to characterize participants, define menopause knowledge, and identify gaps. Chi-squared statistics was used for group comparison, and open questions were analyzed using qualitative content analysis.

RESULTS

Survey responses were collected from 828 students; the average age was 22.1 ± 5.1 and 83.6% were female. Participants belonged to all faculties and included students from a variety of family settings and living conditions. Knowledge questions revealed a good understanding of the basic menopause physiology for most respondents, but there were gaps in understanding of symptoms and symptom management. Female sex and personal connection to menopausal women had a positive effect on the degree of menopause knowledge. Both males and females reported increased knowledge confidence at the end of the survey.

CONCLUSION

Our survey provides evidence that young adults of both sexes have a general baseline knowledge of menopause and its symptoms and are open to learning strategies to help support menopausal women. Our findings will assist in developing targeted educational resources to increase social support and awareness, reduce stigma and improve the quality of life for menopausal women, and help prepare younger women for their future menopause journey.

Nehiyawak (Cree) women's strategies for aging well: community-based participatory research in Maskwacîs, Alberta, Canada, by the Sohkitehew (Strong Heart) group

BACKGROUND

The Sohkitehew (Strong Heart) Research Group, which included an Elders Advisory Committee of seven Nehiyawak (Cree) women, set out to bring Maskwacîs community members together to understand Nehiyawak women's experiences of "aging well". The goals of this research were to generate information honouring Indigenous ways of knowing, and gather strengths-based knowledge about aging well, to help Maskwacîs, women maintain wellness as they age.

METHODS

We facilitated qualitative Sharing Circles in three different settings in Maskwacîs. Discussions were prompted using the four aspects of the self, guided by Medicine Wheel teachings: Physical, Mental, Emotional, Spiritual. Detailed notes were recorded on flip charts during the discussions of each Sharing Circle. Data were analysed using descriptive content analysis to identify practical strategies for aging well.

RESULTS

Thirty-six community members attended one or more Sharing Circle. Strategies included: Physical-keeping active to remain well; Mental-learning new skills to nourish your mind; Emotional-laughing, crying, and being happy; Spiritual-practicing Nehiyawak traditional ways. Participants commented that balancing these four aspects of the self is necessary to achieve wellness. Following the analysis of the Sharing Circle comments, three community feedback sessions were held to discuss the results in the wider community. These strategies were formatted into a draft booklet which incorporated Cree language, and archive photographs of Maskwacîs women and families.

CONCLUSIONS

The Nehiyawak Sharing Circles identified practical strategies that help women to remain well as they age. This positive approach to aging could be adopted in other Indigenous and non-Indigenous communities.

Cannabis use for menopause in women aged 35 and over: a cross-sectional survey on usage patterns and perceptions in Alberta, Canada

OBJECTIVE

Use of cannabis for medical reasons has increased in Canada since legalisation of recreational cannabis in 2018. The objective of this study was to examine the pattern of use and perceptions about cannabis for menopause in women aged 35 and over in Alberta, Canada.

DESIGN

Cross-sectional, web-based survey.

SETTING

Online (location of participant residence in Alberta, Canada).

PARTICIPANTS

Self-selected sample of women recruited through social media (Facebook, Instagram, Twitter) between October and December 2020. Inclusion criteria included: identified as woman, ages 35 and over, living in Alberta, Canada.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Self-reported data were collected on demographics, menopause status and symptoms, cannabis usage and how participants perceived cannabis. Descriptive statistics, comparative analysis and logistic regression explored relations in cannabis use and participant characteristics.

RESULTS

Of 1761 responses collected, 1485 were included for analysis. Median age was 49 years; 35% were postmenopausal and 33% perimenopausal. Among analysed responses, 499 (34%) women reported currently using cannabis and 978 (66%) indicated ever using cannabis. Of the 499 current cannabis users, over 75% were using cannabis for medical purposes. Most common reasons for current use were sleep (65%), anxiety (45%) and muscle/joint achiness (33%). In current users, 74% indicated that cannabis was helpful for symptoms. Current cannabis users were more likely to report experiencing menopause symptoms compared with non-users. History of smoking and general health status were associated with current cannabis use.

CONCLUSIONS

Some women are using cannabis for symptoms related to menopause. Further research is required to assess safety and efficacy of cannabis for managing menopause and develop clinical resources for women on cannabis and menopause.

Genome-wide gene expression responses to experimental manipulation of Saccharomyces cerevisiae repressor activator protein 1 (Rap1) expression level

Precise regulation of transcription in gene expression is critical for all aspects of normal organism form, fitness, and function and even minor alterations in the level, location, and timing of gene expression can result in phenotypic variation within and between species including evolutionary innovations and human disease states. Eukaryotic transcription is regulated by a complex interplay of multiple factors working both at a physical and molecular levels influencing this process. In Saccharomyces cerevisiae, the TF with the greatest number of putative regulatory targets is the essential gene Repressor Activator Protein 1 (RAP1). While much is known about the roles of Rap1 in gene regulation and numerous cellular processes, the response of Rap1 target genes to systematic titration of RAP1 expression level remains unknown. To fill this knowledge gap, we used a strain with a tetracycline-titratable promoter replacing wild-type regulatory sequences of RAP1 to systematically reduce the expression level of RAP1 and followed this with RNA sequencing (RNA-seq) to measure genome-wide gene expression responses. Previous research indicated that Rap1 plays a significant regulatory role in particular groups of genes including telomere-proximal genes, homothallic mating (HM) loci, glycolytic genes, DNA repair genes, and ribosomal protein genes; therefore, we focused our analyses on these groups and downstream targets to determine how they respond to reductions in RAP1 expression level. Overall, despite being known as both an activator and as a repressor of its target genes, we found that Rap1 acts as an activator for more target genes than as a repressor. Additionally, we found that Rap1 functions as an activator of ribosomal protein genes and a repressor of the silent mating locus genes consistent with predictions from the literature. Unexpectedly, we found that Rap1 functions as a repressor of glycolytic enzyme genes contrary to prior reports of it having the opposite effect. We also compared the expression of RAP1 to five different genes related to DNA repair pathway and found that decreasing RAP1 downregulated four of those five genes. Finally, we found no effect of RAP1 depletion on telomere-proximal genes despite its functioning to silence telomeric repeat-containing RNAs. Together our results enrich our understanding of this important transcriptional regulator. The graphical abstract is provided as a supplementary fig. (S-Fig 1).

The (commercialised) experience of operating: Embodied preferences, ambiguous variations and explaining widespread patient harm

This article provides a detailed account of how surgeons perceived and used a device-procedure that caused widespread patient harm: transvaginal mesh for the treatment of pelvic floor disorders in women. Drawing from interviews with 27 surgeons in Canada, the UK, the United States and France and observations of major international medical conferences in North America and Europe between 2015 and 2018, we describe the commercially driven array of operative variations in the use of transvaginal mesh and show that surgeons' understanding of their hands-on, sensory experience with these variations is central to explaining patient harm. Surgeons often developed preferences for how to manage actual and anticipated dangers of transvaginal mesh procedures through embodied operative adjustments, but collectively the meaning of these preferences was fragmented, contested and deferred. We critically reflect on surgeons' understandings of their operative experience, including the view that such experience is not evidence. The harm in this case poses a challenge to some ways of thinking about uncertainty and errors in medical sociology, and calls for attention to a specific feature of surgical work: the extent and persistence of operative practices that elude classification as right or wrong but are still most certainly better and worse.

Amoebic crab disease (ACD) in edible crab Cancer pagurus from the English Channel, UK

The genera Paramoeba and Neoparamoeba (Amoebozoa, Dactylopodida, Paramoebidae) include well-known opportunistic pathogens associated with fish (N. peruans; amoebic gill disease), lobsters, molluscs and sea urchins, but only rarely with crabs (grey crab disease of blue crabs). Following reports of elevated post-capture mortality in edible crabs Cancer pagurus captured from a site within the English Channel fishery in the UK, a novel disease (amoebic crab disease, ACD) was detected in significant proportions of the catch. We present histopathological, transmission electron microscopy and molecular phylogenetic data, showing that this disease is defined by colonization of haemolymph, connective tissues and fixed phagocytes by amoeboid cells, leading to tissue destruction and presumably death in severely diseased hosts. The pathology was strongly associated with a novel amoeba with a phylogenetic position on 18S rRNA gene trees robustly sister to Janickina pigmentifera (which groups within the current circumscription of Paramoeba/Neoparamoeba), herein described as Janickina feisti n. sp. We provide evidence that J. feisti is associated with ACD in 50% of C. pagurus sampled from the mortality event. A diversity of other paramoebid sequence types, clustering with known radiations of N. pemaquidensis and N. aestuarina and a novel N. aestuarina sequence type, was detected by PCR in most of the crabs investigated, but their detection was much less strongly associated with clinical signs of disease. The discovery of ACD in edible crabs from the UK is discussed relative to published historical health surveys for this species.

POS1060 CHANGES IN DISEASE ACTIVITY AND PATIENT-REPORTED OUTCOMES IN PSORIATIC ARTHRITIS PATIENTS TREATED WITH IXEKIZUMAB IN A REAL-WORLD US COHORT

Background

Ixekizumab (IXE), an IL-17A inhibitor, has demonstrated efficacy in clinical trials1-3 but real-world effectiveness (RWE) data are limited.4

Objectives

To describe changes in disease activity and patient-reported outcomes (PROs) at 6 and 12 months follow-up among psoriatic arthritis (PsA) patients initiating IXE in a routine clinical setting.

Methods

This retrospective cohort study included patients from the OM1 PsA Registry (OM1, Boston, MA), a linked electronic medical record and administrative claims dataset with over 50,000 patients. Eligible patients had ≥1 prescription for IXE (first = index), were ≥18 years old at index, had ≥1 diagnosis code for PsA in the 12 months before or on index, and had ≥12 months of baseline and ≥6 months of follow-up data as of June 2021. For patients with baseline and follow-up measures available, changes in Clinical Disease Activity Index (CDAI), PROs, and other clinical outcomes from baseline to 6 and 12 months were described. For patients on IXE monotherapy, change in CDAI score from baseline to 6 and 12 months was assessed using mixed effects linear models adjusted for age, sex, and baseline CDAI score.

Results

The study population included 1,812 patients with a mean age of 53.7 years (Table 1). Psoriasis was present in 82% and enthesitis in 28%. Over 60% of patients were obese, and the mean Charlson Comorbidity Index was 1.3. Most patients (84%) had prior treatment with a biologic disease-modifying antirheumatic drug (bDMARD) and 40% with a targeted synthetic DMARD (tsDMARD). The mean number of bDMARDs and tsDMARDs used during all available prior history was 2.3 and 1.1, respectively. The most common prior bDMARDs were secukinumab (n=428, 24%) and adalimumab (n=245, 14%).

Table 1.

Demographic and Clinical Characteristics by Therapy Status

All Patients(N=1,812)Monotherapy(N=1,485)Combination Therapy(N=327)Age (years)Mean (s.d.)53.7 (12.2)53.9 (12.3)52.9 (11.7)Median (Q1-Q3)55 (46-62)55 (46-62)54 (45-61)SexFemale1,108 (61.1%)909 (61.2%)199 (60.9%)Male704 (38.9%)576 (38.8%)128 (39.1%)Charlson Comorbidity IndexMean (s.d.)1.3 (1.6)1.3 (1.6)1.5 (1.7)Median (Q1-Q3)1 (0-2)1 (0-2)1 (0-2)BMIUnderweight: <18.510 (0.6%)10 (0.7%)0 (0.0%)Normal weight: 18.5-24.9210 (12.2%)172 (12.2%)38 (12.1%)Overweight: 25-29.9455 (26.5%)379 (27.0%)76 (24.2%)Obese: >= 301,045 (60.8%)845 (60.1%)200 (63.7%)Missing927913Domains of PsA: PsoriasisYes1,490 (82.2%)1,222 (82.3%)268 (82.0%)No322 (17.8%)263 (17.7%)59 (18.0%)Domains of PsA: EnthesitisYes510 (28.1%)409 (27.5%)101 (30.9%)No1,302 (71.9%)1,076 (72.5%)226 (69.1%)

Of patients with a baseline CDAI score, 61% had moderate or severe disease activity. For all patients, CDAI scores improved (decreased) by an average of 3.4 and 3.7 points at 6 and 12 months, respectively, from a baseline mean of 15.4. All disease activity measures and PROs improved from baseline to 6 and 12 months (Figure 1). In patients persistent with IXE, 35.3% and 33.7% were in CDAI remission or low disease activity at 6 and 12 months after initiation, respectively. For IXE monotherapy users (82% of patients), at baseline, patients had a mean CDAI of 14.3 (n=131) and 15.1 (n=105) for the 6 and 12 month analyses, respectively. Adjusted mean changes in CDAI from baseline to 6 months (-3.6 points, p < 0.0001) and 12 months (-4.9 points, p < 0.0001) were statistically significant.

Conclusion

In this cohort of PsA patients with multiple prior b/tsDMARD failures, improvements in disease activity and PROs were observed at 6 and 12 months after initiating treatment with IXE. Improvements were observed in patients overall and in the monotherapy subgroup. More real-world research on IXE and other bDMARDs are important to understand the effect of treatment choices on clinical and PROs in both bDMARD-naive and experienced PsA patients.

References

[1]Mease PJ. Ann. Rheum. Dis. 2017;76(1):79-87

[2]Nash P. Lancet. 2017;389(10086):2317-2327

[3]Mease PJ. Ann. Rheum. Dis. 2020;79(1):123-131

[4]Berman J. Biologics. 2021 Nov 18;15:463-470

Disclosure of Interests

Julie Birt Shareholder of: Shareholder of Eli Lilly and Company, Employee of: Employee of Eli Lilly and Company, William Tillett Speakers bureau: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, MSD, Novartis,, Pfizer, UCB, Consultant of: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Pfizer, UCB, Grant/research support from: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, UCB, Cristi Cavanaugh: None declared, Yoojin Jung: None declared, Aisha Vadhariya Shareholder of: Shareholder of Eli Lilly and Company, Employee of: Employee of Eli Lilly and Company, Sarah Ross Shareholder of: Shareholder of Eli Lilly and Company, Employee of: Employee of Eli Lilly and Company, Jess Paulus: None declared, Aubrey Trevelin Sprabery Shareholder of: Shareholder of Eli Lilly and Company, Employee of: Employee of Eli Lilly and Company, Ennio Lubrano: None declared

Impact of homeometric autoregulation using a stepwise change in heart rate on dP/dtmax and time to peak dP/dt with resynchronization therapy

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Norwegian South East heath Authorities

Background

We investigated the homeometric autoregulation utilizing a stepwise change in heart rate on dP/dtmax and time to peak dP/dt (Td) with biventricular pacing (BIVP) and the LV lead positioned in the apical, anterior and lateral positions. Pacing at low HR (LHR) and high heart rates (HHR) changes contractility through homeometric autoregulation (Bowditch effect) without changing the resynchronization itself.

Purpose

To determine the effect of a change in contractility through homeometric autoregulation on two different effect measures of resynchronization therapy.

Methods

Twenty-nine patients in heart failure with LBBB underwent CRT implantation with continuous LV pressure registration. The LV lead was first placed in either apical or anterior position followed by a permanent placement in a lateral position. Sequential BIVP pacing was performed for one minute, at a rate 10% above intrinsic heart rate (LHR = 75 ± 9bpm), before dP/dtmax measurements were recorded, and the sequence was repeated with pacing rate increased by 30% (HHR = 98 ± 11bpm). Td was defined as the time from pacemaker stimuli to peak dP/dt. Mixed linear models were used for statistics, numbers are estimated marginal means ± SEM. Significance was set at p &lt; 0.05.

Results

DP/dtmax was higher with HHR in lateral position (1036 ± 41mmHg/s) than with LHR (933mmHg/s). The same was observed for all other lead positions. However, there was no difference between lateral position with LHR and apical position with HHR (930 ± 44mmHg/s). There were no differences in Td between LHR and HHR, but Td was shorter with BIVP in lateral position at pacing LHR (158 ± 4ms) and HHR (155 ± 4ms) than in all other positions. Overall dP/dtmax increased by 10% from LHR to HHR (888 ± 41mmHg/s vs. 980 ± 41 mmHg/s), while overall Td decreased by 2.4% from 168 ± 4ms to 164 ± 4ms. We found a linear relationship between Td and dP/dtmax (R = 0.7) with β=-0.07 that would indicate a 6ms reduction in Td going from LHR to HHR. The overall change in Td from LHR to HHR could therefore be attributed to the change in dP/dtmax.

Conclusion

Homeometric regulation does not influence Td, but Td is sensitive to changes in resynchronization and pacing lead position. Td is shorter with BIVP in lateral position at both high and low HR as would be expected from a biomarker of resynchronization. HR influences dP/dtmax so distinction between optimal and non-optimal positions using dP/dtmax may be difficult without knowledge of homeometric state.

The missing link- time to maximal rate of left ventricular pressure rise reflects resynchronization with biventricular pacing in patients with heart failure and left bundle branch block

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Norwegian South East Health Authorities

Introduction

Resynchronization therapy effectively restores myocardial function. No measures exist that specifically quantifies resynchronization. A parameter that quantifies resynchronization should be able to detect effective resynchronization and should not respond to changes in contractility caused by heterometric regulation.  Left ventricular pacing (LVP) is associated with dyssynchronous contraction patterns, while biventricular pacing (BIVP) promotes resynchronization dependent on the pacing position of the LV electrode.

Purpose

We compared the acute differences between BIVP and LVP with regards to the preload dependent maximum rate of the LV pressure rise (dP/dtmax), and time to peak dP/dt (Td) to determine which better reflect dyssynchrony and resynchronization.

Methods

Twenty nine patients in heart failure with LBBB underwent CRT implantation with continuous LV pressure registration. The LV lead was first placed in either apical or anterior position followed by a permanent placement in a lateral position. Sequential LVP and BIVP pacing were performed for one minute, at a rate 10% above intrinsic heart rate, before dP/dtmax measurements were recorded. For LVP, BIVP and RVP a patient specific AV delay was used to avoid fusion with intrinsic conduction. Td was defined as the time from pacemaker stimuli to peak dP/dt. Mixed linear models were used for statistics, numbers are estimated marginal means ± SEM and are only reported when with significance set at p &lt; 0.05.

Results

We found no differences in dP/dtmax between BIVP (899 ± 37mmHg/s) and LVP (910 ± 37mmHg/s), while RVP (799 ± 37mmHg/s) was lower. Td was lower with BIVP (165 ± 4ms) than LVP (178 ± 4ms) and RVP (184 ± 4ms).  We found no differences in dP/dtmax between lateral (890 ± 35mmHg/s) and anterior (874 ± 38mmHg/s) while apical (824 ± 38mmHg/s) was lower. Td was lower in lateral (171 ± 4ms) than in anterior (179 ± 4ms) and apical (182 ± 4ms) positions. BIVP in lateral position (158 ± 4ms) was lower than any other pacingmode*position, with BIVP*anterior at 173 ± 4ms) and LVP*lateral at 170 ± 2ms. No difference was seen in dP/dtmax between  (BIVP + LVP)*(lateral + anterior) that was higher than all other pacingmode*positions.

Conclusion

Td shortens with BIVP and lateral position, and even more so with BIVP in lateral position and thus reflects resynchronization compared to all other combinations tested. DP/dtmax did not reflect resynchronization as BIVP/LVP and lateral/anterior performs equally good. There are no differences between dP/dtmax with any combination of pacing mode (BIVP + LVP) with position (anterior + lateral). This suggests that Td reflects resynchronization while dP/dtmax does not. Resynchronization with biventricular pacing in lateral position translates into a shorter Td and hence links electrical and mechanical events. Td could be the missing link between electrical and mechanical dyssynchrony and may serve as a biomarker for cardiac resynchronization therapy.

Time delay to peak left ventricular pressure rise identifies the substrate for dyssynchronous heart failure and detects disease modification with resynchronization- an observational clinical study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Norwegian South East Health Authorities

Introduction

Identification of disease modification prior to implantation of Cardiac Resynchronization Therapy may help select the right patients, increase responder-rates and promote the utilization of CRT. We tested the hypothesis that shortening of time-to-peak left ventricular pressure rise (Td) with CRT is useful to predict long-term volumetric response (End-systolic volume (ESV) decrease &gt;15%) to CRT.

Methods

Forty-five heart failure patients admitted for CRT implantation with a class I/IIa indication according to current ESC/AHA guidelines were included in the study. Td was measured from onset QRS at baseline and from onset of pacing with CRT.

Results

Baseline characteristics were mean age 63 ± 10 years , 71% males, NYHA class 2.5, 87% LBBB, QRS duration 173 ± 15ms, EF biplane 31 ± 1%, ESV 144 ± 12mL and end-diastolic volume 2044 ± 14mL. At 6-months follow-up six patients increased ESV by 5 ± 8%, while 37 responders (85%) had a mean ESV decrease of 40 ± 2%.  Responders presented with a higher Td at baseline compared to non-responders (163 ± 4ms vs 119 ± 9ms, p &lt; 0.01). Td decreased to 156 ± 4ms (p = 0.02) with CRT in responders, while in non-responders Td increased to 147 ± 10ms (p &lt; 0.01) with CRT. A decrease in Td of less than +3.5ms from baseline accurately identified responders to therapy (AUC 0.98, p &lt; 0.01, sensitivity 97%, specificity 100%). AUC was 0.92 for baseline Td and a cut-off at 120ms yielded a sensitivity of 100% and specificity of 80% to identify volumetric responders. A linear relationship between the change in Td from baseline and ESV decrease on long term was found (β=-61, R = 0.58, P &lt; 0.01).

Conclusions

Td at baseline and the shortening of Td with CRT accurately identifies responders to CRT, with incremental value on top of current guidelines, in a population with already high response rates. Td carries the potential to become the marker for prediction of long-term volumetric response in CRT candidates. Abstract Figure.

Menopause experience in First Nations women and initiatives for menopause symptom awareness; a community-based participatory research approach

BACKGROUND

Little research has been conducted about menopause in First Nations women. In response to the wishes of Cree women living in Maskwacis, Alberta, to start a dialogue on menopause, we undertook community-based participatory research (CBPR) to explore menopause experience and raise awareness of menopause symptoms in the community.

METHODS

The research adhered to the principles of Ownership, Control, Access and Possession (OCAP™) and was guided by the interest of the participating women. Local women (target age 40-65 years) were invited to participate in workshops using word-of-mouth and community posters in health centers. Five research workshops were held in community settings, attended by experienced women's health researchers and consenting women. The participants guided the informal discussions. They also completed questionnaires which included menopause-related quality of life. The researchers used extensive hand-written field notes to record data; qualitative content analysis was applied to identify themes. Simple descriptive analysis was used for the questionnaire results. The findings were discussed at a community feedback session and laid the basis for further knowledge translation initiatives.

RESULTS

The five workshops included a total of 37, mostly post-menopausal women with 6-11 women/workshop. The main discussion themes were: "experiences of menopause symptoms" including their impact on quality of life; "menopause knowledge prior to their own experience" with most women feeling that they had insufficient information before menopause; "menopause symptom management" which mainly included practical strategies; "impact of menopause on family members" which was of prime concern with uncontrollable mood changes affecting the whole family and sometimes causing matrimonial disharmony. Questionnaire responses corroborated the workshop discussions. Knowledge translation of the research findings produced two information pamphlets specifically for the Maskwacis community: one for husband/partner, the other for women and family members. These pamphlets have been distributed in all areas of the community.

CONCLUSION

This CBPR project addressed a topic identified by the community as being important. Community members developed informative pamphlets in response to the women's concern of lack of understanding for menopause symptoms among families. This simple solution has been widely accepted by community members, opening the possibility of wider discussion about menopause.

Evidence of Three-Dimensional Asymmetries Seeded by High-Density Carbon-Ablator Nonuniformity in Experiments at the National Ignition Facility

Inertial confinement fusion implosions must achieve high in-flight shell velocity, sufficient energy coupling between the hot spot and imploding shell, and high areal density (ρR=∫ρdr) at stagnation. Asymmetries in ρR degrade the coupling of shell kinetic energy to the hot spot and reduce the confinement of that energy. We present the first evidence that nonuniformity in the ablator shell thickness (∼0.5% of the total thickness) in high-density carbon experiments is a significant cause for observed 3D ρR asymmetries at the National Ignition Facility. These shell-thickness nonuniformities have significantly impacted some recent experiments leading to ρR asymmetries on the order of ∼25% of the average ρR and hot spot velocities of ∼100  km/s. This work reveals the origin of a significant implosion performance degradation in ignition experiments and places stringent new requirements on capsule thickness metrology and symmetry.

Developing and evaluating a patient decision aid for hormone therapy to manage symptoms of surgical menopause: the story behind the "SheEmpowers" patient decision aid

OBJECTIVES

To develop and evaluate an evidence-based patient decision aid (PDA) that can support women making decisions on hormone therapy (HT) for the management of early surgical menopause.

METHODS

The PDA development was guided by the Ottawa Decision Support Framework and the International Patient Decision Aid Standards and involved three phases: an exploratory phase to identify women's decisional needs; a development phase to identify evidence related to treatment options and draft initial prototype; and an evaluation phase to evaluate the prototype and elicit views on acceptability in women (N = 12). All phases were driven by a multidisciplinary group of researchers, clinicians, and patient stakeholders to ensure women's priorities were met.

RESULTS

A prototype PDA was drafted based on needs identified from the exploratory phase. The PDA has five domains: information on surgical menopause and HT; HT outcome probabilities; patient stories; values clarification; and guidance in deliberation. Participants in the evaluation phase perceived the tool as acceptable and offered suggestions for modifications.

CONCLUSION

Through our adopted, systematic approach the SheEmpowers PDA was developed to help women overcome deterrents to decision-making related to lack of knowledge, decision-making skills, and involvement in therapy decisions. The decisional effectiveness of the tool is to be assessed in future studies.

Walking together: women with the severe symptoms of menopause propose a platform for a walking program; outcome from focus groups

Background

Menopause and midlife are stages in a woman’s life that can be marked by debilitating symptoms and increasing risks for cancer, cardiovascular, metabolic, and bone health issues. Walking represents a simple, low cost, and widely accessible activity with proven health benefits, though its therapeutic effect on alleviating menopause symptoms is not well characterized. Women are generally not opposed to exercise programs; however, increasing or maintaining exercise levels remains a challenge. We undertook a qualitative descriptive study to explore features of a walking program that would be conductive to menopausal women’s participation, as well as to inform the development of such a program.

Methods

We conducted focus groups with women recruited from two menopause clinics and who suffered from moderate to severe menopause symptoms. The focus groups were audio recorded and transcribed. Women were prompted to talk about their menopause experience and exercise practice and how they would envision a walking exercise program that would keep them engaged. Qualitative content analysis was used to analyze the data and to identify characteristics of a walking exercise program.

Results

Twenty women participated in 5 focus groups. Women were very interested in trying walking as a means of staying healthy and possibly reducing menopause symptoms. Four major characteristics emerged as important for a walking program: (a) sensitivity to health realities of menopausal women, (b) inclusivity of various needs/levels of physical ability, (c) attentiveness to the need for mutual social support, (d) flexibility in planning of locations and scheduling.

A restricted social network platform with features catering to women in menopause was suggested as suitable to initiate and sustain an adequate walking program.

Conclusions

The findings of this study will be essential in designing a program that would be attractive for women to start and maintain a walking habit. The program would assist in elucidating whether walking is a useful and valuable alternative therapy for menopausal symptoms and, ultimately, might help women staying fit in midlife and postmenopausal.

From anatomy to patient experience in pelvic floor surgery: Mindlines, evidence, responsibility, and transvaginal mesh

Beginning in the late 1990s, surgeons around the world widely adopted the transvaginal placement of permanent synthetic mesh for the treatment of several common pelvic floor disorders in women. By 2012 it had become the subject of extensive litigation, including one of the biggest mass-tort cases in U.S. history, with litigants reporting debilitating and unexpected complications. Based on qualitative research that includes interviews with surgeons, observations of medical conferences, and analysis of archival materials, we argue the adoption of transvaginal mesh cannot be fully explained without recognizing the role of mindlines, or collective moral-epistemological ways of knowing and acting responsibly. The adoption of mesh was anchored in a mindline focused on repairing anatomy. The harms that resulted from transvaginal mesh necessitated a shift to a focus on patient experience. We analyze the role of evidence-based medicine (EBM) in the re-organization of these surgeons' mindlines, showing that mindlines are not reducible to evidence as defined by EBM and that evidence thus defined facilitated the adoption of transvaginal mesh.

Contraception Use and Attitudes Among Women Seeking Pregnancy Termination: Descriptive Cross-Sectional Survey

OBJECTIVE

Unintended pregnancy has been linked to poor health and social outcomes for both mother and child. Efforts to reduce unintended pregnancies have been challenged by many financial, social, religious, and cultural factors. This study aimed to investigate how contraception use and misuse in a cohort of females seeking termination of pregnancy contribute to unintended pregnancies.

METHODS

We conducted a cross-sectional study with women presenting to a women's health clinic for pregnancy termination from April to December 2017. Consenting participants completed a self-administered, confidential questionnaire that included questions on demographic, ethnic, and social characteristics, as well as behaviours and attitudes related to contraception. Data analysis used descriptive statistics.

RESULTS

Data were collected from 334 women; about half (45%) had used contraception at the time of conception, representing a variety of different methods. Contraceptive use was associated with higher education, stable relationship status, and ethnic majority status but not with previous pregnancies or immigration status. Among contraceptive users, imperfect and inconsistent use of contraception (50% and 31%, respectively), and method failure (48%), including condom breakage, were cited as reasons for the current pregnancy. Non-users reported perceived low risk of pregnancy (55%), concerns about contraception (47%), and problems accessing contraception (27%). While the majority of participants were aware of emergency contraception, only 52% reported ever using it. Most participants (89%) planned to use contraception in the future.

CONCLUSION

Our study highlights contraceptive behaviours and patterns of individuals seeking abortion. Patient-centered contraceptive counselling in order to facilitate contraceptive choice and access can include information about the most effective contraceptives and the need for back-up contraception methods.

Object Permanence, Reaching, and Locomotion in Infants who are Blind

This article reviews research and other work that suggests that congenital total blindness during infancy retards motor functions, most notably reaching for sound-making stimuli. Since there is a correlation between when infants who are blind begin to reach for rattles, bells, and the like and when sighted infants search for hidden toys in Piagetian experiments, it has been argued that for sound cues alone to elicit reaching, infants must first develop an object concept. Problems with this formulation are highlighted, and an alternative explanation is proposed that suggests possible interventions to redress the effects of congenital blindness on development.

Taking the Leap Toward Cost-Conscious Education in Obstetrics and Gynaecology: A Preliminary Randomized Controlled Trial

OBJECTIVE

Residents have a professional obligation with respect to the stewardship of health care resources, yet there is a paucity of research on how to improve residents' cost-awareness. Rising health care expenditures highlight a critical need to improve education related to this competency. This study aimed to test if an educational module can teach residents to make cost-conscious decisions and reduce health care spending.

METHODS

All Canadian obstetrics and gynaecology residents in 2017 were eligible to participate in this randomized controlled trial. The study was administered online via REDCap. Interested residents were enrolled, stratified by level of training, and block randomized. Residents completed a survey to determine their management of 4 obstetrical scenarios. The intervention group reviewed an educational module on cost-effective ordering prior to completing the survey; the control group was given the option to review the module afterward. The primary outcome was mean total expenditures, compared between the 2 groups using the t test.

RESULTS

Eighty-five residents were enrolled between August and November 2017, and 63 residents from 13 Canadian residency programs completed the study requirements (33 control and 30 intervention). Mean total expenditure was CAD$291.03 (95% CI 259.38-322.68) versus CAD$192.98 (95% CI 170.67-215.29) for the control and intervention groups, respectively. These figures corresponded to a 33.69% or CAD$98.05 reduction in total expenditures (P = 0.0001).

CONCLUSION

This educational module decreased expenditures by Canadian obstetrics and gynaecology residents managing hypothetical obstetrical cases. This introduces a potential curriculum innovation to improve resident education in judicious use of health care resources.

Pelvic floor disorders in women who consult primary care clinics: development and validation of case definitions using primary care electronic medical records

BACKGROUND

To date, there has been no validated method to identify cases of pelvic floor disorders in primary care electronic medical record (EMR) data. We aimed to develop and validate symptom-based case definitions for urinary incontinence, fecal incontinence and pelvic organ prolapse in women, for use in primary care epidemiologic or clinical research.

METHODS

Our retrospective study used EMR data from the Southern Alberta Primary Care Research Network (SAPCReN) and the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) in southern Alberta. Trained researchers remotely reviewed a random sample of EMR charts of women aged 18 years or older from 6 rural and urban clinics to validate case definitions for urinary incontinence, fecal incontinence and pelvic organ prolapse. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), and estimated SAPCReN prevalence as appropriate.

RESULTS

Charts of 900 women were included. Sensitivity was 81.9% (95% confidence interval [CI] 75.1-87.2) for urinary incontinence, 61.2% (95% CI 46.2-74.5) for fecal incontinence, and 51.8% (95% CI 40.6-62.8) for pelvic organ prolapse. Corresponding specificity values were 71.9% (95% CI 68.4-75.1), 99.2% (95% CI 98.2-99.6) and 98.8% (95% CI 97.7-99.4), PPVs 40.6% (95% CI 35.4-46.0), 81.1% (95% CI 64.3-91.4) and 81.1% (95% CI 67.6-90.1), and NPVs 94.4% (95% CI 92.1-96.1), 97.8% (95% CI 96.5-98.6) and 95.3% (95% CI 93.6-96.6). The SAPCReN-observed prevalence for urinary incontinence was 29.7% (95% CI 29.3-30.0), but the adjusted prevalence was 2.97%.

INTERPRETATION

The case definition for urinary incontinence met our standard for validity (sensitivity and specificity > 70%), and the case definitions for fecal incontinence and pelvic organ prolapse had PPVs greater than 80%. The urinary incontinence definition may be used in epidemiologic research, and those for fecal incontinence and pelvic organ prolapse may be used in quality-improvement studies or creation of disease registries. Our symptom-based case definitions could also be adapted for research in other EMR settings.

Screening Nitrate in Forages with a Test Strip: Collaborative Study

A collaborative study was conducted for screening nitrate in forages with a commercially available test strip. The method involves extracting a finely ground sample with deionized water. The test strip is dipped in the sample extract. The color of the reaction zone on the test strip changes from white to pink or purple depending on the nitrate concentration in sample extract. The nitrate present in the extract is determined by comparing the color of the test strip to the color scale on the test strip container. Six blind quintuplicates of forage samples were analyzed by 20 collaborators. Nitrate concentrations in forage samples tested ranged from &lt;1000 ppm nitrate to &gt;10 000 ppm nitrate on dry matter basis. Each collaborator was asked to assign each sample to one of the 4 following nitrate concentration ranges: (1) &lt;1000 ppm, (2) 1000 to 5000 ppm, (3)&gt;5000 ppm to 10 000 ppm, and (4) &gt;10 000 ppm. Nineteen of 20 collaborators reported results. Results from 2 laboratories were rejected as outliers by inspection and χ2 test. Sensitivity rates (p+) ranged from 0.965 to 0.998, with standard errors of 0.006 to 0.16. Specificity rates (p−) ranged from 0.991 to 0.997 for the 4 ranges, with standard errors of 0.003 to 0.006. False-positive rates (pf+) ranged from 0.006 to 0.046, with standard errors of 0.006 to 0.025. False-negative rates (pf−) ranged from 0.003 to 0.007, with standard errors of 0.003 to 0.006. Screening nitrate in forages with a test strip has been adopted first action by AOAC INTERNATIONAL.

Can a simple 'cost-awareness' campaign for laparoscopic hysterectomy change the use and costs of disposable surgical supplies? Pre-post non-controlled study

OBJECTIVES

Does a cost-awareness campaign for gynaecologists lead to a change in use and costs of disposable surgical supplies for laparoscopic hysterectomy (LH) without increasing hospital utilisation measures (operating room (OR) time or hospital length of stay (LOS))?

DESIGN

Pre-post non-controlled study. The OR database was used to identify relevant cases before and after the cost-awareness intervention, and provided information on quantity of each supply item, operative details and LOS.

SETTING

Lois Hole Hospital for Women, Edmonton, Alberta, Canada.

PARTICIPANTS

12 laparoscopic trained gynaecologists (7 female, 5 male) participated in both phases of the study. Eligible surgical cases were all LH cases for any indication for women aged ≥18 years. 201 cases were undertaken before the intervention (2011-2013) and 229 cases after the intervention (2016-2017).

INTERVENTION

The cost-awareness intervention for gynaecologists included site meetings and rounds providing information on costs of disposable and reusable instruments, a full day skills lab, OR posters about cost and effectiveness of disposable and reusable surgical supplies and demonstrations of reusable equipment (2015-2016).

PRIMARY OUTCOME MEASURE

Disposable supplies costs per case (standardised for 2016 unit costs).

RESULTS

There was a significant (p<0.05) reduction (unadjusted) in disposable supplies cost per case for LH between cases before and after the intervention: from $C1073, SD 281, to $C943 SD 209. Regression analysis found that the adjusted cost per case after the intervention was $C116 lower than before the intervention (95% CI -160 to -71). Neither OR time nor hospital LOS differed significantly between cohorts.

CONCLUSIONS

Our study suggests that cost-awareness campaigns may be associated with reduction in the cost of surgery for LH. However, many other factors may have contributed to this cost reduction, possibly including other local initiatives to reduce costs and emerging evidence indicating lack of effectiveness of some surgical practices.

B-50 Frequency of Sports-Related Concussion in Athletes with Neurodevelopmental Conditions

Objective

Research demonstrates that athletes with neurodevelopmental diagnoses may have a higher frequency of lifetime concussions (Iverson et al., 2016; Alosco, Fedor & Gunstad, 2014) possibly due to underlying attention, processing speed, or reaction time difficulties. The present study investigates concussion history and sports-related concussions between athletes with and without a history of neurodevelopmental disorders in a longitudinal, state-wide sample.

Method

Participants included 39,586 high school athletes (Mage = 15.18; 56.2% males) who were assessed pre and post-concussion with ImPACT between 2008 and 2016. There were 36,880 athletes (55.1% males) who did not report neurodevelopmental disorders and served as the control group and 2,706 athletes (71.4% males) in the clinical group who self-reported diagnosis of ADHD (55.6%), Learning Disability (LD;13.6%), Autism (3.2%), ADHD+LD (4.5%), and athletes in special education but no reported diagnosis (SpEd; 22%). Concussion frequency in each group was analyzed using chi-square analysis.

Results

Athletes were more likely to report prior concussions if they had a self-reported neurodevelopmental diagnosis (17%) compared to the control group (9%, χ2(1) = 112.11, p < .001). Odds ratios indicated that athletes with neurodevelopmental conditions were 1.43 times more likely to have a sports-related concussion.

Conclusions

Consistent with past research, results indicate that neurodevelopmental conditions are associated with greater lifetime risk of concussion, including sport-related concussions. Future studies may expand this research by examining underlaying causes of this increased risk in order to develop specific interventions to help reduce rates of concussion for this population.

B-55 Performance of ImPACT Validity Indices for Athletes with Neurodevelopmental Disorders

Objective

Research demonstrates neurodevelopmental diagnoses may increase likelihood of failing scores on ImPACT embedded validity indicators that flag questionable effort. New criteria have been proposed to enhance sensitivity of these indicators although their utility in athletes with neurodevelopmental diagnosis have not been thoroughly examined. This study investigates the effect of neurodevelopmental history on frequency of invalid performance on the standard and three proposed validity indicators.

Methods

Participants included 41,214 high school athletes (Mage = 15.1; 44.2% female; Meducation = 9.1) who completed baseline ImPACT testing. Athletes included these groups: ADHD (3.7%), Learning Disability (LD; 1.5%), Autism (0.2%), ADHD+LD (0.6%), Autism+ADHD/LD (0.1%), athletes with special education history but no diagnosis reported (SpEd; 2.8%), and healthy athletes (91.1%). Odds ratios were calculated to determine differences in invalid performance by both standard and proposed cutoffs.

Results

Neurodevelopmental disorder was associated with increased invalid performance using standard and proposed cutoffs with odds ratios ranging from 1.32 to 3.25. Invalid performance differed significantly across groups for both standard and two sets of proposed criteria (chi square p < .00001). For standard cutoffs, athletes with ADHD, LD, and ADHD/LD were significantly more likely than healthy athletes to have invalid performance. This pattern remained similar across the two sets of proposed criteria.

Conclusions

Results indicate increased incidence of invalid ImPACT performance based on standard and proposed validity indicators in athletes who self-report neurodevelopmental disorders. Findings indicate current and proposed cutoffs may not accurately capture low effort for neurodevelopmental populations. Future research should examine utility of separate cutoff criteria and expanded norms for athletes with neurodevelopmental history.

Does Cost Influence the Choice of Disposable Versus Reusable Instruments? Mailed Survey of Obstetrician/Gynaecologists

OBJECTIVE

A "cost-awareness" campaign was undertaken at a tertiary hospital from 2015 to 2016 to raise awareness about costs of disposable versus reusable instruments in laparoscopic procedures. We undertook a before and after survey of obstetrician/gynecologists (Ob/Gyns) to find out if the campaign had affected their attitudes about choosing disposable versus less expensive reusable instruments.

METHODS

In 2015 (before the cost-awareness campaign) and 2017 (after the cost-awareness campaign), all full-time university-associated Ob/Gyns were mailed a cover letter, questionnaire, and coffee card ($5) with a postage-paid return envelope. Responses (with unique identification) from Ob/Gyns who perform laparoscopic procedures were entered into a password-protected REDCap database on a secure server. All statistical analyses were performed using SAS software version 9.4 (SAS Institute Inc, Cary, NC) (Canadian Task Force Classification II-3).

RESULTS

A total of 35 of 42 eligible Ob/Gyns (85%) with a median 10 years in practice completed questionnaires before and after the intervention. The majority had undertaken minimally invasive surgery training, mainly during residency (80%) and conferences (71%). Before the intervention, the three most important qualities influencing their decision to use a particular instrument were safety (66%), effectiveness (57%), and personal experience (49%). After the intervention, the three most important qualities were effectiveness (57%), safety (57%), and ease of use (46%). Device cost was ranked sixth (26%) before and seventh (17%) after the intervention. The majority (57%) of participants did not change their choice of disposable or reusable instruments, or they would make the choice according to the specific procedure.

CONCLUSION

Given the current economy, operative costs are constantly under review. Knowledge about Ob/Gyns' attitudes provides information to design more effective awareness campaigns to encourage use of less costly instruments. To change practice, a campaign increasing Ob/Gyns' exposure to less expensive but safe and effective instruments may help to increase uptake and potentially lead to cost reduction. Cost awareness alone is unlikely to change practice.

P81 Intraoperative MEP recordings from a urethral sphincter electrode for spinal conus tumour surgery and its importance

Objectives

To emphasise the importance of motor evoked potential (MEP) recordings from a simple urethral sphincter electrode along with routine use of bulbocavernosus reflex recordings, anal sphincter and other lower limb muscle free running and stimulated EMG and MEP’s, and SEP techniques for sphincter preservation.

Design

Case report.

Subjects

Patients with conus or other spinal lesions at risk of postoperative sphincter disturbance.

Methods

Transcranial ‘train of 5’ stimulation (5 pulses, interstimulus interval 4msec, 200 µsec pulse width) was applied, with recordings from the urethral sphincter (small electrode taped to Foley catheter to lie just inside the urethra, referred to nearby needle anteriorly in mons pubis) and anal sphincter (paired needle electrodes in both left and right sides of external sphincter).

Results

Intraoperative stimuli of structures during dissection at one point gave a motor response confined to the urethral sphincter suggesting that these fibres may have been considered non-functional and cut had these not been assessed separately. Urethral sphincter MEP’s during the dissection confirmed that these motor fibres remained in continuity throughout.. The patient was intact after tumour removal.

Conclusions

This is an avant-garde technique by which we managed to save the nerve supply to the urethral sphincter and eventually urinary continence which would have been compromised if separate urethral monitoring was not attempted along with usual intraoperative nerve monitoring. We believe its first in the UK.

Note on Color Preference and Color Vision Test Performance

The incidence of color deficient vision was investigated using the Pseudo-Isochromatic Plates on a relatively large and representative group. in the sample of 112 adults aged 20 to 80 yr. and comprised of 53% women and 12% minorities, 8% of men and 3% of women were color deficient. Over-all performance indicated no effects for sex or race. Nearly half of the plates were nondiscriminating among sex, minority/majority, and ”normal” and ”defective” color vision groups. Named color preferences within the ”normal” group strongly favored blues and reflected no sex differences.