Association between direct transport to a cardiac arrest centre and survival following out-of-hospital cardiac arrest: A propensity-matched Aotearoa New Zealand study

Background and Objectives

Direct transport to a cardiac arrest centre following out-of-hospital cardiac arrest may be associated with higher survival. However, there is limited evidence available to support this within the New Zealand context. This study used a propensity score-matched cohort to investigate whether direct transport to a cardiac arrest centre improved survival in New Zealand.

Methods

A retrospective cohort study was conducted using the Aotearoa New Zealand Paramedic Care Collection (ANZPaCC) database for adults treated for out-of-hospital cardiac arrest of presumed cardiac aetiology between 1 July 2018 to 30 June 2023. Propensity score-matched analysis was used to investigate survival at 30-days post-event according to the receiving hospital being a cardiac arrest centre versus a non-cardiac arrest centre.

Results

There were 2,297 OHCA patients included. Propensity matching resulted in 554 matched pairs (n = 1108). Thirty-day survival in propensity score-matched patients transported directly to a cardiac arrest centre (56%) versus a non-cardiac arrest centre (45%) was not significantly different (adjusted Odds Ratio 0.78 95%CI 0.54, 1.13, p = 0.19). Shockable presenting rhythm, bystander CPR, and presence of STEMI were associated with a higher odds of 30 day survival (p < 0.05). Māori or Pacific Peoples ethnicity and older age were associated with lower survival (p < 0.05).

Conclusions

This study found no statistically significant difference in outcomes for OHCA patients transferred to a cardiac arrest compared to a non-cardiac arrest centre. However, the odds ratio of 0.78, equivalent to a 22% decrease in 30-day mortality, is consistent with benefit associated with management by a cardiac arrest centre. Further research in larger cohorts with detailed information on known outcome predictors, or large randomised clinical trials are needed.

Correction: Identifying areas of Australia with high out-of-hospital cardiac arrest incidence and low bystander cardiopulmonary resuscitation rates: A retrospective, observational study

[This corrects the article DOI: 10.1371/journal.pone.0301176.].

Identifying areas of Australia with high out-of-hospital cardiac arrest incidence and low bystander cardiopulmonary resuscitation rates: A retrospective, observational study

AIM

This study aims to explore regional variation and identify regions within Australia with high incidence of out-of-hospital cardiac arrest (OHCA) and low rates of bystander cardiopulmonary resuscitation (CPR).

METHOD

Adult OHCAs of presumed medical aetiology occurring across Australia between 2017 and 2019 were mapped onto local government areas (LGA) using the location of arrest coordinates. Bayesian spatial models were applied to provide "smoothed" estimates of OHCA incidence and bystander CPR rates (for bystander-witnessed OHCAs) for each LGA. For each state and territory, high-risk LGAs were defined as those with an incidence rate greater than the state or territory's 75th percentile and a bystander CPR rate less than the state or territory's 25th percentile.

RESULTS

A total of 62,579 OHCA cases attended by emergency medical services across 543 LGAs nationwide were included in the study. Nationally, the OHCA incidence rate across LGA ranged from 58.5 to 198.3 persons per 100,000, while bystander CPR rates ranged from 45% to 75%. We identified 60 high-risk LGAs, which were predominantly located in the state of New South Wales. Within each region, high-risk LGAs were typically located in regional and remote areas of the country, except for four metropolitan areas-two in Adelaide and two in Perth.

CONCLUSIONS

We have identified high-risk LGAs, characterised by high incidence and low bystander CPR rates, which are predominantly in regional and remote areas of Australia. Strategies for reducing OHCA and improving bystander response may be best targeted at these regions.

Age, Gender, and Liver Enzyme Impact Hospital Stay in COVID-19 Minority Patient with Cancer in the USA: Does Race Matters in the Pandemic?

Patients with cancer are known to have a poor prognosis when infected with SARS-CoV-2 infection. We aimed in this study to assess health outcomes in COVID-19 patients with different cancers in comparison to non-cancer COVID-19 patients from different centers in the United States (US). We evaluated medical records of 1,943 COVID-19 Cancer patients from 3 hospitals admitted between December 2019 to October 2021 and compared them with non-cancer COVID-19 patients. Among 1,943 hospitalized COVID-19 patients, 18.7% (n=364) have an active or previous history of cancer. Among these 364 cancer patients, 222 were African Americans (61.7%) and 121 were Caucasians (33.2%). Cancer patients had significantly longer hospitalization compared to controls (8.24 vs 6.7 days). Overall, Lung cancer is associated with high mortality. Patients with a previous history of cancer were more prone to death (p=0.04) than active cancer patients. In univariate and multivariate analyses, predictors of death among cancer patients were male sex, older age, presence of dyspnea, elevated troponin, elevated AST (0.001) and ALT (0.05), low albumin (p=0.04) and mechanical ventilation (p=0.001). Patients with a previous history of cancer were more prone to death when compared to active cancer COVID-19 patients. Early recognition of cancer COVID-19 patients' death-associated risk factors can help determine appropriate treatment and management plans for better prognosis and outcome.

Occult tension pneumothorax discovered following imaging for adult trauma patients in the modern major trauma system: a multicentre observational study

BACKGROUND

Tension pneumothorax following trauma is a life-threatening emergency and radiological investigation is normally discouraged prior to treatment in traditional trauma doctrines such as ATLS. Some trauma patients may be physiologically stable enough for diagnostic imaging and occult tension pneumothorax is discovered radiologically. We assessed the outcomes of these patients and compared them with those with clinical diagnosis of tension pneumothorax prior to imaging.

METHODS

A multicentre civilian-military collaborative network of six major trauma centres in the UK collected observational data from adult patients who had a diagnosis of traumatic tension pneumothorax during a 33-month period. Patients were divided into 'radiological' (diagnosis following CT/CXR) or 'clinical' (no prior CT/CXR) groups. The effect of radiological diagnosis on survival was analysed using multivariable logistic regression that included the covariates of age, gender, comorbidities and Injury Severity Score.

RESULTS

There were 133 patients, with a median age of 41 (IQR 24-61); 108 (81%) were male. Survivors included 49 of 59 (83%) in the radiological group and 59 of 74 (80%) in the clinical group (p=0.487). Multivariable logistic regression showed no significant association between radiological diagnosis and survival (OR 2.40, 95% CI 0.80 to 7.95; p=0.130). There was no significant difference in mortality between the groups.

CONCLUSION

Radiological imaging may be appropriate for selected trauma patients at risk of tension pneumothorax if they are considered haemodynamically stable. Trauma patients may be physiologically stable enough for radiological imaging but have occult tension pneumothorax because they did not have the typical clinical presentation. The historical dogma of the 'forbidden scan' no longer applies to such patients.

The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Asymptomatic esophageal perforation discovered after elective cardiac surgery: the importance of clinical awareness

Transesophageal echocardiography (TEE) has become an indispensable part of cardiothoracic surgery at present and is considered to be a safe procedure, rarely associated with complications. However, TEE may cause serious and life threatening complications, as presented in this case report. We describe a patient who developed an empyema after elective cardiac surgery due to an esophageal perforation caused by TEE, without any clinical symptoms. Risk factors for TEE-related complications, identified in recent literature, will be discussed as well as the remarkable absence of clinical symptoms in this particular patient.

Finger Thoracostomy for Tension Pneumothorax

One of the injuries associated with chest trauma is pneumothorax, a condition where air accumulates between the parietal and visceral pleura in the chest leading to collapse of the lung due to pressure. Left untreated, a tension pneumothorax may develop leading to cardiovascular collapse. This article reviews the development of a tension pneumothorax, discusses the clinical recognition of the diagnosis, and outlines the procedure for performing a finger (or simple) thoracostomy. A simple mnemonic for the procedure is offered as a memory aid to reduce cognitive load for this procedure.

A study protocol for a cluster-randomised controlled trial of smartphone-activated first responders with ultraportable defibrillators in out-of-hospital cardiac arrest: The First Responder Shock Trial (FIRST)

Objective

To describe the First Responder Shock Trial (FIRST), which aims to determine whether equipping frequently responding, smartphone-activated (GoodSAM) first responders with an ultraportable AED can increase 30-day survival rates in OHCA.

Methods

The FIRST trial is an investigator-initiated, bi-national (Victoria, Australia and New Zealand), registry-nested cluster-randomised controlled trial where the unit of randomisation is the smartphone-activated (GoodSAM) first responder. High-frequency GoodSAM responders are randomised 1:1 to receive an ultraportable, single-use AED or standard alert procedures using the GoodSAM app.The primary outcome is survival to 30 days. The secondary outcome measures (shockable rhythm, return of spontaneous circulation, event survival, and time to first shock delivery) are routinely collected by OHCA registries in both regions. The trial was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) (Registration: ACTRN12622000448741) on 22 March 2022.

Results

The trial started in November 2022 and the last patient is expected to be enrolled in November 2024. We aim to detect a 7% increase in the proportion of 30-day survivors, from 9% in patients attended by control responders to 16% in patients attended by responders randomised to the ultraportable AED intervention arm. With 80% power, an alpha of 0.05, a cluster size of 1.5 and a coefficient of variation for cluster sizes of 1, the sample size required to detect this difference is 714 (357 per arm).

Conclusion

The FIRST study will increase our understanding of the potential role of portable AED use by smartphone-activated community responders and their impact on survival outcomes.

Clinical Utility of Dual Phase FDG PET for Distinguishing Tumor Progression from Radionecrosis in the Modern Era

PURPOSE/OBJECTIVE(S)

Dual-phase PET CT, a technique by which two PET/CT scans are taken hours apart, has previously shown utility in differentiating radionecrosis (RN) from tumor progression (TP) after radiation for brain metastases. We sought to validate the utility of this technique in an independent, contemporary patient cohort. Understanding the difficulty of validation without the gold standard of pathologic confirmation in a majority of cases, we hypothesized that a dual-phase PET/CT indicating likely RN would correlate with improved overall survival (OS).

MATERIALS/METHODS

We performed a retrospective cohort study of all patients who received dual-phase FDG-PET between April 2015 and January 2023 at a single center for the purpose of distinguishing RN from TP in brain metastases previously treated with radiation. Scans were classified as indicating likely RN (dpPET-RN), likely TP (dpPET-TP), or unclear (dpPET-Unc) based on final radiology report. A Kaplan Meier (K-M) analysis was performed to evaluate differences in survival among the different dual-phase PET finding categories. An alpha level of 0.05 in the log-rank test was used to determine statistical significance.

RESULTS

We identified 36 patients who met inclusion criteria. All patients had received prior radiation - stereotactic radiosurgery (SRS), whole brain radiotherapy (WBRT) or both- to the lesion, and 21 (58%) had received surgery at some point prior to the dual phase PET CT. One patient received brachytherapy. Median time from the most recent course of radiation until dual-phase PET was 294 days, while median time from most recent surgery to dual-phase PET was 379 days. 14/36 (39%) of scans were called as dpPET-TP,15/36 (42%) were dpPET-RN, and 7/36 (19%) were dpPET-Unc. There were 10 cases where pathology was available after subsequent resection of the lesion. Five of the 10 path reports were concordant with the dual phase PET read, 5 were discordant. On K-M, median survival was 11 months (95% CI: 7.8 to 14.2 months) for dpPET-TP patients, 18 months (95% CI: 7.9 to 33.5 months) for dpPET-RN, and 12 months (95% CI: 0.0 to 51.2 months) for dpPET-Unc. On log rank testing, differences in the survival distribution for the different groups of dual-phase FDG-PET results were not statistically significant, χ2(2) = 4.085, p = .130.

CONCLUSION

Dual-phase PET CT has been proposed as a useful tool for distinguishing TP from RN after prior radiation. In the small subset of cases from our study with pathologic confirmation of outcomes, dual-phase PET failed to show high concordance with pathology. Although the dpPET-RN cohort had numerically superior OS compared to the dpPET-TP and dpPET-unc groups, this result was not statistically significant. Further independent validation of this imaging technique is warranted before it can be relied upon for routine clinical management.

Out-of-Hospital emergency airway management practices: A nationwide observational study from Aotearoa New Zealand

Background and Objectives

Airway management is crucial for emergency care in critically ill patients outside the hospital setting. An Airway Registry is useful in providing essential information for quality improvement purposes. Therefore, this study aimed to develop an out-of-hospital airway registry and describe airway management practices in Aotearoa New Zealand (AoNZ).

Methods

Data from the Aotearoa New Zealand Paramedic Care Collection (ANZPaCC) database were used in a retrospective cohort study covering July 2020 to June 2021. All patients receiving airway interventions were included. An airway intervention was defined as one or more of the following: non-drug assisted endotracheal intubation (NDA-ETI), drug-assisted endotracheal intubation (DA-ETI; where a combination of paralytic agent and sedative were used to aid in intubation), laryngeal mask airway (LMA), oropharyngeal airway (OPA), nasopharyngeal airway (NPA), surgical airway (cricothyroidotomy), suction, jaw thrust. Descriptive statistics were analysed using Chi-Square and logistic regression modelling investigated the relationship between advanced airway success and patient characteristics.

Results

The study included 4,529 patients who underwent 7,779 airway interventions. Basic airway interventions were used most frequently: OPA (45.1%), NPA (29.3%), LMA (28.9%), suction (19.9%) and jaw thrust (17.6%). Advanced airway interventions were used less frequently: NDA-ETI (19.8%), DA-ETI (8.7%), and surgical airways (0.2%). The success rate for ETI (including both NDA-ETI and DA-ETI) was 89.4%, with NDA-ETI success at 85.8% and DA-ETI success at 97.7%. ETI first-pass success rates were significantly lower for males (aOR 0.65, 95%CI 0.48-0.87, p < 0.001) and higher for non-cardiac arrest injury patients (aOR 2.94, 95%CI 1.43-6.00, p < 0.001). In this cohort receiving airway interventions the 1-day mortality rate was 41.1%, demonstrating that a high proportion of these patients were severely clinically compromised.

Conclusions

Out-of-hospital airway management practices and success rates in AoNZ are comparable to those elsewhere. This research has determined the variables to be used as the AoNZ Paramedic Airway Registry ongoing and has demonstrated baseline outcomes in airway management for ongoing quality improvement using this registry.

A systematic review and meta-analysis of the effects of community use of oral nutritional supplements on clinical outcomes

The impact of oral nutritional supplements (ONS) on patients with complications (disease related morbidity) requires further exploration. This systematic review included 44 randomised controlled trials (RCT) (29 RCT surgical, 15 RCT medical patients) examining the effect of ONS in community settings on the incidence of complications (n = 716, mean age 67 years, range 35-87). ONS (mean intake 588 kcal/day, range 125-1750; protein 22 g/day, range 0-54; mean energy from protein 22 %, range 0-54) were prescribed for a mean 74 days, range 5-365. Most RCT (77 %) reported fewer complications in the ONS group versus control. Meta-analysis (39 RCT) showed ONS consumption reduced complications including infections, pressure ulcers, wound and fracture healing (OR 0.68, 95 % CI 0.59,0.79; p<0.001). Results showed reductions when ONS were used in hospital and community settings (OR 0.72, 95 % CI 0.59,0.87; p = 0.001) or just in the community (OR 0.65, 95 % CI 0.52, 0.80; p<0.001). Reductions in complications were only seen with high ONS adherence ≥ 80 % (OR 0.63, 95 % CI 0.48,0.83; p = 0.001) and ready-to-drink ONS (OR 0.69, 95 % CI 0.60,0.81; p<0.001). This systematic review and meta-analysis show community-based use of ONS in addition to the diet substantially reduces the incidence of complications. The diversity of ONS, patient populations and complication outcomes within the trials included in this review mean further research is warranted.

The development of a risk-adjustment strategy to benchmark emergency medical service (EMS) performance in relation to out-of-hospital cardiac arrest in Australia and New Zealand

INTRODUCTION

The aim of this study was to develop a risk adjustment strategy, including effect modifiers, for benchmarking emergency medical service (EMS) performance for out-of-hospital cardiac arrest (OHCA) in Australia and New Zealand.

METHOD

Using 2017-2019 data from the Australasian Resuscitation Outcomes Consortium (Aus-ROC) OHCA Epistry, we included adults who received an EMS attempted resuscitation for a presumed medical OHCA. Logistic regression was applied to develop risk adjustment models for event survival (return of spontaneous circulation at hospital handover) and survival to hospital discharge/30 days. We examined potential effect modifiers, and assessed model discrimination and validity.

RESULTS

Both OHCA survival outcome models included EMS agency and the Utstein variables (age, sex, location of arrest, witnessed arrest, initial rhythm, bystander cardiopulmonary resuscitation, defibrillation prior to EMS arrival, and EMS response time). The model for event survival had good discrimination according to the concordance statistic (0.77) and explained 28% of the variation in survival. The corresponding figures for survival to hospital discharge/30 days were 0.87 and 49%. The addition of effect modifiers did little to improve the performance of either model.

CONCLUSION

The development of risk adjustment models with good discrimination is an important step in benchmarking EMS performance for OHCA. The Utstein variables are important in risk-adjustment, but only explain a small proportion of the variation in survival. Further research is required to understand what factors contribute to the variation in survival between EMS.

Genomic Sequencing to Diagnose Prosthetic Joint Infection in the Knee: A Case Report

There is currently no "gold-standard" method to diagnose prosthetic joint infections (PJI), and the current practice of using microbiological cultures has many limitations. The identification of the bacterial species causing the infection is crucial to guide treatment; therefore, a robust method needs to be developed. Here, we attempt to use genomic sequencing with the MinION device from Oxford Nanopore Technologies to identify the species of bacteria causing PJI in a 61-year-old male. Genomic sequencing with the MinION presents an opportunity to produce species identification in real-time and at a smaller cost than current methods. By comparing results with standard hospital microbiological cultures, this study suggests that nanopore sequencing using the MinION could be a faster and more sensitive method to diagnose PJI than microbiological cultures.

A conflicted tribe under pressure: A qualitative study of negative workplace behaviour in nursing

AIM

This study explored workplace interactions of Australian nurses in regional acute care hospitals through an examination of nurses' experiences and perceptions of workplace behaviour.

DESIGN

This research is informed by Social Worlds Theory and is the qualitative component of an overarching mixed methods sequential explanatory study.

METHODS

Between January and March 2019, data were collected from 13 nursing informants from different occupational levels and roles, who engaged in semi-structured, in-depth, face-to-face interviews. Data analysis was guided by Straussian grounded theory to identify the core category and subcategories.

RESULTS

Theoretical saturation occurred after 13 interviews. The core category identified is A conflicted tribe under pressure, which is comprised of five interrelated subcategories: Belonging to the tribe; 'It's a living hell'; Zero tolerance-'it's a joke'; Conflicted priorities; Shifting the cultural norm.

CONCLUSION

This study provides valuable insight into the nursing social world and the organizational constraints in which nurses work. Although the inclination for an individual to exhibit negative behaviours cannot be dismissed, this behaviour can either be facilitated or impeded by organizational influences.

IMPACT

By considering the nurses' experiences of negative workplace behaviour and identifying the symptoms of a struggling system, nurse leaders can work to find and implement strategies to mitigate negative behaviour and create respectful workplace behaviours.

PATIENT OR PUBLIC CONTRIBUTION

This study involved registered nurse participants and there was no patient or public contribution.

CLINICAL TRIAL REGISTRATION

Study registration Australian New Zealand Clinical Trials Registry (Registration No. ACTRN12618002007213; December 14, 2018).

1174 THE ROLE OF HIP FRACTURE IN TRAJECTORIES OF DEPRESSIVE SYMPTOMS AMONG OLDER ADULTS: ANALYSIS FROM THE ENGLISH LONGITUDINAL STUDY

Introduction

Older adults experience ‘Late life depression’. Hip fractures may negatively influence trajectories of depressive symptoms in older adults. This study aimed to determine trajectories of depressive symptoms among older adults in England, overall and for those after hip fracture, and identify characteristics defining trajectory membership.

Methods

Analysis of adults aged 60 years or more (n=7,050), including a hip fracture subgroup (n = 384), from the English Longitudinal Study of Ageing. Latent class growth mixture modelling was completed. Depressive symptom prevalence was estimated at baseline. Chi-squared tests were completed to compare baseline characteristics across trajectories.

Results

Three trajectory groups were identified overall and for those with hip fracture: no-, mild-, and moderate-severe- symptoms. The moderate-severe group comprised 13.7% and 7% of participants for overall and hip fracture populations respectively. Overall, the proportion of participants with depressive symptoms were 0.4%, 12.4% and 65.4% for no-, mild-, and moderate-severe- symptom groups, respectively. For the hip fracture subgroup, these proportions were 0.7%, 28.8%, and 85.2%. Depressive symptoms were stable over time, with a weak trend towards increasing severity for the moderate-severe group. Individuals with moderate-severe trajectories were older, more likely to be female, live alone and had worse health outcomes (p &lt; 0.001).

Conclusions

Older adults, and those after hip fracture, follow one of three trajectories of depressive symptoms which are broadly stable over time. The prevalence of depressive symptoms was lower for those with hip fracture however, when present, the symptoms were more severe than the overall population. Results suggest a role of factors including age, gender, and marital status in depressive symptoms trajectories.

Understanding the impact of nuclear-data covariances on various integral responses using adjustment

The EUCLID (Experiments Underpinned by Computational Learning for Improvements in Nuclear Data) project created a library of sensitivities for nine different integral responses with respect to nuclear data. These integral responses were obtained from measurements at LLNL (Lawrence Livermore National Laboratory) pulsed spheres, critical and sub-critical assemblies. At the same time, covariances for ENDF/B-VIII.0 were processed at LANL (Los Alamos National Laboratory). The combination of these data allow us to study the impact of nuclear-data covariances on various integral responses, either by forward-propagating covariances via sensitivities, or by using nuclear data, integral responses, and sensitivities for adjustment. Here, we will present: the impact of 1H, 9Be, 12C, 27Al, 56Fe, 235,238U, and 239,240Pu ENDF/B-VIII.0 covariances on simulated bounds of the following integral responses: LLNL pulsed-spheres neutron-leakage spectra, the effective neutron multiplication factor, reaction rates, and reactivity coefficients of ICSBEP critical assemblies. Also, adjustment results with the same nuclear-data covariances and responses will be discussed.

LA-UR-22-31309

Impact of pre-existing vascular disease on clinical outcomes in patients with non-ST-segment myocardial infarction: a nationwide cohort study

Aims

Little is known about the outcomes and processes of care of patients with non ST-segment myocardial infarction (NSTEMI) who present with “polyvascular” disease.

Methods

We analysed 287,279 NSTEMI patients using the Myocardial Infarction National Audit Project (MINAP) registry. Clinical characteristics and outcomes were analysed according to history of affected vascular bed; coronary artery disease (CAD), cerebrovascular disease (CeVD) and peripheral vascular disease (PVD), with comparison to a historically disease-free control group; comprising 167,947 patients (59%). Further analyses compared cumulative number of affected beds with our control.

Results

After adjusting for demographics and management, vascular bed disease was associated with increased likelihood of MACE (CAD OR: 1.06, 95% CI: 1.01–1.12, P=0.02) (CeVD OR: 1.19, 95% CI: 1.12–1.27, P&lt;0.001) (PVD OR: 1.22, 95% CI: 1.13–1.33, P&lt;0.001) and in-hospital mortality (CeVD OR: 1.24, 95% CI: 1.16–1.32, P&lt;0.001) (PVD OR: 1.33, 95% CI: 1.21–1.46, P&lt;0.001). Patients with no vascular disease were less likely to be discharged on statins (PVD 88%, CeVD 86%, CAD 90% and control 78%), and those with moderate (EF 30–49%) or severe left ventricular systolic dysfunction (LVSD) (EF&lt;30%) were less likely to be discharged on ACE inhibitors (CAD 82%, CeVD 77%, PVD 77%, control 74%). Patients with polyvascular disease were less likely to be discharged on DAPT (PVD 78%, CeVD 77%, CAD 80%, control 87%).

Conclusion

Polyvascular disease patients had a higher adjusted incidence of in-hospital mortality and MACE. Patients with no history of vascular disease were less likely to receive statins or ACE inhibitors/ARBs, but more likely to receive DAPT.

Funding Acknowledgement

Type of funding sources: None.

Single vs multiple cat adoptions: A trade-off between longer adoption times and social bonding in shelter cats

Timely adoption is essential for shelters to prevent unnecessary illness or euthanasia in cats (Felis catus). Many studies have examined the role of individual cat characteristics and environmental factors in facilitating cat adoptions, but none have looked at the role the number of cats being adopted plays. In this study, we examined whether or not adopting cats in pairs influences adoption times, in addition to commonly studied factors. We then collected video data on a small subset of cats to determine whether pairs that were adopted together differed behaviourally from pairs who were not. Our results demonstrate that cats who are adopted as part of a multi-cat outcome spent three days (42%) longer on the adoption floor than those adopted individually, independently of other factors such as age and coat colour. This difference increased to 13 days (185%) longer if the cat had a notification indicating they must be adopted together with another cat. While behavioural data show that these pairs of cats engage in significantly more affiliative behaviour with each other than cats who were adopted singly, there was a large discrepancy between which pairs the shelter classified as multi-outcome and those who would be classified that way based on behaviour alone. We suggest that decisions to place cats together should be made carefully given the potential adverse impacts of keeping cats in the shelter longer. Further, we suggest that guidance should be developed to help shelters accurately and consistently identify which cats merit a multi-outcome adoption.

327 To Fuse or Not to Fuse: The Elderly Patient with Lumbar Stenosis and Low-Grade Spondylolisthesis. Systematic Review and Meta-Analysis of Randomised Controlled Trials

Aim

The optimum surgical intervention for elderly patients with lumbar spinal stenosis(LSS) and low-grade degenerative-spondylolisthesis(LGDS) has been extensively debated. We conducted a systematic review and meta-analysis of randomised-controlled-trials(RCTs) comparing the effectiveness of decompression-alone against gold-standard decompression-with-fusion(D+F) in elderly patients with LSS and LGDS.

Method

A systematic literature search was performed on published databases from inception to October-2021. English-language RCTs of elderly patients (mean age over-65) with LSS and LGDS, who had undergone DA or D+F were included. The quality and weight of evidence was assessed, and a meta-analysis performed.

Results

Seven RCTs (n=581; mean age:65.9 years; 59.9% female) were included. There was no difference in visual-analogue-scale(VAS) scores of back-pain(BP) or leg-pain(LP) at mean follow-up of 28.6 months between both DA and D+F groups (BP: mean-difference (MD)-0.22, 95%CI:-0.76–0.32; LP: MD:-0.26, 95%CI:-0.79–0.27). In addition, subgroup analysis of long-term follow-up (&gt;3 years) showed lower VAS scores for BP and LP in patients who underwent DA (BP MD:-1.70, 95%CI:-2.8-(-0.60); LP MD:-1.00, 95%CI:-1.77-(-0.23)). No difference in disability, measured by Oswestry-Disability-Index(ODI) scores, was found between both groups (MD:0.50, 95%CI: -3.31–4.31). However, patients in DA group had less hospital complications and fewer adverse events (total-surgical-complications OR:0.57, 95%CI:0.36–0.90), despite a higher rate of post-operative DS (OR:8.63, 95%CI:3.35–22.26).

Conclusions

DA is not inferior to D+F in elderly patients with LSS and LGDS. DA has better pain outcomes at three-years follow-up and carries lower risk hospital-complications and fewer adverse-events. Surgeons should weigh these findings with increased risk of DS-progression.

495 Virtual Reality Simulation Training in Hip Surgery Versus Traditional Surgical Education Method: A Systematic Review of Randomised Controlled Trials

Aim

The purpose of this study was to perform a systematic review of the effects of orthopaedic virtual reality simulators on surgical skills across randomised controlled trials.

Method

The authors searched PubMed, CINAHL, MEDLINE, AMED, Eric, Embase, Cochrane Central Register of Controlled Trials, TRIP database and grey literature from 1946 to November 2020. Inclusion criteria were all level one studies, specifically randomised controlled trials with orthopaedic training simulators in hip surgery and clear evaluation of skills attained after virtual reality simulation (VR) training. The primary outcome was the reported quantitative assessment of operative skills acquisition. The Jadad scale was used as a tool in order to appraise the methodological quality of the included trials. The data collected were not amenable for meta-analysis as they were too heterogenous and were analysed and presented using a narrative analysis and the Synthesis Without Meta-analysis (SWiM) reporting guideline.

Results

A total of 1095 articles were identified. Four level I studies, all randomised controlled trials, including 86 participants were eligible for the final analysis. There were significant differences in the types of simulators, training structure, validity types, performance scores and outcome measures described in each study. In three out of four studies (75%) the use of VR training simulators led to improved surgical skills acquisition compared to other traditional teaching methods.

Conclusions

Overall, this review showed that the use of VR simulation training is a potential tool that can enhance surgical skills acquisition in hip surgery procedures compared to traditional education methods.

Predictive value of the New Zealand Early Warning Score for early mortality in low-acuity patients discharged at scene by paramedics: an observational study

OBJECTIVES

The utility of New Zealand Early Warning Score (NZEWS) for prediction of adversity in low-acuity patients discharged at scene by paramedics has not been investigated. The objective of this study was to evaluate the association between the NZEWS risk-assessment tool and adverse outcomes of early mortality or ambulance reattendance within 48 hours in low-acuity, prehospital patients not transported by ambulance.

DESIGN

A retrospective cohort study.

SETTING

Prehospital emergency medical service provided by St John New Zealand over a 2-year period (1 July 2016 through 30 June 2018).

PARTICIPANTS

83 171 low-acuity, adult patients who were attended by an ambulance and discharged at scene. Of these, 41 406 had sufficient recorded data to calculate an NZEWS.

PRIMARY AND SECONDARY OUTCOMES AND MEASURES

Binary logistic regression modelling was used to investigate the association between the NZEWS and adverse outcomes of reattendance within 48 hours, mortality within 2 days, mortality within 7 days and mortality within 30 days.

RESULTS

An NZEWS greater than 0 was significantly associated with all adverse outcomes studied (p<0.01), compared with the reference group (NZEWS=0). There was a startling correlation between 2-day, 7-day and 30-day mortality and higher early warning scores; the odds of 2-day mortality in patients with an early warning score>10 was 70 times that of those scoring 0 (adjusted OR 70.64, 95% CI: 30.73 to 162.36). The best predictability for adverse outcome was observed for 2-day and 7-day mortality, with moderate area under the receiver operating characteristic curve scores of 0.78 (95% CI: 0.73 to 0.82) and 0.74 (95% CI: 0.71 to 0.77), respectively.

CONCLUSIONS

Adverse outcomes in low-acuity non-transported patients show a significant association with risk prediction by the NZEWS. There was a very high association between large early warning scores and 2-day mortality in this patient group. These findings suggest that NZEWS has significant utility for decision support and improving safety when determining the appropriateness of discharging low-acuity patients at the scene.

Creating respectful workplaces for nurses in regional acute care settings: A quasi-experimental design

AIM

To examine self-reported exposure and experiences of negative workplace behaviour and ways of coping of nursing staff before and after educational workshops.

DESIGN

A Quasi-experimental design.

METHOD/SETTING/PARTICIPANTS

Data were collected pre- /postworkshops using a structured questionnaire. Nurses (N = 230) from 12 units in four regional acute care hospitals were invited to complete a pre-intervention survey. Educational workshops were then implemented by the organization at two of the hospitals, after which, follow-up surveys were undertaken.

RESULTS

There were 74 responses in the pre-intervention and 56 responses in the postintervention time period. There were 111 participants who attended the educational intervention, 20% (n = 22) completed the follow-up survey. Participants were more likely exposed to work-related bullying acts and they used problem-focused coping strategies and sought social support as a way of coping when exposed to the negative behaviours. Overall, there was a decrease in both bullying and incivility experienced by participants; however, our findings were unable to establish that a statistically significant difference was made due to the implementation of the intervention.

STUDY REGISTRATION

Australian New Zealand Clinical Trials Registry (Registration No. ACTRN12618002007213; December 14, 2018).

Factors influencing medical radiation science graduates' early career principal place of practice: a retrospective cohort study

INTRODUCTION

While studies have investigated influences on graduate practice locations of other health professionals, especially medicine, none have investigated practice locations of medical radiation science (MRS) graduates. This study aimed to explore factors influencing the registered principal place of practice (PPP) of diagnostic radiography, radiation therapy and nuclear medicine graduates from the University of Newcastle (UON), Australia, in their second post-graduate year.

METHODS

Data were extracted from the UON enrolment and clinical placement databases and linked to Australian Health Practitioners Regulation Agency (Ahpra) registration data for PPP location in 2019 for 187 graduates who completed their studies in 2017. Explanatory variables included age at enrolment, gender, MRS discipline, location of origin, socio-economic index for location of origin, and locations and duration of undergraduate professional placements. Descriptive statistics, tests of association and logistic regression compared rural and non-rural origin, and professional placement locations with Ahpra PPP.

RESULTS

Factors related to non-metropolitan PPP were location of origin (P = 0.002), number (P = 0.002) and duration (P = 0.007) of rural placements, and MRS discipline (P = 0.033). Controlling for other variables, location of origin and MRS discipline remained significant. Graduates of rural origin had up to 3.54 (95%CI = 1.51-8.28) times the odds of a rural PPP. Diagnostic radiography graduates had up to 5.46 (95%CI = 1.55-19.20) times the odds of nuclear medicine of a rural PPP.

CONCLUSION

To help reduce the gap between rural and metropolitan medical radiation service availability, there is a need for targeted recruitment of rural origin students. Further investigation of the effect of rural undergraduate MRS placements is justified.

POS0691 EMULATING A TARGET TRIAL OF ADALIMUMAB VERSUS TOFACITINIB IN PATIENTS WITH RHEUMATOID ARTHRITIS: A COMPARATIVE EFFECTIVENESS ANALYSIS USING THE OPAL REAL-WORLD DATASET

Background

There is increasing recognition of the complementary role for real-world evidence (RWE) in health care and regulatory decision-making (1). However, careful analysis is required when drugs are compared using observational data to account for differences between treatment groups. Electronic medical records (EMR) are an important source of real-world data (RWD), but outcomes are often recorded incompletely.

We emulated a target trial of adalimumab (ADA) versus tofacitinib (TOF) in patients with rheumatoid arthritis (RA) using the OPAL dataset to illustrate the application of methodologies to address the challenges of non-random treatment assignment and incomplete data. The OPAL dataset is derived from EMR of 112 community-based rheumatologists around Australia, where practitioners have discretion to prescribe whichever b/tsDMARD they consider most clinically appropriate.

Objectives

To estimate the average treatment effect (ATE) of TOF compared to ADA at 3 and 9 months, defined as the difference in mean disease activity score (DAS28CRP), in patients with RA who are new users of a b/tsDMARD. This is equivalent to aiming to estimate the intention-to-treat effect in a randomised controlled trial.

Methods

OPAL patients diagnosed with RA were included if they initiated ADA or TOF between 1 October 2015 and 1 April 2021, were new b/tsDMARD users (no prior recorded b/tsDMARD, at least 6 months of prior csDMARD treatment), and had at least 1 component of DAS28CRP recorded at baseline or during follow-up. Data were also extracted on baseline characteristics. Baseline characteristics were DAS28CRP, patient demographics, regional location, disease duration, prescriber characteristics (including gender, experience), prior recorded comorbidities, and prior and concomitant treatment with csDMARDs and oral corticosteroids.

We used random forest multiple imputation to impute missing baseline and follow-up DAS28CRP components (2). Stable balancing weights (SBW) were then used to balance the treatment groups in terms of their baseline characteristics, including DAS28CRP (3). For each imputed dataset, the ATE at 3 months was estimated as the difference between the mean outcome in the two treatment groups after balancing (i.e. weighting) the sample, and then these estimates were averaged across the 10 imputed datasets. The ATE at 9 months was estimated similarly. The whole procedure was subsequently performed in 1000 bootstrap samples to estimate a 95% confidence interval (CI) for the ATEs using the percentile method (4).

Results

842 patients were identified including n=569 treated with ADA and n=273 treated with TOF. After applying the SBW, the maximum difference between the mean of each baseline characteristic in the ADA and TOF groups was less than 0.03% of the corresponding standard deviation in the whole sample, indicating reasonable balance was achieved in this complex dataset. After weighting, mean DAS28CRP reduced from 5.3 at baseline (both ADA and TOF groups) to 2.6 and 2.3 at 3 and 9 months for ADA, and 2.4 and 2.3 at 3 and 9 months for TOF.

The estimated ATE was -0.22 (95% CI -0.36, -0.03; p=0.02) at 3 months, indicating a modest but significant reduction in disease activity for patients on TOF. The estimated ATE was -0.03 (95% CI -0.19, 0.1; p=0.56) at 9 months, indicating no difference between groups.

Conclusion

DAS28CRP was significantly lower at 3 months for patients treated with TOF compared to ADA. However, 3 months of treatment with either drug led to substantive average reductions in mean DAS28CRP, consistent with remission. There was no difference between drugs at 9 months. Future work will estimate a per-protocol effect.

References

[1]Arlett et al. Clin Pharmacol Ther 2022;111(1):21–3.

[2]van Buuren and Groothuis-Oudshoorn J Stat Softw 201145(3):1–67

[3]Zubizarreta J Am Stat Assoc 2015;110(511):910–22

[4]Bartlett and Hughes Stat Methods Med Res 2020;29(12):3533–46

Acknowledgements

The authors acknowledge the members of OPAL Rheumatology Ltd and their patients for providing clinical data for this study, and Software4Specialists Pty Ltd for providing the Audit4 platform.

Disclosure of Interests

Claire Deakin: None declared, Bianca De Stavola: None declared, Geoff Littlejohn Consultant of: Abbvie, Janssen, Bristol Myers Squibb, Gilead, Eli Lilly, and MSD, Hedley Griffiths Consultant of: AbbVie and Eli Lilly, Sabina Ciciriello: None declared, Peter Youssef Speakers bureau: AbbVie, Novartis, Eli Lilly, David Mathers: None declared, Paul Bird Speakers bureau: Abbvie, Janssen, Bristol Myers Squibb, Pfizer, Novartis, Gilead, Eli Lilly, Consultant of: Abbvie, Janssen, Bristol Myers Squibb, Pfizer, Novartis, Gilead, Eli Lilly, Imaging consulting for Synarc and Boston Imaging Core Lab., Tegan Smith: None declared, Catherine OSullivan: None declared, Tim Freeman: None declared, Dana Segelov: None declared, David Hoffman: None declared, Shaun Seaman: None declared

POS1019 REAL-WORLD EVALUATION OF TREATMENT PATTERNS AND PERSISTENCE OF TOFACITINIB IN TREATMENT OF PSORIATIC ARTHRITIS IN AUSTRALIA: AN ANALYSIS OF THE OPAL DATASET

Background

Tofacitinib (TOF), a potent selective inhibitor of Janus kinase (JAK), is an approved treatment of psoriatic arthritis (PsA). In Australia, patients with active PsA despite six months of therapy with a pre-specified combination of csDMARDs are eligible to receive subsidised b/tsDMARDs. The clinician can prescribe the b/tsDMARD they deem to be the most clinically appropriate for the patient. Limited data exist to describe the real-world treatment patterns, characteristics and clinical outcomes of patients with PsA who receive TOF in the real-world setting.

Objectives

To describe real-world treatment patterns and treatment persistence among patients with PsA treated with TOF in the Australian post-approval setting using the OPAL dataset.

Methods

The OPAL dataset is a collection of deidentified clinical data derived from the electronic medical records of 112 rheumatologists at 43 sites around Australia. Adult patients with a diagnosis of PsA who received at least one prescription of TOF, a tumour necrosis factor inhibitor (TNFi) or an interleukin 17 inhibitor (IL-17Ai) between May 2019 and Sept 2020 were eligible, with data up to Sept 2021 included in the analysis. Results were summarised descriptively. Treatment persistence was summarised using Kaplan-Meier methods.

Results

Of 16,692 patients with PsA identified in the OPAL dataset, 1,486 (TOF n=406, IL-17Ai n=416, and TNFi n=664) were eligible for inclusion in this study. At the time of treatment initiation, the mean (SD) age of TOF, IL-17Ai and TNFi treated patients was 55.56 (12.68), 52.65 (12.72) and 50.32 (14.57) years, respectively. 19.2% of patients receiving TOF were first line compared with 41.8% of IL-17Ai and 62.8% of TNFi treated patients. The mean (SD) time from symptom onset to treatment initiation was longest for patients receiving TOF in first line (153.29 (127.50) months) compared to first line IL-17Ai (116.83 (113.97) months) and TNFi treated patients (92.37 (89.01) months). Overall, 34.2% of TOF, 32.9% of IL-17Ai and 26.4% of TNFi treated patients initiated therapy without concomitant cDMARDs being recorded.

Overall median persistence was 16.54 months (95% CI 13.84, 19.53) for TOF treated patients, 17.65 months (95% CI, 15.75, 19.56) for IL-17Ai treated patients and 17.16 months (95% CI 14.86, 20.48) for TNFi treated patients. As expected, persistence was generally longer in patients treated as first line (Figure 1) with patients receiving TOF observed to have slightly higher persistence in the first 15 months of treatment.

Figure 1.

Treatment persistence of patients receiving TOF, IL-17Ai and TNFi as first line therapy. Plot curtailed at 15 months as relatively few patients have information past this point. Where no stop date was recorded, censoring occurs at last recorded visit

Conclusion

In this analysis of a large Australian real-world dataset, TOF was more commonly utilised as a later line therapy for patients with PsA. Patients receiving TOF were observed to have slightly higher persistence within the first 15 months of starting first line therapy in this preliminary analysis.

Acknowledgements

The authors acknowledge the members of OPAL Rheumatology Ltd and their patients for providing clinical data for this study, and Software4Specialists Pty Ltd for providing the Audit4 platform. Financial support was provided by Pfizer Australia

Disclosure of Interests

Geoff Littlejohn Consultant of: Abbvie, Janssen, Bristol Myers Squibb, Gilead, Eli Lilly, and MSD, Jo Leadbetter: None declared, Belinda Butcher: None declared, Marie Feletar: None declared, Catherine OSullivan: None declared, Tegan Smith: None declared, David Witcombe Employee of: Pfizer Australia, Ho Yin Employee of: Pfizer Australia, Peter Youssef Speakers bureau: AbbVie, Novartis, Janssen and Eli Lilly

POS1034 EVOLVING MECHANISM OF ACTION PREFERENCE FOR THE TREATMENT OF PSORIATIC ARTHRITIS IN AUSTRALIA: AN ANALYSIS OF THE OPAL DATASET

Background

There are currently ten biologic and targeted synthetic (b/ts)DMARDs acting via five different modes of action (MOA) available for the treatment of psoriatic arthritis (PsA) in Australia. b/tsDMARDs are government-subsidised, and once the patient reaches the eligibility requirements, the clinician can prescribe the agent deemed most appropriate. Available agents include TNF inhibitors (TNFi, adalimumab, etanercept, infliximab, golimumab, certolizumab pegol), IL-17A inhibitors (IL-17Ai, secukinumab, ixekizumab), and IL-12/23 inhibitor (IL-12/23i, ustekinumab). Two new MOAs were recently added to the rheumatologist’s armamentarium: the first JAK inhibitor (JAKi, tofacitinib) was subsidized from May 2019 followed by upadacitinib from Oct 2021, and an IL-23 inhibitor (IL-23i, guselkumab) was subsidized from July 2021.

Objectives

The aim of this analysis was to describe the changing patterns of b/tsDMARD use for the treatment of PsA in real-world practice in Australia.

Methods

Deidentified clinical data were sourced from the OPAL dataset, which is collected in a custom-built electronic medical record during the routine consultation1. Data from patients >18 years with a physician diagnosis of PsA who were prescribed a b/tsDMARD between Jan-2007 and Sept-2021 were included in the analysis. The software program Tableau was used to display the data.

Results

At Sept 2021, 6,150 (38% of the total) patients with PsA in the OPAL dataset were prescribed b/tsDMARDs. Of these patients, 3741 (61%) were currently prescribed a TNFi, 1503 (24%) an IL-17Ai, 556 (9%) a JAKi, 222 (4%) an IL-12/23i and 134 patients (2%) an IL-23i. Over time, the 1st line TNFi initiations have decreased from 79.5% in 2018 to 65.2% in 2021. Conversely, 1st line IL-17Ai initiations have increased from 14.4% in 2018 to 22.2% in 2021. In 2021, TNFi accounted for 53.4% of 2nd line initiations and 38.2% of 3rd line initiations. IL-17Ai accounted for 30.4% of 2nd and 37.0% of 3rd line initiations and JAKi accounted for 10.5% of 2nd line and 14.2% of 3rd line initiations. In the 3 months that IL-23i has been subsidised, this MOA was the most initiated agent for patients who had been treated with more than two prior b/tsDMARDs. In 2021, 52.1% of patients switching from a 1st line TNFi switched to an alternative TNFi, 33.3% switched to an IL-17Ai and 11.3% switched to a JAKi in 2nd line. Of those switching from a 1st line IL-17Ai, 59.6% initiated a TNFi, 21.2% switched to an alternative IL-17Ai and 11.5% switched to a JAKi.

Conclusion

The patterns of b/tsDMARD utilisation for the treatment of PsA, when the choice of agent is at the discretion of the rheumatologist, remains dynamic and is evolving as new MOAs become available. TNFi remains the most prescribed b/tsDMARD for first line therapy. However an increase in first line use of alternative MOAs has been observed. TNFi cycling remains a commonly utilised real world treatment strategy but appears to be declining as new MOAs become available.

References

[1]Littlejohn GO, Tymms KE, Smith T, Griffiths HT. Using big data from real-world Australian rheumatology encounters to enhance clinical care and research. Clin Exp Rheumatol. Sep-Oct 2020;38(5):874-880.

Figure 1.

Percentage of patients initiating b/tsDMARDs by year and line of therapy.

Acknowledgements

The authors acknowledge the members of OPAL Rheumatology Ltd and their patients for providing clinical data for this study, and Software4Specialists Pty Ltd for providing the Audit4 platform.

Disclosure of Interests

Peter Youssef Speakers bureau: AbbVie, Novartis, Eli Lilly, Sabina Ciciriello: None declared, Gene-Siew Ngian: None declared, Juan Aw: None declared, Barry Kane: None declared, Catherine OSullivan: None declared, Tegan Smith: None declared, Claire Deakin: None declared, Geoff Littlejohn Consultant of: Abbvie, Janssen, Bristol Myers Squibb, Gilead, Eli Lilly, and MSD

Potential for Use of Portable Ultrasound Devices in Rural and Remote Settings in Australia and Other Developed Countries: A Systematic Review

Introduction

Objective

Methods

Results

Conclusion

Surveillance of RNase P, PMMoV, and CrAssphage in wastewater as indicators of human fecal concentration across urban sewer neighborhoods, Kentucky

Wastewater surveillance has been widely used as a supplemental method to track the community infection levels of severe acute respiratory syndrome coronavirus 2. A gap exists in standardized reporting for fecal indicator concentrations, which can be used to calibrate the primary outcome concentrations from wastewater monitoring for use in epidemiological models. To address this, measurements of fecal indicator concentration among wastewater samples collected from sewers and treatment centers in four counties of Kentucky (N = 650) were examined. Results from the untransformed wastewater data over 4 months of sampling indicated that the fecal indicator concentration of human ribonuclease P (RNase P) ranged from 5.1 × 101 to 1.15 × 106 copies/ml, pepper mild mottle virus (PMMoV) ranged from 7.23 × 103 to 3.53 × 107 copies/ml, and cross-assembly phage (CrAssphage) ranged from 9.69 × 103 to 1.85 × 108 copies/ml. The results showed both regional and temporal variability. If fecal indicators are used as normalization factors, knowing the daily sewer system flow of the sample location may matter more than rainfall. RNase P, while it may be suitable as an internal amplification and sample adequacy control, has less utility than PMMoV and CrAssphage as a fecal indicator in wastewater samples when working at different sizes of catchment area. The choice of fecal indicator will impact the results of surveillance studies using this indicator to represent fecal load. Our results contribute broadly to an applicable standard normalization factor and assist in interpreting wastewater data in epidemiological modeling and monitoring.

Approaches Used to Describe, Measure, and Analyze Place of Practice in Dentistry, Medical, Nursing, and Allied Health Rural Graduate Workforce Research in Australia: A Systematic Scoping Review

Redressing the maldistribution of the health workforce in regional, rural, and remote geographical areas is a global issue and crucial to improving the accessibility of primary health care and specialist services. Geographical classification systems are important as they provide an objective and quantifiable measure of access and can have direct policy relevance, yet they are not always consistently applied in rural health research. It is unclear how research focusing on the graduate health workforce in Australia has described, measured, and analyzed place of practice. To examine approaches used, this review systematically scopes Australian rural studies focusing on dentistry, medicine, nursing, and allied health graduates that have included place of practice as an outcome measure. The Joanna Brigg’s Institute Scoping Review Methodology was used to guide the review. Database searches retrieved 1130 unique citations, which were screened, resulting in 62 studies for inclusion. Included studies were observational, with most focusing on the practice locations of medical graduates and predicators of rural practice. Variations in the use of geographical classification approaches to define rurality were identified and included the use of systems that no longer have policy relevance, as well as adaptations of existing systems that make future comparisons between studies challenging. It is recommended that research examining the geographical distribution of the rural health workforce use uniform definitions of rurality that are aligned with current government policy.

Not All STEMI Patients Receive Timely Reperfusion: Considerations for Rural Emergency Departments

Early reperfusion for ST-elevation myocardial infarction (STEMI) is well known to improve patient outcomes. A review of patient records in one rural health service in New South Wales, Australia, suggested that not all STEMI patients were receiving timely reperfusion. Consequently, the aim of this study was to further investigate factors influencing clinical decision making by primary care providers in relation to rural STEMI patients. This cross-sectional observational study was in two phases, a retrospective audit of patient records and a survey of rural general practitioners (GPs). In the first phase, patients with STEMI who were referred from small rural hospitals to a regional hospital emergency department (ED) were identified through the local health district database. In phase two, information from the database informed questions for a survey distributed to the GP visiting medical officers (VMOs) at small rural hospitals in the region. The survey was designed to ascertain factors that may contribute to delays in the care of STEMI patients. Of the STEMI patients identified (n = 139), 15% (21) who were eligible for medical reperfusion were not administered thrombolysis within 4 hours of triage. Auditing of this group's records found that ECGs were inaccurately interpreted for 76% of the missed STEMI patients. In the survey, about 55% of the GP respondents said they “very much agree” with the statement that they felt competent in STEMI management. Only 64% of the GP VMOs agreed they felt competent in diagnosis and management of a failed thrombolysis and not all respondents were aware of the relevant clinical guideline. Patients with missed STEMI are at higher risk of morbidity and mortality and increased length of stay, adding burden to the patient, carer and health service. Without addressing gaps in service provision and better adherence to clinical guidelines, unacceptable delays in STEMI management in rural health services are likely to continue.

93 The Effects of Kinesiophobia on Outcome following Total Knee Replacement: A Systematic Review

Aim

Kinesiophobia, the fear of physical movement and activity related to injury vulnerability, has been linked to sub-optimal outcomes following total knee replacement (TKR). This systematic review has two aims: to define the relationship between kinesiophobia and functional outcomes, pain and range of motion following TKR, and to evaluate published treatments for kinesiophobia following TKR.

Method

A primary search was performed in March 2020. English-language studies recruiting adult primary TKR patients, using the Tampa Scale of Kinesiophobia (TSK) were included. Study quality was assessed using the Newcastle Ottawa Scale for cohort or case control studies, and the Cochrane Collaboration Risk of Bias tool for randomised controlled trials.

Results

All thirteen included papers (82 identified) showed adequately low risk of methodological bias. TSK1 (activity avoidance) correlated with WOMAC functional score at 12 months in three studies (r = 0.20 p &lt; 0.05, R = 0.317 p = 0.001, and correlation coefficient 0.197 p = 0.005). TSK score significantly correlated with mean active range of motion (ROM) at six months (105.33 (SD = 12.34) vs 85.53 (SD = 14.77) p = 0.000) post-operation. Three post-operative interventions improved TSK score vs control following TKR: a home-based functional exercise programme (TSK -14.30 (SD = 0.80) vs -2.10 (SD = 0.80) p &lt; 0.001)), an outpatient CBT programme (TSK 27.76 (SD = 4.56) vs 36.54 (SD = 3.58), and video-based psychological treatment (TSK 24 (SD = 5) vs 29 (SD = 5) p &lt; 0.01).

Conclusions

Kinesiophobia negatively affects functional outcomes up until one year post-operatively, while active ROM is reduced up to six months post procedure. Post-operative functional and psychological interventions can improve kinesiophobia following TKR.

178 Outcomes After Paediatric Extracorporeal Cardiopulmonary Resuscitation (ECPR) In A Tertiary Centre

Objective

To report our outcomes in utilizing extracorporeal membrane oxygenation (ECMO) institution for cardiac arrest.

Method

Retrospective records of all patients that needed ECPR between January 2015 and July 2020 have been reviewed. Primary outcomes were survival to ECMO decannulation, hospital discharge and one year survival. Secondary outcomes were the need for ECMO re-cannulation and neurology outcome using Paediatric Cerebral Performance Category (PCPC).

Results

A total of 44 consecutive patients were identified. 75 % were post cardiac surgery (n = 33), mean time from arrest to initiation of ECMO was 39.5 mins +/- 17.7 mins. Mean highest lactate prior to ECMO was 12.9 +/- 4.4. 79.6 % of patients received central cannulation. 11.4 % of patients (n = 5) needed more than one run of ECMO. Mean hours on ECMO were 175.4 +/- 212.5 hours and mean PCPC score was 2.14 +/- 1.68. Mean ICU stay was 16.2 +/- 16.9 days and total hospital stay was 47 +/- 68.5 days. Overall Survival to ECMO weaning was 68.4 % (n = 13) vs 92 % (n = 23) in neonates and paediatric patients, respectively. Survival to hospital discharge was 47.4 % (n = 9) vs 72 % (n = 18) and one year survival was 42.1 % (n = 8) vs 72 % (n = 18) in the neonatal and paediatric cohort, respectively.

Conclusions

Our survival rates are encouraging and in line with current published literature and comparable favourably to International ELSO (Extracorporeal life support organisation) registry for neonates and paediatric patients of all cause ECPR. Paediatric patients showed a survival advantage over neonates after ECPR.

92 Increased Proportion of Alcohol-Related Trauma in A South London Major Trauma Centre During Lockdown, A Cohort Study

Background

Alcohol has been associated with 10-35% trauma admissions and 40% trauma-related deaths globally. In response to the Covid-19 pandemic, the United Kingdom (UK) entered a state of ‘lockdown’ on 23rd March 2020. Restrictions were most significantly eased on 1st June 2020, when shops and schools re-opened. The purpose of this study was to quantify the effect of lockdown on alcohol-related trauma admissions.

Method

All adult patients admitted as ‘trauma calls’ to a London Major Trauma Centre (MTC) during April 2018 and April 2019 (pre-lockdown; N = 316), and 1st April – 31st May 2020 (lockdown; N = 191) had electronic patient records analysed. Patients’ blood alcohol level and records of intoxication were used to identify alcohol-related trauma. Trauma admissions from pre- and post-lockdown cohorts were compared using multiple regression analyses.

Results

Alcohol-related trauma was present in a significantly higher proportion of adult trauma calls during lockdown (lockdown 60/191 (31.4%), versus pre-lockdown 62/316 (19.6%); (Odds Ratio (OR) 0.83, 95% CI 0.38 to 1.28, p &lt; 0.001). Lockdown was also associated with increased weekend admissions of trauma (lockdown 125/191 weekend (65.5%) vs pre-lockdown 179/316 (56.7%); OR -0.40, 95% CI -0.79 to -0.02, p = 0.041). No significant difference existed in the age, gender, or mechanism between pre-lockdown and lockdown cohorts (p &gt; 0.05).

Conclusions

UK lockdown was independently associated with an increased proportion of alcohol-related trauma. Trauma admissions were increased during the weekend when staffing levels are reduced. With the possibility of subsequent global ‘waves’ of Covid-19, the risk of long-term repercussions of dangerous alcohol-related behaviour to public health must be addressed.

Rationale and protocol for the Nursing and Allied Health Graduate Outcomes Tracking (NAHGOT) study: a large-scale longitudinal investigation of graduate practice destinations

INTRODUCTION

Inequitable distribution of health workforce limits access to healthcare services and contributes to adverse health outcomes. WHO recommends tracking health professionals from their points of entry into university and over their careers for the purpose of workforce development and planning. Previous research has focused on medical students and graduates' choice of practice location. Few studies have targeted nursing and allied health graduates' practice intentions and destinations. The Nursing and Allied Health Graduate Outcomes Tracking (NAHGOT) study is investigating factors affecting Australian nursing and allied health students and graduates' choice of graduate practice location over the course of their studies and up to 10 years after graduation by linking multiple data sources, including routinely collected university administrative and professional placement data, surveys of students and graduates, and professional registration data.

METHODS

By using a prospective cohort study design, each year a new cohort of about 2000 students at each participating university (Deakin University, Monash University and the University of Newcastle) is tracked throughout their courses and for 10 years after graduation. Disciplines include medical radiation practice, nursing and midwifery, occupational therapy, optometry, paramedicine, pharmacy, physiotherapy, podiatry and psychology. University enrolment data are collected at admission and professional placement data are collected annually. Students' practice destination intentions are collected via questions added into the national Student Experience Survey (SES). Data pertaining to graduates' practice destination, intentions and factors influencing choice of practice location are collected in the first and third years after graduation via questions added to the Australian Graduate Outcomes Survey (GOS). Additionally, participants may volunteer to receive a NAHGOT survey in the second and fourth-to-tenth years after graduation. Principal place of practice data are accessed via the Australian Health Practitioner Regulation Agency (Ahpra) annually. Linked data are aggregated and analysed to test hypotheses comparing associations between multiple variables and graduate practice location.

RESULTS

This study seeks to add to the limited empirical evidence about factors that lead to rural practice in the nursing and allied health professions. This prospective large-scale, comprehensive study tracks participants from eight different health professions across three universities through their pre-registration education and into their postgraduate careers, an approach not previously reported in Australia. To achieve this, the NAHGOT study links data drawn from university enrolment and professional placement data, the SES, the GOS, online NAHGOT graduate surveys, and Ahpra data. The prospective cohort study design enables the use of both comparative analysis and hypothesis testing. The flexible and inclusive study design is intended to enable other universities, as well as those allied health professions not regulated by Ahpra, to join the study over time.

CONCLUSION

The study demonstrates how the systematic, institutional tracking and research approach advocated by the WHO can be applied to the nursing and allied health workforce in Australia. It is expected that this large-scale, longitudinal, multifactorial, multicentre study will help inform future nursing and allied health university admission, graduate pathways and health workforce planning. Furthermore, the project could be expanded to explore health workforce attrition and thereby influence health workforce planning overall.

Topography and climate in the upper Indus Basin: Mapping elevation-snow cover relationships

The Upper Indus Basin (UIB), which covers a wide range of climatic and topographic settings, provides an ideal venue to explore the relationship between climate and topography. While the distribution of snow and glaciers is spatially and temporally heterogeneous, there exist regions with similar elevation-snow relationships. In this work, we construct elevation-binned snow-cover statistics to analyze 3415 watersheds and 7357 glaciers in the UIB region. We group both glaciers and watersheds using a hierarchical clustering approach and find that (1) watershed clusters mirror large-scale moisture transport patterns and (2) are highly dependent on median watershed elevation. (3) Glacier clusters are spatially heterogeneous and are less strongly controlled by elevation, but rather by local topographic parameters that modify solar insolation. Our clustering approach allows us to clearly define self-similar snow-topographic regions. Eastern watersheds in the UIB show a steep snow cover-elevation relationship whereas watersheds in the central and western UIB have moderately sloped relationships, but cluster in distinct groups. We highlight this snow-cover-topographic transition zone and argue that these watersheds have different hydrologic responses than other regions. Our hierarchical clustering approach provides a potential new framework to use in defining climatic zones in the cyrosphere based on empirical data.