The 4Ms Provide A Structural Framework For Organizing Educational Materials

The John A Hartford Foundation and the Institute for Healthcare Improvement (IHI)’s 4Ms of mentation, mobility, medications and (what) matters most provide a much-needed framework for helping system leaders and frontline teams consistently deliver high-quality, age-friendly care. Geriatric Fast Facts (GFFs) is a virtual resource providing teachers/learners with peer-reviewed, evidence-based summaries on topics essential to older adult care via a searchable website [www.geriatricfastfacts.com]. To determine if GFFs can be classified by the 4Ms we initially did a free text search of all GFFs. That revealed GFFs whose foci were unrelated to the 4Ms (e.g., mobility emerged in a fluoroscopy GFF as a minor element related to patient positioning). Therefore, all GFFs were independently reviewed by a geriatrician and the website manager and classified according to the 4M rubric (a single GFF can be classified in multiple M’s such as #93 on Age Friendly Health Systems). Any differences were adjudicated by the GFF editor. 64% (60/ 93) of GFFs strongly linked to one of the 4Ms. The number of GFFs dedicated to the 4Ms are as follows: 20 what matters most, 18 medications, 13 mentation, and 9 mobility. Those that were not coded within 4Ms were often very disease/specialty oriented. A total of 36 were not classified. For example, GGF #39 focuses on the etiologies of anemia among older adults. The 4M framework can be easily applied to educational materials to support consistent and clear conceptual model across learning conditions and materials.

Objective Assessment of Aerosolization During Transnasal Endoscopy: A Systematic Review

Objective The goal of this systematic review is to assimilate the literature on objective assessment of particulate aerosolization during transnasal endoscopic procedures. Data Sources PubMed and hand-searched articles. Review Methods The PubMed electronic database was searched using Medical Subject Headings and free-text search terms relating to aerosolization and transnasal endoscopic procedures from inception to November 16, 2020. References were hand-searched to identify additional publications for consideration. Inclusion in the systematic review required quantification of aerosol generation during clinic transnasal endoscopic procedures. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and flowchart were followed during the systematic review. Results Eight of 900 studies met criteria for inclusion in the systematic review. Five studies tested nasal endoscopy with mixed findings on the risk of aerosol generation during this procedure. Two studies assessed flexible fiberoptic laryngoscopy and also reported mixed findings. Breathing, sneezing, speech, and spray anesthetic/decongestants were found to consistently increase aerosol generation above baseline. A number of studies tested new and general mitigation strategies and were found to be effective in decreasing aerosol generation. Conclusions The coronavirus disease 2019 pandemic has informed many considerations regarding patient and provider safety. It is valuable to understand the risk during outpatient otolaryngology procedures through the quantification of aerosolization. There are several effective methods to control aerosolization during these procedures. The findings of this systematic review will inform appropriate precautions to protect against spread of infectious agents by aerosolization.

DWD Geoportal – Converging open data, metadata and documentation in a user-friendly way

<p>Since 2017, Open Data has been a part of the DWD data distribution strategy. Starting with a small selection of meteorological products, the number of available datasets has grown continuously over the last years. Since the start, users can access datasets anonymously via the website https://opendata.dwd.de to download file-based meteorological products. Free access and the variety of products has been welcomed by the general public as well as private met service providers. The more datasets are provided in a directory structure, however, the more tedious it is to find and select among all available data. Also, metadata and documentation were available, but on separate public websites. This turned out to be an issue, especially for new users of DWD's open data.</p><p>To help users explore the available datasets as well as to quickly decide on their suitability for a certain use case, the Open Data team at DWD is developing a geoportal. It enables free-text search along with combined access to data, metadata, and description along with interactive previews via OGC WMS.</p><p>Cloud technology is a suitable way forward for hosting the geoportal along with the data in its operational state. Benefits are expected for the easy integration of rich APIs with the geoportal, and the flexible and fast deployment and scaling of optional or prototypical services such as WMS-based previews. Flexibility is also mandatory to respond to fluctuating user demands, depending on time of day and critical weather situations, which is supported by containerization. The growing overall volume of meteorological data at DWD may mandate to allow customers to bring their code to the data – for on-demand processing including slicing and interpolation –  instead of transferring files to every customer. Shared cloud instances are the ideal interface for this purpose.</p><p>The contribution will outline a protoype version of the new geoportal and discuss further steps for launching it to the public.</p>

Abstract P243: Identifying Cerebral Venous Thrombosis Through Administrative Data: Icd-10 Case Ascertainment Depends on Clinical Context

Background: Recent reported population-based rates of cerebral venous thrombosis (CVT) are higher than in older studies, though the context of these diagnoses is not well-defined. To better understand these trends, we examined the accuracy of administrative codes ( ICD-10 ) for CVT in different clinical scenarios. Methods: Cases of CVT presenting to a tertiary center between 2008-2018 were identified in two ways: free text search through all hospital electronic radiology reports regardless of modality and body part and any ICD-10 discharge codes (see Table 1). Electronic medical records were reviewed to verify diagnoses of CVT and their clinical context (Figure 1) to calculated Positive Predictive Value (PPV) of ICD-10 codes. Additionally, sensitivities of ICD-10 codes were calculated against all CVTs identified using either searches that were verified on chart review as the gold standard. Results: There were 289 confirmed cases: 239 new diagnoses, 204 of which were acute events. Only 75 cases (37%) were new, symptomatic CVTs not provoked by trauma or structural processes. Sensitivity and PPV for ICD-10 codes depending on clinical context is reported in Table 1. Conclusion: The majority of CVT identified at our institution were incidentally diagnosed in context of intracranial processes such as trauma, surgery, infection, or masses; 37% were symptomatic, non-structural incident diagnoses. Our findings have implications in interpreting CVT rates identified through administrative data, as the management and prognosis of CVT may differ based on clinical context.

A systematic literature review of pharmacists in general practice in supporting the implementation of shared care agreements (SCA) in primary care

Background Rising demand for healthcare continues to impact on all sectors of the health service. As a result of the growing ageing population and the burden of chronic disease, healthcare has become more complex, the need for more efficient management of specialist medication across the healthcare interface is of paramount importance. With the rising number of pharmacists working in primary care in clinical roles, is this a role that pharmacist could support to ensure the successful execution of Shared Care Agreement (SCA) in primary care for these patients?Aim of the review Systematic review to identify activities and assess interventions provided by pharmacists in primary care on SCA provision and how it affects health-related quality of life (HRQoL) for patients.MethodThe following electronic databases were systematically searched from the date on inception to January 2020: AMED®, CINAHL®, Cochrane Database of Systematic Reviews (CDSR), EMBASE®, EMCARE®, Google Scholar, HMIC®, MEDLINE®, PsycINFO®, Scopus, Web of Science® and grey literature sources were also searched. The search was adapted according to the respective database-specific search tools. It was searched using a combination of medical subject heading terms (MeSH), free-text search terms and Boolean operators.ResultsA total of 6,489 titles/abstracts were screened, and 59 full articles were assessed for eligibility. On examination of full text, no studies met the inclusion criteria for this reviewConclusionThis review highlights the need for further research to evaluate how pharmacists in general practice can support the safe and effective integration of specialist medication in primary care with the use of SCA.

TWISTED POUCH SYNDROME - A DIFFICULT TO DIAGNOSE MECHANICAL COMPLICATION OF ILEAL POUCH-ANAL ANASTOMOSIS: OUTCOMES AFTER REDO POUCH PROCEDURES

Background Ileal pouch-anal anastomosis (IPAA) is a technically demanding procedure. Intraoperatively, great care must be taken to assure a straight superior mesenteric axis. Rarely, twisted pouches are inadvertently constructed, resulting in deviations of expected pouch function, i.e. patients readily able to open their bowels on average 7x/24 hours without pain. Twisted pouches may result in symptoms classified as pouch dysfunction. Herein we describe our quaternary pouch referral center experience with twisted pouch syndrome (TPS). Methods We performed a retrospective review of our prospectively maintained pouch registry from 1995 – 2020. Patients were identified using free-text search of redo IPAA operative reports for variations of the term “twist”. We defined twisted pouch syndrome as intraoperative findings of twisting of the pouch as the primary pathology. Data are presented as frequency (proportion) or median (interquartile range). Results Over 25-years, we identified 29 patients with confirmed TPS who underwent a redo pouch procedure by 10 surgeons. Overall, 65% were female, median BMI 21.2 (19.5 – 26) kg/m2. The duration from the index IPAA to the redo procedure was 4 (2 – 8) years; all (100%) were referral cases constructed elsewhere. Original diagnoses included: ulcerative colitis (90%), FAP (10%), lack of interstitial cells of Cajal in 1 patient (10%). All patients presented with symptoms of pouch dysfunction including erratic bowel habits (96%) with urgency/frequency, abdominal/pelvic/rectal pain (92%), and obstructive symptoms (88%). Most had (75%) been treated for chronic pouchitis with antibiotics or biologics, and 46% had undergone 1 or more additional surgery. Prior to redo IPAA procedure patients underwent a thorough workup: 100% pouchoscopy, 96% GGE, 93% underwent EUA, 88% MRI, 73% manometry, and 42% defecography. TPS was diagnosed in 15% by pouchoscopy, in 10% by imaging, and in 75% was diagnosed intra-operatively at re-diversion (20%) or revision/redo IPAA (55%). In terms of surgical intervention, 85% were initially re-diverted. A total of 18 (62%) underwent pouch revision, and 10 (38%) required redo-IPAA. Short-term outcomes: LOS 7.5 (5 – 9) days, any complication 48%, readmission 11%, reoperation 3.4%, zero mortalities. After a median follow-up 50 (28 – 60) months, 2 never had loop ileostomy closure, 1 had pouch excision, and 1 a Kock pouch, yielding an overall pouch survival rate of 86%. Conclusions Twisted pouch syndrome presents with pouch dysfunction manifest by erratic bowel habits, unexplained pain, and obstructive (defecation) symptoms. This syndrome may also mimic chronic pouchitis. Despite a thorough workup which may suggest a mechanical problem, many patient may not be diagnosed until time of redo pouch surgery. Redo surgery for twisted pouch syndrome results in long-term pouch survival for the majority.

The empirical evidence underpinning the concept and practice of person-centred care for serious illness: a systematic review

IntroductionPerson-centred care has become internationally recognised as a critical attribute of high-quality healthcare. However, the concept has been criticised for being poorly theorised and operationalised. Serious illness is especially aligned with the need for person-centredness, usually necessitating involvement of significant others, management of clinical uncertainty, high-quality communication and joint decision-making to deliver care concordant with patient preferences. This review aimed to identify and appraise the empirical evidence underpinning conceptualisations of ‘person-centredness’ for serious illness.MethodsSearch strategy conducted in May 2020. Databases: CINAHL, Embase, PubMed, Ovid Global Health, MEDLINE and PsycINFO. Free text search terms related to (1) person-centredness, (2) serious illness and (3) concept/practice. Tabulation, textual description and narrative synthesis were performed, and quality appraisal conducted using QualSyst tools. Santana et al’s person-centred care model (2018) was used to structure analysis.ResultsPRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow data: n=12,446 studies screened by title/abstract, n=144 full articles assessed for eligibility, n=18 studies retained. All studies (n=18) are from high-income countries, and are largely of high quality (median score 0.82). The findings suggest that person-centred care encompasses the patient and family being respected, given complete information, involved in decision-making and supported in their physical, psychological, social and existential needs. The studies highlight the importance of involving and supporting family/friends, promoting continuation of normality and self-identity, and structuring service organisation to enable care continuity.ConclusionPerson-centred healthcare must value the social network of patients, promote quality of life and reform structurally to improve patients’ experience interacting with the healthcare system. Staff must be supported to flexibly adapt skills, communication, routines or environments for individual patients. There remains a need for primary data investigating the meaning and practice of PCC in a greater diversity of diagnostic groups and settings, and a need to ground potential components of PCC within broader universal values and ethical theory.

Pneumomediastinum with COVID-19: a natural process or complication? A literature review

COVID-19 pneumonia is a serious respiratory viral infection that recently spread all over the world. It carries a significant mortality risk. Little is known about the pathophysiology of the disease, being a newly mutated virus. Knowledge of the clinical disease manifestations kept evolving as unfamiliar findings and presentations are constantly reported. Pneumomediastinum had been frequently reported since the start of the pandemic, and its significance was questioned. The aim of this review is to analyze the reported cases of pneumomediastinum with coronavirus infection to look for its pathophysiology, prognostic value, and best treatment. A systematic literature search was conducted using free text search for pneumomediastinum with COVID-19 case reports and case series. PubMed and Google scholar data bases were searched. Twenty three articles were retrieved. All are case reports and case series, 39 cases of the reported cohort qualified for inclusion into analysis. Chronic respiratory conditions were found in 23% of the patients. There was about five folds risk of developing the condition with oxygen therapy (both through invasive and non-invasive means). The best diagnostic modality was chest computed tomography scan (74.4%). Management was conservative in 69%, while pleural drainage was necessary in 23% of the patients. Both treatment strategies were successful with no statistical difference (p value=0.327). It is not yet clear if pneumomediastinum is a pathological disease process or an interventional complication. Interventional and conservative treatment had similar outcomes depending on individual case merits. No prognostic value could be demonstrated.

Exploring the use of nudging in public health lifestyle interventions: A literature review

Background The concept of nudging has been imported from behavioral economics into the public health context to correct 'unhealthy behaviours' and produce health-promoting behavior changes in individuals. However, there is lack of clarity as to what constitutes a nudge and whether nudging techniques in public health lifestyle interventions are effective. The aim of this literature review is to identify nudging techniques used in public health lifestyle interventions and to investigate whether nudging techniques induce expected healthy lifestyle changes in interventions that relate to diet, exercise, sleep, alcohol and smoking. Methods A systematic literature review on the concept “nudging” in public health lifestyle interventions was conducted, applying a free text search strategy on a set of search terms in three databases: PubMed, CINAHL and PsycINFO. Articles meeting the inclusion criteria were included in our data set, and we performed a meta-synthesis to construct interpretative explanations. Results 66 original studies published in international peer-reviewed journals were identified. The findings showed that most nudging interventions involved diet/nutrition (n = 55), were carried out as single experiments, lasted for a short period of time and that the majority had the intended effects. Specific nudging techniques were identified and sorted into eight broader categories. The most commonly used nudging technique involved making healthier food items more apparent and accessible than less healthy foods. Conclusions The synthesis showed that these studies were limited with regard to their design, target groups, duration of the intervention, measures of effectiveness and critical reflection on ethical issues. Key messages Nudging may be effective in producing immediate behavioral changes; however, there is little evidence that nudging interventions result in lasting behavioral changes outside the setting of the studies. Further critical discussions about the implications of nudging in public health lifestyles intervention are required.

8 Catatonia: demographic, clinical and laboratory associations in a large dataset

Objectives/AimsCatatonia is an important neuropsychiatric disorder with a high morbidity and mortality. However, due to a perception that it is very infrequent and because of the acuity of the patients, it has remained poorly studied and research has often been confined to small groups.We hypothesised that: catatonia would remain a significant clinical problem; catatonic patients would have a longer duration of admission and higher mortality; serum iron would be reduced, reflecting a systemic inflammatory response, and high rates of NMDA receptor antibody serum positivity would be observed.MethodsThis was a prospective cohort study that included patients in a large mental health trust who were diagnosed with catatonia between 2007 and 2016. We used the Clinical Records Interactive Search (CRIS) system hosted at the NIHR Maudsley Biomedical Research Centre to search the clinical records for patients with catatonia. An initial free-text search was refined by use of a natural language processing app. The results of the app were validated by three of the authors, who included patients in the analysis only if a clinician had made a diagnosis of catatonia and two or more items of the Bush-Francis Catatonia Screening Instrument were in evidence.Demographic, clinical and blood-based markers could then be extracted for these patients and compared, where relevant, to non-catatonic psychiatric patients.Results1,456 patients with catatonia (of whom 787 were psychiatric inpatients) and 37,456 psychiatric inpatient controls were identified. There was no evidence for a reduction in the rate of catatonia over time. Patients with catatonia were younger than the controls by 2.52 years (95% CI 1.30 to 3.73) and similar in gender composition. Patients with catatonia were more likely to be black (53.5% vs 24.5%, p<0.001). Duration of hospitalisation was greater in the catatonic group (221 days vs 86 days, p<0.001), but there was no difference in mortality when controlling for demographic variables (HR 0.96 [95% CI 0.84–1.23]). Serum iron was lower in catatonic patients (11.6 vs 14.2 µmol/L [95% CI -4.88 to -0.30 µmol/L]), but there was no difference in C-reactive protein, erythrocyte sedimentation rate or white cell count. NMDA receptor antibodies were present at a higher rate (OR 5.6 [95% CI 1.3–24.1]). Principal component analysis divided the elements of the Bush-Francis Catatonia Screening Instrument into three components (hyperkinetic, hypokinetic and amotivation).ConclusionsThis is the largest study of catatonia to date. There is evidence that catatonia is not dying out and confers high morbidity but without affecting mortality. The innate immune system does not seem to be activated, but NMDA receptor antibodies are present at higher rates than in psychiatric controls. We demonstrate that catatonia remains an important clinical problem and may be associated with neuroimmunological dysfunction.