The Importance of Perceived Relevance: A Qualitative Evaluation of Patient’s Perceptions of Value and Impact Following a Low-Intensity Group-Based Pain Management Program

Background and objectives: Limited evidence exists exploring perceptions of which aspects of a pain management program are perceived as valuable and impactful. The aim of this study was to explore patient beliefs about which aspects of a pain management program were valued and/or had perceived impact. Materials and Methods: One-on-one structured interviews were conducted with 11 adults three months after their completion of the Spark Pain Program at Westmead Hospital, Sydney, Australia. Concepts in the transcripts were inductively identified and explored, utilizing thematic analysis to better understand their relevance to the study aim. Results: Four themes emerged: (1) “The program overall was positive, but…”; (2) “I valued my improved knowledge and understanding of pain, but…”; (3) “I valued the stretching/relaxation/pacing/activity monitoring”; and (4) “I valued being part of a supportive and understanding group”. Participants reported that they liked being treated as an individual within the group. A lack of perceived personal relevance of key messages was identified in some participants; it appears that patients in pain programs must determine that changes in knowledge, beliefs, and attitudes are personally relevant in order for the changes to have a significant impact on them. Conclusions: This study provides new insights into aspects of a pain management program that were perceived as valuable and impactful, areas that “missed the mark”, and hypotheses to guide the implementation of service delivery and program redesign.

Abstract 13621: Predictors of Short-term and Long-term Clinical Outcomes After an Acute Atrial Fibrillation or Flutter Admission

Introduction: Atrial fibrillation (AF) is a major cause of mortality and morbidity globally. This study aims to identify predictors of AF-related rehospitalization following an acute AF/flutter admission. Methods: Patients admitted to Westmead Hospital with a primary diagnosis of AF/flutter from 1 May 2014 to 31 May 2018 were included and followed up until 31 May 2019. We defined AF-related rehospitalization as an admission due to recurrent AF/flutter, congestive heart failure, stroke and/or myocardial infarction. Multivariable logistic regression was used to identify independent predictors of 30-day outcomes. Cox regression was used to identify independent predictors of long-term outcomes: first AF-related rehospitalization or all-cause mortality. Results: Of 1664 consecutive patients admitted with AF/flutter, 55.8% were male and the median age was 68.0. At 30 days, 123 (7.4%) had an AF-related readmission (110 for AF/flutter and 13 for other cardiovascular outcomes). During a mean follow-up period of 2.1 ± 1.5 years, 683 (41.0%) of patients had at least one AF-related rehospitalization (38.1%, n=634) or died (2.9%, n=49). Chronic kidney disease (CKD) (OR 1.94, 95% CI 1.07 - 3.50) was an independent predictor of 30-day AF-related rehospitalization. Age (HR 1.01, 95% CI 1.01 - 1.02 for each additional year), initial admission via emergency (HR 1.29, 95% CI 1.08 - 1.54), CKD (HR 1.64, 95% CI 1.24 - 2.18), chronic obstructive pulmonary disease (HR 1.42, 95% CI 1.09 - 1.83) and the presence of additional comorbidities (HR 1.38, 95% CI 1.04 - 1.83) were independent predictors of first AF-related rehospitalization or death (all p <0.05). Conclusion: AF-related rehospitalization is common following an acute AF/flutter admission. AF/flutter patients with comorbidities, particularly renal and pulmonary diseases, are at high risk of readmission. Such patients could be targeted for increased surveillance and additional post-discharge support to prevent readmission.

Enteric Leaks from Simultaneous Pancreas Kidney Transplantation at a Single Centre: Risk Factors and Management Over a 20-Year Period

Background: Simultaneous pancreas-kidney transplantation (SPK) remains the gold standard treatment for patients with type I diabetes mellitus and end-stage renal failure. Enteric drainage is utilised to handle exocrine secretions from the graft, with enteric leaks being the most challenging of complications. There remains a lack of published research regarding risk factors for enteric leaks. Methods: As such we undertook a retrospective cohort study of SPK transplants performed at Westmead Hospital over twenty years (between 1998-2017, n=425) to identify the occurrence of enteric leaks as well as donor, recipient and transplantation procedure risk factors. Descriptive statistics were generated using SPSS version 22.0 (IBM SPSS Statistics for Windows, Armonk, NY, USA). The student’s t-test and/or Mann-Whitney U test was used to detect significance. All tests were two tailed and any statistically significant difference was considered at the P <0.05 level. Results: Of the 425 patients, 16 (3.5%) experienced an enteric leak. Of these, 12 (80%) had significant vascular disease, defined as coronary artery disease, cerebrovascular disease, retinopathy, peripheral neuropathy or peripheral vascular disease requiring surgical intervention. The risk of an enteric leak increased in recipients with significant vascular disease. Conclusion: The rates at Westmead Hospital were lower than those published in the literature. We demonstrated that the presence of significant vascular disease predisposed recipients to enteric leak. These findings highlight the importance of careful donor and recipient selection to optimise patient outcomes.

Primiparous women's narratives of confidence in the perinatal period

Background Pregnancy and childbirth are described as transitional phases or existential thresholds that childbearing women have to cross. Aim To gather insights into the personal experiences of women in pregnancy, labour and the days immediately after birth. Methods We conducted a qualitative study in the postpartum ward at Westmead Hospital. We invited 16 primiparous women who had given birth to a single baby to participate in our study. After the participants signed the consent form, we conducted individual, in-depth interviews. We analysed the data using thematic analysis. Findings Confidence was an overarching theme that contributed to the women's experiences of pregnancy, labour and the immediate days after birth. The experiences encompassed two main categories: positive experiences that aided in building confidence, and negative experiences that adversely affected women's confidence. The themes relating to positive experiences, including effective interpersonal relationships, knowledge promotion and positive self-concept, made the women feel more confident. The themes relating to negative experiences, including lack of control and feeling unprepared, made the women feel less confident in their mothering capabilities. Conclusion Confidence was the overarching theme in this study and knowledge was shown to be the fundamental feature of confidence.

Quality and targeting of new referrals for ocular complications of diabetes from primary care to a public hospital ophthalmology service in Western Sydney, Australia

Patients with diabetes require regular examination for eye disease, usually in primary care settings. Guidelines recommend patients with at least moderate non-proliferative diabetic retinopathy (NPDR) be referred to an ophthalmologist for treatment; however, poorly targeted referrals lead to access blocks. The quality of new referrals associated with diabetes to a public ophthalmology service in Sydney, New South Wales, Australia, were assessed for referral completeness and targeting. A cross-sectional audit of medical records for new patients referred to Westmead Hospital Eye Clinic in 2016 was completed. Completeness of medical and ophthalmic information in referrals and subsequent patient diagnosis and management in 2016–17 was recorded. Sub-analyses were conducted by primary care referrer type (GP or optometrist). In total, 151 new retinopathy referrals were received; 12% were sent directly to a treatment clinic. Information was incomplete for diabetes status (&gt;60%), medical (&gt;50%) and ophthalmic indicators (&gt;70%), including visual acuity (&gt;60%). GP referrals better recorded medical, and optometrists (37%) ophthalmic information, but information was still largely incomplete. Imaging was rarely included (retinal photos &lt;1%; optical coherence tomography &lt;3%). Median appointment wait-time was 124 days; 21% of patients received treatment (laser or anti-vascular endothelial growth factor) at this or the following encounter. Targeting referrals for ocular complication of diabetes to public hospitals needs improvement. Education, feedback and collaborative care mechanisms should be considered to improve screening and referral in primary care.

Safety and Tolerability of Bacteriophage Therapy in Severe Staphylococcus aureus Infection

ImportanceThe effect of IV administration of a bacteriophage cocktail produced under GMP conditions on patients with severe S. aureus infection, including complicated bacteraemia, endocarditis and septic shock, is unknown.ObjectiveTo assess safety and tolerability of adjunctive bacteriophage therapy in patients with severe S. aureus infections.Design, Setting, ParticipantsObservational, open-label clinical trial of thirteen critically-ill patients admitted to a tertiary-referral hospital with S. aureus bacteraemia (including infective endocarditis, n=6) were assessed by the treating clinician and two consulting infectious diseases physicians to independently verify that routine medical and surgical therapy was optimal and that a poor outcome remained likely. Compassionate access to therapy was approved by both US and Australian regulators and by the Westmead Hospital Human Research Ethics Committee.InterventionA GMP-quality preparation of three combined Myoviridae bacteriophages with specific activity against S. aureus (AB-SA01), was administered intravenously in conjunction with optimal antibiotic therapy.Main Outcome and MeasurementsPhysiological, haematological and biochemical markers of infection, bacterial and bacteriophage kinetics in blood, development of resistance to bacteriophages, and mortality at 28 (D28) and 90 (D90) days were measured. Main outcomes were safety and tolerability.ResultsBacteriophage therapy was initiated 4-10 days after antibiotic commencement, at 109 plaque-forming units (PFU) twice daily. Infecting staphylococci were typical of common local subtypes. Initial input ratio of phages to bacteria in the bloodstream (MOIinput) was >100. Five of the thirteen patients died by D28 and a sixth patient suffered sudden cardiac death on D90. Bacteriophage therapy coincided with a marked reduction in staphylococcal bacterial DNA in the blood and in sepsis-associated inflammatory responses in almost all cases. No bacteriophage-attributable adverse events were identified. Development of bacteriophage resistance was not observed. Population analysis revealed no significant effect of bacteriophage therapy on the gut microflora.Conclusions and RelevanceAdjunctive bacteriophage therapy appears to be safe and well-tolerated in critically ill patients with severe S. aureus infection. Two weeks of twice daily intravenous administration may be a suitable protocol. Controlled trials are needed.Trial RegistrationWestmead Hospital Human Research Ethics Committee approval July 11, 2017; ClinicalTrials.gov Identifier: NCT03395769, AB-SA01-EAP01 (January 10, 2018); Clinical Trials Notification (Australian Therapeutic Goods Association): CT-2018-CTN-02372-1 (July 23, 2018).Key PointsQuestionIs intravenous (IV) administration of investigational bacteriophage (phage) therapy safe and well-tolerated in patients with severe Staphylococcus aureus infection?FindingsThirteen patients with severe S. aureus infections received AB-SA01, a bacteriophage product prepared according to Good Manufacturing Practices (GMP), as adjunctive therapy to antibiotics. AB-SA01 was well-tolerated with no adverse events identified. Bacterial burden and inflammatory responses were reduced and no phage-resistant staphylococci were isolated during or after therapy.MeaningOur results will inform future randomised controlled trials assessing the antibacterial and anti-inflammatory potential of bacteriophages in the treatment of severe S. aureus infection.