Australia's national asthma research agenda: Priorities for end-users of research

Introduction/Aim: The fifth objective of the 2018 National Asthma Strategy called for the development of a national research agenda. Asthma Australia and partners have completed this project: the National Asthma Research Agenda. Method(s): A national, mixed-method study design adapted from the James Lind Alliance Priority Setting Partnership was adopted. Comprising two discrete phases . A cross-sectional purposive survey of people with asthma, their careers, clinicians and public health professional. The survey findings were analysed thematically. Themes containing questions already answered by high quality research were removed. The project executive team approved the remaining list of themes for phase 2. Three consensus workshops were held comprising health and policy professionals, people with asthma, parents and people from diverse backgrounds to achieve consensus on prioritising and ranking the themes. Workshop participants did this under the guidance of a trained/skilled facilitator. The ranked themes from the workshops were filtered through a computer algorithm, resulting in a top ten list of asthma research priority themes. These themes summarise specific topics and questions and form the National Asthma Research Agenda. Result(s): 593 people completed the survey. Most respondents were female and had asthma. The top ten research priority themes are: Asthma in children Asthma and COVID-19 Asthma care and self-management Diagnosis and medication Managing asthma attacks Causes, prevention and features of asthma Mental health Asthma and ageing Severe asthma Asthma and other health conditions These themes include sub-topics, which reflect the specific inputs of the survey participants. Results were consistent among subgroups. Conclusion(s): The end-user methodology used has been useful in determining what's important to the people who rely on the answers provided by asthma research in Australia. This is a broad research agenda, which highlights the extent of research output that consumers require in order to manage asthma.

Post Covid-19 Syndrome Dysautonomia: A Tertiary Referral Centre Experience

Post-coronavirus disease 19 (COVID-19) syndrome has substantial health and economic implications. It is multi-systemic, with prevalent autonomic symptoms. Understanding presentations and potential autonomic causes may help guide treatment strategies and recovery. All patients with a suspected or confirmed history of COVID-19 infection who underwent autonomic testing between May 2020 and October 2021 were reviewed retrospectively. We evaluated 62 patients (20 male, 42 female, mean age of 41.38 +/-11.52). COVID-19 was PCR confirmed in 15 patients (26%), and five (8%) required acute hospital intervention. Most common symptoms included palpitations (81%), lightheadedness/ dizziness (62%), dyspnoea (48%), fatigue (46%), or cognitive symptoms (33%) Autonomic testing showed normal blood pressure responses to pressor stimuli, a mean respiratory sinus arrhythmia of 18.89b/m, and Valsalva ratio of 2.09. Postural tachycardia syndrome (PoTS) was diagnosed in 12 patients, autonomically mediated syncope (AMS) in 11, neurogenic orthostatic hypotension (NOH) in two, and initial orthostatic hypotension (IOH) in seven. Normal supine and upright plasma noradrenaline levels were measured in 34 patients (mean 283.38 pg/ml supine;472.43pg/ml tilted). Autonomic testing was reassuring (PoTS and syncope) in the majority with abnormal testing (n=32, or 52%). Further phenotyping of PoTS to exclude neuropathic pathology may be needed. IOH and OH are important considerations.

Untrammelled ways: Reflecting on the written text, nourishment and care in online teaching

As the COVID-19 pandemic gathered momentum in 2020, it became clear that online teaching spaces risked a distancing from the embodied knowledge so necessary to creative education. Teaching written texts to creative practitioners is a process that calls for alternative spatial and visual literacies, for ontological methods, for honouring experience and reflection - especially in a neo-liberal climate of higher education. In my teaching practice, as well as writing and painting practices, I like so many others have sought spaces for nourishment during this era. Through my teaching and a collaborative research group, one space in which I located this was via hope. This is a time to ask if we can use this moment in history to encourage thinking in an untrammelled manner and to move more freely in the unfamiliar, to transform the classroom;to seek materiality as a method of interpretation, even online;to encourage fearlessness, plurality and relationality;to use craft methods;and to enter a space of care and emotional openness. This contribution will consider creative allyship between staff and students, with the written text as a place of beginning. This is a deliberately open-ended, exploratory, personal and reflective piece of writing, gathered during teaching and research from 2020 to 2022. 'Ways of Writing' are explored both through the method of this article as well as its content. © 2022 Intellect Ltd Article. English language.

47. Cultural Connection and Mental Health for American Indian Adolescents

Purpose: American Indian and Alaska Native (AI/AN) adolescents face significant physical and mental health disparities. These inequities result from historical and intergenerational traumas, which are the cumulative, permeating effects that impact individuals and communities who share a specific identity. Currently there is a paucity of research focusing on the mental health of AI/AN youth as well as the relationship between mental health and cultural connection. This project assesses the relationship between cultural identity (ethnic identity and tribal affiliation) and outcomes associated with mental health (loneliness, friendships, emotional support, and sleep) for AI/AN adolescents. It also aims to understand the impact of the COVID-19 pandemic on stress management for AI/AN adolescents. Methods: 12 to 18 year old adolescents from the Lumbee Tribe of North Carolina participated in this mixed-methods study. The project involved two phases informed by the principles of community-based participatory research. Phase 1, discussed in this , involved surveys using validated instruments to assess cultural connection, mental health outcomes, stress management, and resilience among participants. Phase 2 involves semi-structured interviews with adolescents. Results: Of 123 AI/AN youth who completed the survey, 54.5% (N=67) were 15-18 years old with mean age of 14.9 (SD=2.0). 61% (N=75) were assigned female at birth, 56% (N=70) identified as female, and 4.1% (N=5) identified as non-binary. Mean tribal affiliation (TA) and ethnic identity (EI) scores suggest strong cultural connection among participants (TA: mean 3.1/5, SD 0.6;EI: 3.4/5, SD 0.9). Sleep quality (mean 2.63/5) and positive stress management (mean 2.06/5) were low, suggesting room for improvement. Bivariate analysis and logistic regressions demonstrated moderate positive correlations between ethnic identity and friendship, ethnic identity and emotional support, tribal affiliation and friendship, and tribal affiliation and emotional support. Conclusions: Results highlight that AI/AN adolescents in this sample have a moderate-strong connection with culture, marked by ethnic identity and tribal affiliation. They also demonstrate the impact of cultural connection on mental health for AI/AN adolescents. Phase 2 will draw upon Phase 1 findings to further understand the relationship between cultural connection and mental health outcomes, and to promote community-driven interventions emphasizing inherent strengths and resiliencies identified through qualitative interviews of AI/AN youth. Data related to cultural connection and mental health outcomes may also be used to set the framework for policy formulation which may allow for increased funding and programming addressing mental health for AI/AN youth. Sources of Support: This research received support from the UNC Chapel Hill Office of Global Health.

Impaired exercise capacity in post-COVID syndrome: The role of VWF-ADAMTS13 axis

Background: Post-COVID syndrome (PCS) is an increasingly recognised complication of acute SARS-CoV- 2 infection, characterised by persistent fatigue, reduced exercise tolerance, chest pain, shortness of breath and cognitive slowing. Acute COVID-19 is strongly linked with increased risk of thrombosis;a prothrombotic state. Elevated Von Willebrand Factor (VWF) Antigen (Ag):ADAMTS13 ratio is associated with severity of acute COVID-19 infection. Aim(s): We hypothesised that the pro-thrombotic state is implicated in the pathogenesis of PCS. We investigated specialist coagulation parameters associated with reduced exercise capacity in patients with PCS to identify the utility of these parameters to determine ongoing disease activity. We also investigated if an association exists between elevated VWF(Ag):ADAMTS13 ratio and impaired exercise capacity in patients with PCS. Method(s): Retrospective analysis of VWF(Ag):ADAMTS13 ratio in patients with PCS at a dedicated post-COVID clinic. VWF(Ag):ADAMTS13 ratio was correlated with symptoms including exercise capacity as assessed by 1 minute sit-to- stand (STS) test and/or 6 minute walk test (6MWT). Peripheral oxygen desaturation >=3% for 6MWT and STS test, and increase in lactate>1 from baseline during 6MWT were taken as markers of impaired exercise capacity. Result(s): Elevated VWF(Ag):ADAMTS13 ratio (>=1.5) was found to be four times (OR 4.3) more likely in patients with impaired exercise capacity. 20% (56/276) had impaired exercise capacity, of which 55% (31/56) had a raised VWF(Ag):ADAMTS13 ratio >=1.5 (p < 0.0001). A higher median VWF(Ag):ADAMTS13 ratio of 1.5 (IQR 1.2-1.7) in patients with abnormal exercise testing compared to 1.1 (IQR 0.9-1.4) in patients with normal exercise testing was found (p < 0.0001). FVIII and VWF(Ag) were elevated in 26% and 18% respectively and support a hypercoagulable state in patients with PCS. Conclusion(s): These findings suggest possible ongoing microvascular/ endothelial dysfunction in the pathogenesis of PCS and highlight the potential role for prophylactic anticoagulation in the management of these patients.

Rural disparities in oncology patient portal enrollment and use

Background: Patient portals support patient access, engagement, and care coordination, yet could also widen the digital divide and exacerbate disparities among vulnerable populations. There is emerging evidence that racial/ethnic minority patients are less likely to use portals, yet prior research has not examined potential rural differences. We identified sociodemographic factors associated with portal enrollment and use among a racially and geographically diverse population of cancer patients. Methods: We retrospectively examined portal enrollment and use at an NCI-designated comprehensive cancer center from January 2015 until February 2022 among patients 18+ years old with a neoplastic disease diagnosis (ICD-10-CM C00-D49). Potential predictors included gender, race/ethnicity, marital status, age, rural (Rural-Urban Continuum Codes [RUCC] 4-9) vs nonrural (RUCC 1-3) residence, residential distance from the cancer center, and time since diagnosis. We used multivariable logistic regression to generate odds ratios (ORs) for portal enrollment and having ever sent a portal message, and Poisson regression to determine incidence rate ratios (IRRs) for number of logins and number of healthcare team interactions (portal messages or appointment requests), controlling for ICD-10 diagnosis (SAS 9.4). Results: We identified 11,333 patients (average age 67 years, 59% female, 24% rural, 10% Non-Hispanic Black, 1% Hispanic, 20% non-melanoma skin cancer, 14% breast cancer, 9% lung cancer). 36% of patients had enrolled in the portal, and of these, 80% had sent at least one message. Patients logged in a median of 203.5 times and had a median of 19 portal interactions. Rural residents were less likely to enroll in the portal than urban patients (28% vs 38%, p < 0.0001). Non-Hispanic Black patients and Hispanic/Latinx patients were less likely to enroll in the portal compared with non-Hispanic White patients (22% and 27%, respectively, vs 38.5%, p < 0.0001). Women, younger patients, more recently diagnosed cancer patients, and patients who were married/ partnered were significantly more likely to enroll. In multivariable analysis controlling for cancer type, rural patients were half as likely to enroll in the portal (OR: 0.48 [0.43-0.54]). Among those enrolled, rural residents were 25% less likely to have ever sent a portal message (OR: 0.75 [(0.62-0.92]), and had nearly half the login and interaction rates (IRR: 0.66 [0.66-0.67];IRR: 0.58 [0.58-0.59], respectively). Patients who were Non-Hispanic Black, Hispanic, or unmarried were also significantly less likely to enroll or engage in the portal. Conclusions: Patient portals remain underutilized among cancer patients, despite an increased reliance on virtual communications in the COVID era. Interventions to support portal engagement among rural residents and racial/ethnic minority patients are needed to avoid potentially exacerbating health disparities.

Remote ischaemic conditioning: defining critical criteria for success-report from the 11th Hatter Cardiovascular Workshop.

The Hatter Cardiovascular Institute biennial workshop, originally scheduled for April 2020 but postponed for 2 years due to the Covid pandemic, was organised to debate and discuss the future of Remote Ischaemic Conditioning (RIC). This evolved from the large multicentre CONDI-2-ERIC-PPCI outcome study which demonstrated no additional benefit when using RIC in the setting of ST-elevation myocardial infarction (STEMI). The workshop discussed how conditioning has led to a significant and fundamental understanding of the mechanisms preventing cell death following ischaemia and reperfusion, and the key target cyto-protective pathways recruited by protective interventions, such as RIC. However, the obvious need to translate this protection to the clinical setting has not materialised largely due to the disconnect between preclinical and clinical studies. Discussion points included how to adapt preclinical animal studies to mirror the patient presenting with an acute myocardial infarction, as well as how to refine patient selection in clinical studies to account for co-morbidities and ongoing therapy. These latter scenarios can modify cytoprotective signalling and need to be taken into account to allow for a more robust outcome when powered appropriately. The workshop also discussed the potential for RIC in other disease settings including ischaemic stroke, cardio-oncology and COVID-19. The workshop, therefore, put forward specific classifications which could help identify so-called responders vs. non-responders in both the preclinical and clinical settings.

COVID-19 DISRUPTION TO PROSTATE CANCER MANAGEMENT IN A UK TERTIARY REFERRAL CENTRE

INTRODUCTION AND OBJECTIVE: Covid-19 caused major disruptions to cancer diagnosis and treatment. We aimed to evaluate the longitudinal disruption to prostate cancer management. METHODS: We completed a prospective service evaluation from 01/09/2019 to 31/08/2021 of all referrals, investigations, and treatments for prostate cancer at a single centre. The first UK Covid-19 lockdown occurred from 23/03/20 to 04/07/2020: monthly data for the time period before, during, and after the first UK lockdown were compared using ANOVA and Tukey HSD. RESULTS: We identified 4501 patients for inclusion. There was a profound decrease in all aspects of prostate cancer management during the first lockdown period. For pre-lockdown, lockdown, and postlockdown periods respectively, the mean monthly rates were: 256 v 125 v 363 PSA tests (p=0.0003);86 v 40 v 79 two-week-wait referrals (p=0.0005);62 v 18 v 54 MRI imaging for possible cancer (p<0.0001);32 v 15 v 36 diagnoses (p=0.002);17 v 9 v 14 prostatectomies (p=0.06). In the period after the first lockdown, despite the previous drop, we did not observe an increase in the number of referrals, MRI imaging, diagnoses, or treatment required (including active monitoring, chemotherapy, radiotherapy, prostatectomy, and palliative care) in comparison to pre-lockdown levels (all p>0.05). However, interestingly, we did see an increase in the number of PSA tests performed (p=0.04), which continued through the two subsequent UK lockdowns. CONCLUSIONS: To our knowledge, this is the first study to provide an overview of the impact of COVID-19 national lockdowns on the whole prostate cancer management pathway - from initial referral to final treatment. Despite the disruption to prostate cancer management during the first UK Covid-19 lockdown leading to a decrease in referrals, diagnoses and treatment in the context of reduced PSA testing, we have not seen a subsequent increase in these numbers after lockdown despite a rise in PSA testing. The rise in the number PSA tests performed post-lockdown may suggest a degree of compensatory PSA observation in the community. (Figure Presented).

Engaging the American Indian community in North Carolina to assess cancer research and training opportunities

Background: American Indians have significant barriers to cancer prevention and control due to a number of social structural factors. North Carolina has the largest American Indian population east of the Mississippi River with eight tribes and four urban Indian centers, yet there have been few coordinated strategies to address cancer disparities in this population. Engagement with tribal communities is vital in successful implementation of research and outreach activities. Methods: The Wake Forest Baptist Comprehensive Cancer Center (WFBCCC) received a supplement to their P30 Cancer Center Support Grant to inform Community Outreach and Engagement initiatives through The Healing Walk project which was designed to determine the most pressing cancer concerns for American Indian communities in North Carolina and identify needs for research training for American Indian students. Feedback was obtained from tribal leaders, educators, and college students through one large and three mini-round table discussions and solicited by email throughout late 2018 and 2019. The final round table occurred two days before the 2020 COVID 19 mitigation mandates. Results: Community interviews produced a wealth of information on the self-reported issues within American Indian populations in North Carolina. Tribal community leaders identified systemic and demographic issues that contribute to health disparities among their people. These issues include: lack of trust in the medical community, structural barriers to care leading to late-stage diagnosis, perceptions related to cancer, high rates of cancer risk factors, including obesity and tobacco use, and historical trauma. Students identified factors which contribute to barriers in pursuing careers in cancer research, including a lack of American Indian mentors, financial barriers, mental health challenges that arise in attending majority institutions, and a lack of culturally competent research training. Conclusions: By relying on the viewpoints of tribal leaders, the WFBCCC can accurately address the needs of the communities and develop cancer prevention and control initiatives that are culturally responsible, such as Tribal Health Ambassadors. In accordance with the majority of the requests both students and educators made, the WFBCCC is creating an undergraduate research program for engaging AI students. Focusing on community identified areas of need, students will develop a research question relative to the health concerns of their tribe. The goal of this research program is two fold. First, to enable tribal communities to accurately assess cancer risk, incidence, and mortality, and with that knowledge reduce the current health disparities in AI populations. Second, to provide American Indian students with the opportunity to not only serve their community, but to give them the tools and experience to help understand and eliminate cancer disparities in their tribal communities.

Cancer case trends following the onset of the COVID-19 pandemic: A community-based observational study with extended follow-up.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has impacted health care delivery worldwide. Cancer is a leading cause of death, and the impact of the pandemic on cancer diagnoses is an important public health concern. METHODS: This cross-sectional study retrospectively analyzed the electronic medical records of 80,138 cancer patients diagnosed between January 1, 2019, and May 31, 2021. Outcome measures included weekly number of new cancer cases and trends in weekly cancer cases, before and after the pandemic; patient demographics; and positive COVID-19 test rates. RESULTS: Beginning March 4, 2020, defined as the onset of the pandemic, weekly cancer cases declined precipitously (-110.0 cases per week [95% confidence interval, -190.2 to -29.8]) for 4 weeks, followed by a moderate recovery (+23.7 cases per week [9.1 to 38.4]) of 10 weeks duration. Thereafter, weekly cancer cases trended slowly back toward pre-COVID-19 baseline levels. Following the pandemic onset, there was a cumulative year-over-year decline in cancer cases overall of 7.3%, including a 20.2%, 14.3%, and 12.8% decline in nonmelanoma skin cancer, breast cancer, and prostate cancer, respectively. Changes in case volumes were accompanied by variations in patient characteristics, including region, age, gender, race, insurance coverage, and COVID-19 positive test rates (P < .01 for all). Among patients tested for COVID-19, 5.3% had a positive result. CONCLUSIONS: The data in this study demonstrate a substantial reduction in cancer diagnoses following the onset of COVID-19, which appear to reach expected pre-COVID norms 12 months later. The largest reduction was noted among cancers that are typically screen-detected or identified as part of a routine wellness examination.

Review of diabetes control before and during COVID era at District General Hospital

Introduction: In Paediatrics, there was a significant reduction and delays in patients presenting to the emergency department during the COVID-19 pandemic (1,2). Diabetes Service provision was affected during the pandemic with a move towards virtual clinics and fewer face to face appointments. We studied the nature and severity of presentation of TIDM, the impact of the pandemic on diabetes control in newly diagnosed TIDM patients. Objectives: To evaluate presentation at diagnosis and effect on subsequent diabetes control due to COVID 19 pandemic's impact on health care provision. Methods: This retrospective study involved case notes review of 65 newly diagnosed T1DM patients up to the age of 16 years over two years (March 2019 to March 2020: Pre-pandemic cohort, March 2020 to March 2021: Pandemic cohort). Results: The percentage of patients presenting in severe diabetic ketoacidosis at diagnosis was higher in the pandemic year by 10%. The data showed no differences between the two groups regarding mean age at presentation, antibody status, vitamin D level at the diagnosis and frequency of diabetes-related hospital attendances. In contrast, in the pandemic group, 12% (3) newly diagnosed patients spent more than 72 hours during their first diabetes-related admission compared to 5% (2) in the pre-pandemic year. Interestingly, the HbA1C control over one year period was similar in the pre-pandemic and pandemic cohorts (figure 1). Conclusions: Our study suggests that during the pandemic year, more patients presented with severe DKA, higher HbA1C and had a longer length of stay in the hospital during the initial admission. A longitudinal review of HbA1C level over one year suggests that the diabetes control was not adversely affected during the pandemic. (Table Presented).

Guideline on the peri-operative management of patients with sickle cell disease: Guideline from the Association of Anaesthetists.

Sickle cell disease is a multisystem disease characterised by chronic haemolytic anaemia, painful vaso-occlusive crises and acute and chronic end-organ damage. It is one of the most common serious inherited single gene conditions worldwide and has a major impact on the health of affected individuals. Peri-operative complications are higher in patients with sickle cell disease compared with the general population and may be sickle or non-sickle-related. Complications may be reduced by meticulous peri-operative care and transfusion, but unnecessary transfusion should be avoided, particularly to reduce the risk of allo-immunisation. Planned surgery and anaesthesia for patients with sickle cell disease should ideally be undertaken in centres with experience in caring for these patients. In an emergency, advice should be sought from specialists with experience in sickle cell disease through the haemoglobinopathy network arrangements. Emerging data suggest that patients with sickle cell disease are at increased risk of COVID-19 infection but may have a relatively mild clinical course. Outcomes are determined by pre-existing comorbidities, as for the general population.