A regional clinical audit of the provision of adjuvant systemic anti-cancer treatment following lung cancer resection in eligible patients across Greater Manchester to support national benchmarking

Introduction: Adjuvant anti-cancer systemic therapy (SACT) following lung resection improves overall survival in stage II/II non-small cell lung cancer (NSCLC). The Getting It Right First Time (GIRFT) National Specialty Report for Lung Cancer recommends centres publish adjuvant SACT rates for National benchmarking and proposes a target of >40% of eligible patients undergo SACT. We report a regional audit into the uptake of adjuvant SACT in Greater Manchester (GM). Method(s): A retrospective case review of all patients undergoing curative-intent NSCLC surgery with a pathological stage of II/III from 01/01/21 to 30/04/21. Data collected included patient demographics, uptake of adjuvant SACT, reasons for no adjuvant SACT and tolerance and complications of SACT. Result(s): 58 patients underwent surgical resection within the audit period and were eligible for adjuvant SACT. Median age was 70 years (range 45 - 81) and 60% were female. 47% (27/58) commenced adjuvant SACT;41% (24/58) were treated with chemotherapy and 7% (4/58) were treated with tyrosine kinase inhibitors. 58% (14/24) of patients that commenced adjuvant chemotherapy completed 4 cycles. Carboplatin/Vinorelbine was the commonest regimen (82%, 18/22). There were no grade III-V complications and no chemotherapy-related deaths. Dose reduction due to toxicity was required in 14% (3/22). The reasons adjuvant systemic therapy was not given were patient choice in 32% (10/31), poor physical health such that risks outweighed benefits in 42% (13/31), and other reasons (e.g. need to treat synchronous primary tumours) in 26% (8/31). COVID-19 was not recorded as a cause for adjuvant omission/ dose reduction. Conclusion(s): This data provides national benchmarking information for adjuvant SACT in NSCLC and suggests the target of >40% is achievable and appropriate. Interventions that improve patient fitness pre- and post-operatively might increase adjuvant SACT uptake. This regional audit will be extended to review all eligible patients in 2021 and further data will be presented. Disclosure: No significant relationships.Copyright © 2023 Elsevier B.V.

Diversity in medical publications: a cross-sectional evaluation of COVID- 19 vaccine research

Objective: Representing diverse perspectives in medical publications is of great importance. We assessed diversity among investigators, study participants, authors and tweeters of recent publications on COVID-19 vaccine trials, a topic likely to have significant global implications. Research design and methods: Primary publications reporting on COVID vaccine randomized controlled trials (RCTs) were identified via PubMed (n=302 hits, 23 September 2022). The 100 articles with the greatest impact (Altmetric score) were selected for evaluation. National affiliation of authors and investigators, and demographics of participants were collected. Geographic locations of Tweets mentioning the publications were collected via Altmetric. Result(s): In our preliminary analysis, as expected, selected publications most frequently appeared in top-tier journals, e.g. New England Journal of Medicine (n=24) and Lancet (n=19), and had high Altmetric scores (median 886, range 30-29,153). Articles included authors from mean 2.2 countries, most frequently the USA (n=43 articles), the UK (n=31) and China (n=23). Investigators' locations were often not reported, but most frequent were the UK (n=2711 investigators), USA (n=1029) and South Africa (n=269). There was a gender balance among participants across the studies (mean 49.4% female). The most frequent ethnic groups were white, Hispanic and Asian. Tweets mentioning the publications most commonly came from the USA (8.1%), the UK (3.1%) and Japan (2.9%). Conclusion(s): Despite COVID-19 being a global health emergency, most authors, investigators and readers of high impact COVID-19 vaccine RCT publications were from a small group of countries, with some notable exceptions. Numerous studies did not report the geographic location of investigators or participant ethnicity. Consistent and transparent reporting would support the drive towards greater diversity and representation in medical research.

Implementation of behaviour change training in practice amongst pharmacy professionals in primary care settings: Analysis using the COM-B model.

BACKGROUND: The Pharmacy Integration Fund (PhIF) was established in England in 2016, with funded learning programmes or 'pathways' designed to support the development of clinical pharmacy practice in a range of settings. Despite pharmacy staff being well positioned to provide more clinical work, limited research has investigated behaviour change training targeted at widespread practice transformation. OBJECTIVE(S): To investigate implementation of PhIF learning in practice, using the COM-B model of behaviour change. METHODS: An online survey distributed in February and October 2020 included questions on motivations for learning, confidence in target behaviours and impact of PhIF training on behaviour. The October 2020 survey also included questions exploring the effect of the COVID-19 pandemic. Quantitative data were analysed in SPSS. v.27 (IBM). Inferential statistics were used to compare between the pathways (Primary care pathways [PCP], Post-registration pathway [PRP] and Accuracy Checking Pharmacy Technician [ACPT] pathway). Free text comments were categorised and themed. RESULTS: Three-hundred and eighty-three responses were received (49% PRP learners, 39% PCP learners and 12% ACPT learners). Learners generally had the capacity and opportunities to apply learning, and were strongly motivated to implement behaviours in practice, although learners based in community pharmacy (those on the PRP) were less likely to report receiving employer support. Enhanced knowledge/skills (capacity) were more commonly reported than change to patient-facing activities, leading clinical services and conducting medication reviews with patients with complex needs (clinical practice behaviours targeted by the pathways). The COVID-19 pandemic heightened barriers to implementing practice change. CONCLUSIONS: Implementation of a range of clinical practice behaviours following at scale training appears to have been largely successful. Despite this, the community pharmacy context, where funded service opportunities may be lacking, continues to present challenges to workforce transformation plans. More work is needed to understand how training can be implemented to promote practice change for pharmacy professionals in all settings.

Increasing access to COVID-19 testing in underserved Black American neighborhoods

Background. Black Americans have been disproportionately impacted by COVID-19, with systemic inequities contributing to increased incidence and mortality. In Chicago, access to COVID-19 testing was scarce in many predominantly Black neighborhoods early in the pandemic, exacerbating inequities. We aimed to assess uptake and yield of a COVID-19 testing campaign to increase access in high-risk, underserved Chicago communities. Methods. The Alive Church Network (ACN) is a community-driven coalition of Black pastors and public health researchers developed to address health inequities in Chicago. For this initiative, ACN implemented two strategies to improve access to COVID-19 testing in underserved neighborhoods: 1) church-based testing, with nurses and community health workers (CHWs) stationed in churches to perform PCR testing for community members and church staff (Dec 2020-Dec 2021) and 2) community site testing, with nurses and CHWs deployed to 8 local sites (e.g., Salvation Army) to conduct weekly PCR testing for employees and clients (May 2021-Mar 2022). We assessed characteristics of individuals undergoing testing;symptom and exposure history;and COVID-19 positivity. In addition, we compared positivity for ACN sites with Chicago citywide positivity over time. Results. A total of 3420 tests were performed for 1703 individuals. Of those tested, 931 (54.7%) were tested at churches and 772 (45.3%) were tested at community partner sites. Those presenting to churches were older (mean 44.8 vs. 39.1 years), more likely to be female (56.5% vs. 48.5%), and more likely to have a chronic medical condition (37.1% vs. 22.5%, Table). Prevalence of COVID-19 symptoms and exposure history were similar for those presenting to church and community sites (Table). Overall, ACN test positivity was similar to Chicago citywide positivity;however, ACN test positivity was much higher during the Omicron surge (24% vs. 11%, Figure). Characteristics of individuals tested for COVID-19 at church and community sites COVID-19 test positivity, ACN sites vs. Chicago citywide Conclusion. The ACN testing campaign increased access to COVID-19 testing in underserved neighborhoods in Chicago and had high yield during the Omicron surge. Church-based testing was successful for reaching older, medically vulnerable individuals. Ensuring widespread access to testing is essential for health equity and to reduce COVID-19 morbidity and mortality.

Real-world use of different pembrolizumab regimens (3 weekly versus 6 weekly) in non-small cell lung cancer (NSCLC) patients

Background and objectives: Pembrolizumab monotherapy given 3-weekly (3w) (200mg) is approved for the treatment of nonsmall cell lung cancer (NSCLC). In June 2019, NICE endorsed the 6w regimen (400mg) based on computer modelling data (Lala, Eur J Cancer 2020), which has been used during the COVID-19 pandemic to reduce hospital visits. This study compared immune-related adverse events (irAEs), discontinuation rates, and patient experience of 3w vs 6w patients treated at The Christie NHS Foundation Trust, Manchester, UK. Methodology: Pharmacy records were used to identify NSCLC patients treated with pembrolizumab, 1st, 2nd or 3rd line. IrAEs and discontinuation rates were analysed using Kaplan Meier curves to compare the 3w vs 6w cohorts. A sample of the cohort who received 3w then 6w undertook a questionnaire assessing patient experience. Results: 38 patients received pembrolizumab 6w, and 91 received pembrolizumab 3w, of the 3w, 51 switched to 6w. Baseline characteristics were similar. Any grade irAEs and G1-2 irAEs were significantly higher in the 6w cohort (p=0.006 and p=0.04, respectively). Both cohorts showed low rates of G3-5 irAEs at 6 months, 2.3% vs 14.5%, 3w vs 6w, p=0.3. Discontinuation rates at 6 months due to any irAES, G1-2 irAEs or G3-5 irAEs were insignificant in both cohorts (3w to 6w respectively): 4.5% vs 11.2%, p=0.2;2.8% vs 8.7%, p=0.4;2.0% vs 2.5%, p=0.3. Quality of life questionnaires showed stability (60%) or improvement (20%) in the 6w cohort compared to 3w. 90% said their mental health did not differ between regimens. 45% and 40% of patients preferred 6w and 3w respectively, 15% had no preference. Conclusion: NSCLC patients treated with 6w pembrolizumab appear to experience more low-grade irAEs compared to 3w. Highgrade irAEs and discontinuation rates due to irAEs were insignificant in both cohorts. Patients preferred the 6w regiment and found it tolerable.

THE PATHWAYS PROJECT: IMPROVING SUPPORTIVE CARE FOR PATIENTS RECEIVING DIALYSIS

Dialysis patients frequently receive unwanted high intensity end-of-life care. The Pathways Project tested implementation of evidence-based supportive care best practices to identify seriously ill (SI) patients, engage them in goals of care conversations (GOCC), and track outcomes respectful of patient preferences. Teams at 10 dialysis centers participated in a learning collaborative to adopt supportive care best practices. They were trained to screen patients with the surprise question- “Would I be surprised if this patient died the next six months?”- to identify those who are SI;hold GOCC;and document patient preferences. Centers submitted monthly reports to benchmark improvement, including the number of patients screened, percent SI, GOCC, and death. Project processes were interrupted at 9 months by COVID-19, then resumed with adjustments 90 days later. A mortality risk ratio was calculated for the risk of death over the first 9 months for SI versus not SI, and a Cochran-Armitage one-sided test for increasing trend was used to assess potential increases in GOCC. Team members completed a 17-item Kidney Supportive Care Implementation Quotient at baseline and at project completion to assess perceived implementation of each best practice. The average monthly census was 1,529 patients;98.8% were screened, and 18.4% were identified as SI. SI constituted 66% of 114 deaths though only 18.4% of patients. The 9-month mortality risk was 27% for SI versus 3% for not SI (risk ratio: 8.52;95% CI: 5.71 -12.88;p <. 0001). Dialysis center teams implemented site-specific approaches to make GOCC part of usual workflow;centers conducting GOCC within 30 days of hospital discharge increased from 30% to a peak of 80% prior to COVID-19 (p =. 01). Teams reported increased implementation of all 17 best practices (p <. 05) with the largest improvements in screening for SI patients and conducting GOCC (Figure). Through the learning collaborative process, center staff shared successful innovations such as lobby days and chairside GOCC to promote advance care planning. The Pathways intervention empowered dialysis staff to improve supportive care best practices. Future research is needed to determine if the intervention results in outcomes more aligned with patient preferences.

Persistence of SARS-CoV-2 Iinfection in Immunocompromised Children

Background. The temporal dynamics of SARS-CoV-2 infectivity in immunocompromised children (IC) are unknown but may have important infection control implications. We evaluated SARS-CoV-2 viral persistence and assessed factors associated with viral persistence and cycle threshold (CT) values as a surrogate of viral load for IC. Methods. We conducted a retrospective cohort study of SARS-CoV-2-positive IC at a large quaternary pediatric hospital from March 2020-2021. Immunocompromised status was defined as primary or secondary/acquired immunodeficiencies due to comorbidities or immunosuppressive treatment. The primary outcome was time to first-of-two consecutively negative SARS-CoV-2 PCR tests ≥ 24 hours apart. Polymerase chain reaction (PCR) testing of sequential patient samples was conducted using the Centers for Disease Control 2019-nCoV Real-Time RT-PCR Diagnostic Panel (CDC assay). Chi-square, Fisher exact, and Wilcoxon tests were used to compare demographic and clinical characteristics. Kaplan-Meier curve median event times and log-rank tests were used to compare outcomes. Subjects without 2 consecutive negative tests censored at the last test. Analyses were conducted using SAS v 9.4. Results. Ninety-one children met inclusion criteria, and 67 children had more than 1 test (Figure 1). Median age was 15.5 years (IQR 8-18 yrs), 64% were male, 58% of children were white, and 43% were Latinx. Most (67%) were tested in outpatient settings, and 58% of children were asymptomatic. The median time to two negative tests was 42 days (IQR 25.0,55.0), with no difference in duration of positivity with specific diagnoses, degree of lymphopenia, or symptomatic vs asymptomatic illness. Five of 7 (71%) children with samples available for repeat testing had initial CT values < 30, indicating a moderate to high viral load, and of these, 4 (57%) had repeat testing 21 to 30 days later with CT values < 30 (Figure 2), suggesting persistence of moderate to high viral loads. Figure 1. Plot of immunocompromised children in cohort with positive SARS CoV2 PCR and subsequent testing (n = 67). Timelines of immunocompromised children in cohort with positive SARS CoV2 PCR and subsequent testing, grouped by immunocompromising condition. Each line represents an individual patient. Positive results are shown in light grey, negative results are shown in black. Figure 2. Plot of CT values from SARS-CoV-2 PCR testing over time among children with sequential samples available for retesting (n = 7) Plot of CT values (y axis) from SARS-CoV-2 PCR testing on the CDC assay over time (x axis) in days from initial positive test. Repeated testing which yielded a negative result on the CDC assay or intermittent negative results on clinical testing represented as CT value of 40. Each line represents a unique patient. Conclusion. The median duration of viral persistence among IC with SARS-CoV-2 infection was 6 weeks, with no significant difference in immunocompromised diagnoses or clinical presentation, with over half of children with testing on the same platform having moderate to high viral loads after 3 weeks, suggesting potential transmission risk.

COVID-19: A potential trigger for inflammatory bowel disease?

Introduction: Coronavirus Disease 2019 (COVID-19) has been shown to infect gastrointestinal tissues, and a wide variety of gastrointestinal manifestations have been described including alterations in the composition of the intestinal microbiome. Microbiome changes have been implicated in the pathogenesis of inflammatory bowel disease (IBD), but a clear relationship between viral infection and IBD has not been established. Case description/methods: Case 1 A 45-year-old woman presented to clinic with painless hematochezia and fecal urgency 2 weeks after developing anosmia and being diagnosed with COVID-19. She had a history of constipation but no other gastrointestinal problems. Her vital signs were normal and her exam was unremarkable. Her labs showed iron deficiency anemia with hemoglobin 10.2 and ferritin <2. Colonoscopy showed 10cm of moderately friable rectal mucosa with erosions and loss of vascular pattern. Rectal pathology showed chronic active proctitis. She was diagnosed with ulcerative proctitis and treated with mesalamine suppositories with resolution of her symptoms. Case 2 A 48- year-old woman was admitted for five months of watery, bloody bowel movements that developed after an initial hospitalization for COVID-19 pneumonia. She reported 10-15 bowel movements daily, diffuse abdominal pain, nausea, and 10kg weight loss. She was initially diagnosed with C. difficile at another hospital but her symptoms did not improve with oral vancomycin. She was mildly tachycardic, but her exam was otherwise unremarkable. Labs showed hemoglobin 6.7, CRP 6.9, ESR 50, and fecal calprotectin 1880. C. difficile testing was negative. Colonoscopy showed pancolitis with moderate inflammation, edema, erosions, erythema, and friability most severe in the distal colon with ileal sparing. Pathology showed crypt architectural distortion and branching with cryptitis and crypt abscesses consistent with ulcerative colitis. After not responding to prednisone, she achieved clinical remission with infliximab. Discussion: Prior research has described the role of abnormal immune response to intestinal microbiota in the pathogenesis of IBD. Some studies have found an increased risk of IBD after infectious gastroenteritis, but no specific causal link has been demonstrated and the role of specific infections in the development of the dysregulated immune response is incompletely understood. These cases of new ulcerative colitis diagnosed after COVID-19 infection have implications for understanding potential viral triggers of IBD.

Prolonged impact of pandemic restrictions on healthcare utilization in patients with ibd

Introduction: The COVID-19 pandemic disrupted healthcare delivery due to local restrictions and public health precautions. Who was most impacted, and the duration of these impacts in patients with IBD has not been quantified to date. Methods: This is an analysis of retrospectively collected data in a large urban safety-net hospital. We identified a cohort of patients with IBD, and quantified their healthcare utilization (HU) during three distinct 90-day periods related to the COVID-19 pandemic;pre-restrictions, restriction period, and recovery period. Demographic data were collected for all patients. Health care utilization was determined by the number of IBD clinic visits (in-person and virtual), abdominal imaging scans, emergency department (ED) visits, hospital admissions, and IBD-related endoscopic procedures. Results: We identified and collected data on 311 patients were collected, during the three time periods. The demographics of this cohort were representative of our IBD population;mean age 46, 53% female, 35% Black, 44% federal or state insurance. Clinic visits declined by 60%, imaging by 50%, and endoscopy declined by 91% during the restriction period (Figure 1). Older age and Black race were significantly associated (p<0.05) with clinic absence during the restriction period. During the recovery period, healthcare utilization remained significantly reduced;clinic visits only improved by 14%, despite universal use of telemedicine (Figure 1). Neither ED visits nor hospitalizations increased in the recovery period. No demographic factor was associated with the resumption of clinic visits, ED, or endoscopy. Conclusion: Pandemic public health restrictions significantly reduced HU for patients with IBD, and these had not recovered within 90 days after the opening of restrictions. Age and race were associated with loss of follow-up during the restriction periods. No increase in ED or hospitalization was noted during the recovery period.

Implementation and effectiveness of a supportive care learning collaborative for hemodialysis

Background: The objective of this study was to determine whether a learning collaborative for hemodialysis providers improved delivery of supportive care best practices. Methods: Ten U.S. hemodialysis centers participated in a hybrid implementationeffectiveness pre-post study targeting seriously ill patients between April 2019 and September 2020. The collaborative educational bundle consisted of learning sessions, communication training and implementation support. The primary outcome was change in proportion of seriously ill patients with complete advance care planning (ACP) documentation. Healthcare utilization was a secondary outcome and implementation was assessed qualitatively. Results: One center dropped out during the COVID-19 pandemic. Among the remaining nine centers, 22.9% (320/1395) of patients were identified as seriously ill in the pre-intervention period and 18.0% (226/1254) were identified in the post-intervention period. From the pre-intervention to post-intervention period, the proportion of patients with complete ACP documentation increased, and hospitalizations and emergency department visits decreased (Table). There was no difference in mortality, palliative dialysis, hospice referral or dialysis discontinuation. Screening for serious illness was widely and sustainably adopted. Goals of care discussions were adopted with variable integration and sustainment. Conclusions: Supportive care best practices were feasible to implement in hemodialysis centers and largely sustained during the COVID-19 pandemic. We observed increased documentation of ACP and lower healthcare utilization after the intervention which could reflect a combination of collaborative and pandemic effects. (Table Presented) .

Understanding dialysis patient COVID-19-related mortality

Background: Reported COVID mortality in dialysis patients is high and ranges from 15-25%. We reviewed data from a prospective 14-month study of seriously ill (SI) dialysis patients pre-COVID (May 2019-January 2020) and during COVID (February 2020-June 2020) to better understand COVID-related mortality in SI and not SI patients. Methods: We recruited 10 dialysis centers (6 in NYC, 3 in Denver, CO, and 1 in Dallas, TX) with 1,507 patients. Dialysis staff screened patients monthly with the surprise question (SQ)-Would I be surprised if this patient died in the next 6 months-and recorded outcomes. Those with a No response were identified as SI. A SQ No response is known to identify older patients with multiple comorbidities and an increased risk of early mortality. In this rolling population, we calculated the monthly mortality risk prior to and during COVID and determined the relative risk of death (RR) for SI compared to not SI during both periods. We also compared the increased mortality risk during COVID between patients dialyzed in NYC vs. Denver and Dallas and used logistic regression to determine whether COVID-19-related mortality differed by geographic region. Results: Over 14 months, dialysis centers screened a monthly average of 1,342/1,507 (89.1%) patients and identified 274 (18.2%) as SI, with more consistent screening pre-COVID than during COVID (98.6% vs. 71.2%). Pre-COVID, the monthly mortality rate for SI patients was 2.8% and for not SI patients 0.4%, (RR 7.02, 95% CI, 4.76-10.44). During COVID, the monthly mortality rate for SI patients increased to 4.8% and for not SI to 1.5% (RR 3.19, 95% CI, 2.28-4.44). The absolute increase in monthly mortality risk from pre-COVID to COVID was greater for SI than for not SI patients, 2.0% vs 1.1%. The excess monthly mortality was higher in NYC (2.3% for SI and 1.2% for not SI) than in Denver and Dallas (1.3% for SI and 0.7% for not SI), but the difference was not significant (p = .12). Conclusions: A No response to the SQ identified SI dialysis patients whose 5-month mortality during COVID increased to 23.9% (annualized rate 57.4%). For not SI, the 5-month mortality rate during COVID increased to 7.5% (annualized rate 18%). These findings underscore the importance of advance care planning not only for SI patients but also for all dialysis patients, who are particularly vulnerable to concurrent infections such as COVID-19.

Results of Intervention to Increase Goals-of-Care Conversations in Dialysis Centers (SCI950)

Objectives: 1. Describe the Pathways Project’s evidence-based change package for kidney supportive care. 2. Describe the Results of implementation of goals of care conversations into dialysis center workflow. Background: Many dialysis patients receive unwanted high intensity end-of-life care. Their families rate the quality of this care lower than families of patients with other chronic diseases. At baseline, seriously ill (SI) patients rated communication with dialysis teams very poorly. Research Objectives: The purpose of this study was to test the feasibility of an evidence-based intervention to identify SI patients, engage them in goals-of-care conversations (GOC), and track outcomes to see if aligned with patient preferences. Methods: Researchers recruited 10 dialysis centers with 1,544 patients. Dialysis staff screened patients monthly with the surprise question—"Would I be surprised if this patient died in the next 6 months?"—to identify SI patients and conduct GOC with them. Recorded patient outcomes included number screened, number SI, GOC, hospitalizations, hospice referral, death, and place of death. An odds ratio of SI versus non-SI dying, and a Cochran-Armitage trend test were used to assess for increasing GOC and deaths at home. The study was interrupted at 9 months due to COVID-19. Results: On average, 98.8% of patients were screened monthly, and 18.4% were identified as SI. Of 114 patients who died, SI constituted 66% of deaths. The mortality for SI was 27% versus 3% for non-SI, and the odds ratio for SI dying was 11.22 (95% CI 7.42 to 16.98, P <.0001). Dialysis interdisciplinary teams implemented site-specific approaches to adding GOC into usual workflow;the number conducting GOC with SI within 30 days of hospital discharge increased from 30% to 80% (P=.02). Patients dying at home increased (32.6% vs 18.8%), but the trend was not yet significant (P=.12). Conclusion: It is feasible and useful to identify SI dialysis patients. After 9 months more dialysis centers were conducting GOC with them. Implications for Research, Policy, or Practice: Future research is needed to determine if the intervention increases outcomes more aligned with patient preferences.

Improving supportive care of seriously ill dialysis patients with goals-of-care conversations

Background: Dialysis patients are frequently known to receive unwanted high intensity end-of-life care. Families rate the quality of this care lower than families of patients with other chronic diseases. The purpose of this study was to test the feasibility of a supportive care intervention-the Pathways Project, an evidence-based change package of best practices-to identify seriously ill patients (SI), engage them in goals of care discussions, and track outcomes for patient goal concordance. Methods: Pathways researchers recruited 10 dialysis centers with 1,546 patients. Dialysis staff screened patients with the surprise question (SQ)-“Would I be surprised if this patient died in the next 6-12 months?”- to identify those who were SI and recorded patient outcomes including the number screened, SI, goals of care conversations, hospitalizations, referred to hospice, death, and place of death. An odds ratio was calculated for the odds of SI dying versus those who were not SI, and one-sided Cochran- Armitage trend tests were used to assess for increasing goals of care conversations and deaths at home. The study was interrupted at 9 months due to COVID-19. Results: On average, 98.8% of patients were screened monthly, and 18.4% were identified as SI. Of 114 patients who died, the SI constituted 66% of deaths though only 18.4% of patients. The mortality for the SI was 27% versus 3% for those who were not, and the odds ratio for SI dying was 11.22 (95% CI 7.42 to 16.98, P < .0001). Dialysis interdisciplinary teams implemented site-specific approaches to adding goals of care conversations into usual workflow;the number conducting conversations with SI within 30 days of hospital discharge increased from 30% to 80% (P=.02). The proportion of the patients who died at home in the last 2 months was higher than baseline (32.6% vs 18.8%), but a trend was not yet evident (P=.12). Conclusions: The Pathways intervention is feasible to implement supportive care best practices into existing workflow of dialysis centers. It takes time for teams to get comfortable with new processes and communication approaches;after 9 months more centers were conducting goals of care conversations and more patients were dying at home. Future research is needed to determine if the Pathways intervention results in outcomes more aligned with patient preferences.

Health status of free-ranging ring-necked pheasant chicks (Phasianus colchicus) in North-Western Germany.

Being a typical ground-breeding bird of the agricultural landscape in Germany, the pheasant has experienced a strong and persistent population decline with a hitherto unexplained cause. Contributing factors to the ongoing negative trend, such as the effects of pesticides, diseases, predation, increase in traffic and reduced fallow periods, are currently being controversially discussed. In the present study, 62 free-ranging pheasant chicks were caught within a two-year period in three federal states of Germany; Lower Saxony, North Rhine-Westphalia and Schleswig-Holstein. The pheasant chicks were divided into three age groups to detect differences in their development and physical constitution. In addition, pathomorphological, parasitological, virological, bacteriological and toxicological investigations were performed. The younger chicks were emaciated, while the older chicks were of moderate to good nutritional status. However, the latter age group was limited to a maximum of three chicks per hen, while the youngest age class comprised up to ten chicks. The majority of chicks suffered from dermatitis of the periocular and caudal region of the head (57-94%) of unknown origin. In addition, intestinal enteritis (100%), pneumonia (26%), hepatitis (24%), perineuritis (6%), tracheitis (24%), muscle degeneration (1%) and myositis (1%) were found. In 78% of the cases, various Mycoplasma spp. were isolated. Mycoplasma gallisepticum (MG) was not detected using an MG-specific PCR. Parasitic infections included Philopteridae (55%), Coccidia (48%), Heterakis/Ascaridia spp. (8%) and Syngamus trachea (13%). A total of 8% of the chicks were Avian metapneumovirus (AMPV) positive using RT-PCR, 16% positive for infectious bronchitis virus (IBV) using RT-PCR, and 2% positive for haemorrhagic enteritis virus (HEV) using PCR. All samples tested for avian encephalomyelitis virus (AEV), infectious bursal disease virus (IBDV) or infectious laryngotracheitis virus (ILTV) were negative. The pool samples of the ten chicks were negative for all acid, alkaline-free and derivative substances, while two out of three samples tested were positive for the herbicide glyphosate. Pheasant chick deaths may often have been triggered by poor nutritional status, probably in association with inflammatory changes in various tissues and organs as well as bacterial and parasitic pathogens. Theses impacts may have played a major role in the decline in pheasant populations.