Places for Healthy Play: A Multi-Pronged Evaluation of Context, Design, and Perceptions for Play Space Improvements.

Community design interventions have prioritized the creation of quality play space, especially in easy to access public places, to improve health outcomes and to reduce health inequities. Evaluations of health-relevant play interventions often fail to assess essential context, design, and perceptions. The Play Everywhere Philadelphia Challenge, led by KABOOM!, funded 16 play spaces to support child health and development and literacy skills for low-income neighborhoods across Philadelphia. In June-October 2022, our interdisciplinary team conducted a process evaluation of completed play space installations (k=9) to identify site aspects that facilitated greater use. We mapped neighborhood context (e.g., child amenities, sociodemographics, pedestrian and bike accessibility), and conducted direct and systematic observations of play space design (e.g., signage, shade), visitation (i.e., number of visitors/hour), and engagement. We summarized visitation and engagement across contextual and design data. While many visitors passed through sites, over half of the children we observed engaged with the installation. Installations with poor condition (i.e., cleanliness and maintenance) had the lowest visitation and engagement. More active/kinetic installations drew more children and engagement. This process evaluation comprehensively analyzed play space design elements and neighborhood context and provides evidence to inform recommendations to increase use of urban play spaces.

Resident Knowledge of and Engagement with Green Infrastructure in Toronto and Philadelphia.

Green infrastructure (GI) initiatives, including programs to plant trees and install bioswales, have been adopted by a growing number of local government and non-governmental organizations. While the details of these programs vary, a common characteristic of most Canadian and US GI initiatives is a distributed approach that includes both public and private land. To date, little research has explored residents' knowledge of GI or their engagement with related initiatives even though residents' installation of GI is often key to creating distributed GI networks. In this study, we (1) assess residents' knowledge of the term GI, (2) identify residents' level of engagement with GI initiatives, and (3) examine whether factors like level of concern about local environmental issues can predict GI knowledge or level of engagement with GI initiatives. We explored these objectives through a survey of residents in Toronto (Ontario, Canada) and Philadelphia (Pennsylvania, US). We found that about a quarter of survey respondents in both cities had previously heard the term "green infrastructure". Neither knowledge of GI nor level of engagement with GI initiatives could be predicted by the level of concern about local environmental issues, but residents' interest in using their outdoor space for nature activities (e.g., gardening) predicted GI knowledge in both cities and level of initiative engagement in Philadelphia. Our results suggest the need for widespread education campaigns that clearly define GI so that residents can be participants in policy discussions, link it with their needs, and identify ways to manage GI to create desired benefits.

Acute Kidney Injury in Primary Care: A Review of Patient Follow-Up, Mortality, and Hospital Admissions following the Introduction of an AKI Alert System.

BACKGROUND/AIMS: In February 2017, our laboratory implemented an electronic AKI flagging system for primary care using the NHS England AKI detection algorithm. Our study investigated the impact on patient follow-up, hospital admission, length of stay, and mortality. METHODS: Primary care results March 2017-February 2018 with an AKI test code were downloaded from the pathology computer. RESULTS: Over 12 months, 1,784 AKI episodes were identified; 81.3% AKI1, 11.3%, AKI2, and 7.5% AKI3. A repeat creatinine was requested within 14 days on 55% AKI1s, 84% AKI2s, and 86% AKI3s. Primary care took the repeat sample in 73.2% AKI1s and 56.7% AKI2s and acute hospital locations for 47.4% AKI3s. Median time to hospital admission was 34 days for AKI1, 6 for AKI2, and 1 for AKI3 (p < 0.05). Length of stay was found to be 1, 2, and 4 days for AKI 1/2/3, respectively (p < 0.05). The 90-day mortality for admitted patients was 15, 18, and 21% for AKI 1/2/3, respectively (p = 0.180). The 90-day mortality for the non-admitted patients was 4, 9, and 50% for AKI 1/2/3, respectively (p < 0.05). AKI patient outcome data pre versus post the start of the AKI flag system were compared. A statistically significant reduction was found in the median length of stay for AKI1 and AKI3 and in mortality for AKI1 and AKI3 patients and for all AKIs as a whole. A further analysis was performed to take into account the difference in pre- and post-alert populations. Mortality overall was significantly improved (p < 0.001), and length of stay was reduced in AKI3 patients (p = 0.048). DISCUSSION/CONCLUSION: Our study demonstrates that an electronic AKI warning alert system for primary care appears to be associated with a beneficial impact on patient management and outcome.

Identifying on admission patients likely to develop acute kidney injury in hospital.

BACKGROUND: The incidence of Acute Kidney Injury (AKI) continues to increase in the UK, with associated mortality rates remaining significant. Approximately one fifth of hospital admissions are associated with AKI and approximately a third of patients with AKI in hospital develop AKI during their time in hospital. A fifth of these cases are considered avoidable. Early risk detection remains key to decreasing AKI in hospitals, where sub-optimal care was noted for half of patients who developed AKI. METHODS: Electronic anonymised data for adults admitted into the Royal Cornwall Hospitals Trust (RCHT) between 18th March and 31st December 2015 was trimmed to that collected within the first 24 h of hospitalisation. These datasets were split according to three separate time periods: data used for training the Takagi-Sugeno Fuzzy Logic Systems (FLS) and the multivariable logistic regression (MLR) models; data used for testing; and data from a later patient spell used for validation. Three fuzzy logic models and three MLR models were developed to link characteristics of patients diagnosed with a maximum stage AKI within 7 days of admission: the first models to identify any AKI Stage (FLS I, MLR I), the second for patterns of AKI Stage 2 or 3 (FLS II, MLR II), and the third to identify AKI Stage 3 (FLS III, MLR III). Model accuracy is expressed by area under the curve (AUC). RESULTS: Accuracy for each model during internal validation was: FLS I and MLR I (AUC 0.70, 95% CI: 0.64-0.77); FLS II (AUC 0.77, 95% CI: 0.69-0.85) and MLR II (AUC 0.74, 95% CI: 0.65-0.83); FLS III and MLR III (AUC 0.95, 95% CI: 0.92-0.98). CONCLUSIONS: FLS II and FLS III (and the respective MLR models) can identify with a high level of accuracy patients at high risk of developing AKI in hospital. These two models cannot be properly assessed against prior studies as this is the first attempt at quantifying the risk of developing specific Stages of AKI for a broad cohort of both medical and surgical inpatients. FLS I and MLR I performance is comparable to other existing models.

The Cornish experience of the ASSIST-CKD project.

Introduction The ASSIST-CKD project is a national quality improvement programme, aiming to decrease the number of patients presenting late to renal services by enabling laboratories to review up to five years of estimated glomerular filtration rate results graphically and report deteriorating patients to their general practitioner. Aim To assess the impact of the project on the laboratory, and of patient reporting on general practitioner management and the local renal service. Method Each week two searches were performed (Search A: maximum age 65 years, maximum eGFR 50 ml/min/1.73 m2 and Search B: Age 66-120 years, maximum eGFR 40 ml/min/1.73 m2) on patients with an estimated glomerular filtration rate requested by their general practitioner within the previous seven days. Patients showing deterioration in estimated glomerular filtration rate had a printed graph sent to their general practitioner. Feedback on the graphs and their impact on patient management were obtained from the general practitioners via a questionnaire. Results A median of 37 patients/week were listed for review for Search A, with 32% reported; and Search B a median of 227 patients/week listed, 32% reported. General practitioner surgery questionnaires (29) showed the reports were well received. Of general practitioners responding to the questionnaire, 67% had reviewed a patient earlier than intended, 54% had reviewed local guidance, 48% had emailed the renal team and 48% had referred a patient on receipt of a graph; 34% had shown a graph to their patients, of whom 70% found that useful. Conclusion There is some evidence that ASSIST-CKD reporting has enhanced patient care; however, further long-term assessment is still required.

Use of an electronic alert to identify patients with acute kidney injury.

Early intervention in the management of acute kidney injury (AKI) has been shown to improve outcomes. To facilitate early review we have introduced real time reporting for AKI. An algorithm using the laboratory computer system was implemented to report AKI for inpatients. Over 6 months there were 1,906 AKI reports in 1,518 patients: 56.3% AKI1, 26.9% AKI2 and 16.8% AKI3. 51.0% were male. Median age was 78 (interquartile range [IQR] 17) years. 62.6% were from general medical wards, 16.9% from surgical wards, 6.9% from orthopaedic wards and 5.3% from specialty wards. 8.3% were from peripheral hospitals. 31% of patients with AKI reports were clinically coded for AKI. 9% (n = 139) showed progression of AKI (mortality 42%). Patients with AKI had a significantly higher length of stay and mortality than those that did not. 4% of patients with AKI received acute renal replacement therapy (RRT). An e-alert system is feasible, allowing early identification of inpatients with AKI.

Increasing age at diagnosis and worsening renal function in patients with primary central nervous system lymphoma.

High-dose Methotrexate (MTX) is the most useful cytotoxic drug used in the treatment of primary central nervous system lymphoma (PCNSL). Dose reduction should be made in patients with reduced renal function. We evaluated the age of patients over a period of 22 years and estimated their glomerular filtration rate. One hundred and two patients were treated in Nottingham University Hospitals (a regional centre for neurosurgery) during the period 1986-2008. Patients were treated either with the BVAM regimen (carmustine, vincristine, cytarabine, MTX) or with CHOD (cyclophosphamide, doxorubicin, vincristine and dexamethasone) given for one cycle prior to BVAM. The age at which patients were diagnosed with PCNSL increased during the period of the study. During the first half of the study period (1986-1997) the median age was 60.5 years, compared to a median age of 65 years during the second half of the study period (1998-2008) (P = 0.001). The estimated glomerular filtration rate decreased with age over 40 years in a similar way to the general population. The increasing age of patients with PCNSL and decreasing renal function limit the intensity of chemotherapy with MTX containing regimens.

Abnormal IgD and IgA1 O-glycosylation in hyperimmunoglobulinaemia D and periodic fever syndrome.

In order to determine the glycosylation pattern for IgD, and to examine whether there are changes in the pattern of IgD and IgA1 O-glycosylation in patients with hyperimmunoglobulinaemia D and periodic fever syndrome (HIDS) during acute febrile attacks and during periods of quiescence, serum was obtained from 20 patients with HIDS and 20 control subjects. In the HIDS group, serum was obtained either during an acute febrile episode (n = 9) or during a period of quiescence (n = 11). The O-glycosylation profiles of native and desialylated IgA1 and IgD were measured in an ELISA-type system using the lectins Helix aspersa and peanut agglutinin, which bind to alternative forms of O-glycan moieties. IgD is more heavily O-galactosylated and less O-sialylated than IgA1 in healthy subjects. HIDS is associated with more extensive O-galactosylation of IgD and a reduction in O-sialylation of both IgD and IgA1. These changes are present both during acute febrile attacks and periods of quiescence. The T cell IgD receptor is a lectin with binding affinity for the O-glycans of both IgD and IgA1. The observed changes in IgD and IgA1 O-glycosylation are likely to have a significant effect on IgD/IgA1-T cell IgD receptor interactions including basal immunoglobulin synthesis, and possibly myeloid IgD receptor-mediated cytokine release.