Intervention Sites Research Articles

Field assessment of coconut-based activated carbon systems for the treatment of herbicide contamination

Once released into the environment, herbicides can move through soil or surface water to streams and groundwater. Filters containing adsorbent media placed in fields may be an effective solution to herbicide loss in the environment. However, to date, no study has investigated the use of adsorbent materials in intervention systems at field-scale, nor has any study investigated their optimal configuration. Therefore, the aim of this paper was to examine the efficacy of low-cost, coconut-based activated carbon (CAC) intervention systems, placed in streams and tributaries, for herbicide removal. Two configurations of interventions were investigated in two agricultural catchments and one urban area in Ireland: (1) filter bags and (2) filter bags fitted into polyethylene pipes. Herbicide sampling was conducted using Chemcatcher® passive sampling devices in order to identify trends in herbicide exceedances at the sites, and to quantifiably assess, compare, and contrast the efficiency of the two intervention configurations. While the Chemcatcher® passive sampling devices are capable of analysing eighteen different acid herbicides, only six different acid herbicides (2,4-D, clopyralid, fluroxypyr, MCPA, mecoprop and triclopyr) were ever detected within the three catchment areas, which were also the only acid herbicides used therein. The CAC was capable of complete herbicide removal, when the water flow was slow (0.5–1 m3 s−1), and the interventions spanned the width and depth of the waterway. Overall, the reduction in herbicide concentrations was better for the filter pipes than for the filter bags, with a 48% reduction in detections and a 37% reduction in exceedances across all the sampling sites for the filter pipe interventions compared to a 13% reduction in the number of detections and a 24% reduction in exceedances across all sampling sites for the filter bag interventions (p < 0.05). This study demonstrates, for the first time, that CAC may be an effective in situ remediation strategy to manage herbicide exceedances close to the source, thereby reducing the impact on environmental and public health.

The concentration booth and the handshaking lane: ideologies of the phatic

Abstract Scholars of language and culture have effectively used the language ideology concept to critique the referentialist assumption in the post-Enlightenment conceptualization of language and society. Continuing with this critical project, this article attempts a further reorientation of our analytic metalanguage to explore the ideology of the phatic, the way in which salient emphasis is placed on problems regarding communicative channels of contact. The article identifies this ideology in the increasingly visible role played by phatic labor and its concrete manifestations in scenes of service and affective labor in contemporary Japan. Two separate instances are analyzed to reveal their common engagement with channels of contact as a metapragmatic concern. First, I analyze one Japanese restaurant chain’s attempt to design and control the material zone of contact in dining experience, as indicative of the larger tendency in the contemporary economy to standardize consumer desire at the level of the phatic. Second, I look to the culture of celebrity, especially popular idols, and examine the institutionalization of fan-idol contact that has become a hegemonic marketing strategy. These cases witness rituals of public encounter that either work to hybridize human speech acts with nonhuman speech-actants inhabiting the material environment of contact, or to regulate forms of interaction deemed detrimental to the channel of affect through monitoring, interruption, and other forms of phatic policing. I use this analysis to draw attention to the necessity of taking the phatic function seriously in the scholarly exploration of language ideology. While scholars in various fields have frequently spoken of the centrality of communicative labor in postindustrial societies, the analytic focus on ideologization of the phatic offers a more precise theoretical and empirical framework for examining how communication is fetishized as the central site of political and economic intervention.

The effect of the SAFE intervention on post-discharge suicidal behavior: a quasi-experimental study using propensity score matching

ObjectivesThe risk of suicidal behavior after discharge from psychiatric admission is high. The aim of this study was to examine whether the SAFE intervention, an implementation of a systematic safer discharge procedure, was associated with a reduction in suicidal behavior after discharge.MethodsThe SAFE intervention was implemented at Mental Health Center Copenhagen in March 2018 and consisted of three systematic discharge procedures: (1) A face-to-face meeting between patient and outpatient staff prior to discharge, (2) A face-to-face meeting within the first week after discharge, and (3) Involvement of relatives. Risk of suicide attempt at six-month post-discharge among patients discharged from the SAFE intervention was compared with patients discharged from comparison mental health centers using propensity score matching.Results7604 discharges took place at the intervention site, which were 1:1 matched with discharges from comparison sites. During the six months of follow-up, a total of 570 suicide attempts and 25 suicides occurred. The rate of suicide attempt was 11,652 per 100,000 person-years at the SAFE site, while it was 10,530 at comparisons sites. No observable difference in suicide attempt 1.10 (95% CI: 0.89–1.35) or death by suicide (OR = 1.27; 95% CI:0.58–2.81) was found between sites at 6-month follow-up.ConclusionNo difference in suicidal behavior between the sites was found in this pragmatic study. High rates of suicidal behavior were found during the 6-months discharge period, which could suggest that a preventive intervention should include support over a longer post-discharge period than the one-week follow-up offered in the SAFE intervention.

Effect of educational intervention on medication reconciliation practice of hospital pharmacists in a developing country – A non-randomised controlled trial

BackgroundMedication reconciliation is an evidence-based practice that reduces medication-related harm to patients. This study evaluated the effect of educational intervention on medication reconciliation practice of pharmacists among ambulatory diabetes and hypertensive patients.MethodsA non-randomized clinical trial on medication reconciliation practice was carried out among 85 and 61 pharmacists at the intervention site and control site, respectively. Medication reconciliation was carried out among 334 (intervention-183; control-151) diabetes and/or hypertensive patients by the principal investigator to indirectly evaluate pharmacists’ baseline medication reconciliation practice at both sites. A general educational intervention was carried out among intervention pharmacists. Medication reconciliation was carried out by the principal investigator among another cohort of 96 (intervention-46; control-50) and 90 (intervention-44; control-46) patients at three and six months postintervention, respectively, to indirectly assess pharmacists’ postintervention medication reconciliation practice. Thereafter, a focused educational intervention was carried out among 15 of the intervention pharmacists. Three experts in clinical pharmacy analysed the medication reconciliation form filled by the 15 pharmacists after carrying out medication reconciliation on another cohort of 140 patients, after the focused intervention. Data was summarized with descriptive (frequency, percentage, mean ± standard deviation) and inferential (Pearson product-moment correlations analysis, independent-samples t-test and one-way ANOVA) statistics with level of significance set at p<0.05.Key findingsBaseline medication reconciliation practice was poor at both sites. Post-general educational intervention, medication discrepancy was significantly reduced by 42.8% at the intervention site (p<0.001). At the intervention site, a significant increase of 54.3% was observed in patients bringing their medication packs for clinic appointments making medication reconciliation easier (p=0.003), at 6-months postintervention. Thirty-five, 66 and 48 drug therapy problems were detected by 31 (43.1%), 33 (66.0%) and 32 (71.1%) intervention pharmacists at 1-, 3- and 6-month post-general educational intervention, respectively. Post-focused educational intervention, out of a total of 695 medications prescribed, 75 (10.8%) medication discrepancies were detected and resolved among 42 (30%) patients by the 15 pharmacists.ConclusionsThe educational interventions improved pharmacists’ medication reconciliation practice at the intervention site. It is expected that this research would help create awareness on medication reconciliation among pharmacists in developing countries, with a view to reducing medication-related patient harm.

Adoption of Emergency Department–Initiated Buprenorphine for Patients With Opioid Use Disorder

Emergency department (ED) initiation of buprenorphine is safe and effective but underutilized in practice. Understanding the factors affecting adoption of this practice could inform more effective interventions. To quantify the factors, including social contagion, associated with the adoption of the practice of ED initiation of buprenorphine for patients with opioid use disorder. This is a secondary analysis of the EMBED (Emergency Department-Initiated Buprenorphine For Opioid Use Disorder) trial, a multicentered, cluster randomized trial of a clinical decision support intervention targeting ED initiation of buprenorphine. The trial occurred from November 2019 to May 2021. The study was conducted at ED clusters across health care systems from the northeast, southeast, and western regions of the US and included attending physicians, resident physicians, and advanced practice practitioners. Data analysis was performed from August 2022 to June 2023. This analysis included both the intervention and nonintervention groups of the EMBED trial. Graph methods were used to construct the network of clinicians who shared in the care of patients for whom buprenorphine was initiated during the trial before initiating the practice themselves, termed exposure. Cox proportional hazard modeling with time-dependent covariates was performed to assess the association of the number of these exposures with self-adoption of the practice of ED initiation of buprenorphine while adjusting for clinician role, health care system, and intervention site status. A total of 1026 unique clinicians in 18 ED clusters across 5 health care systems were included. Analysis showed associations of the cumulative number of exposures to others initiating buprenorphine with the self-practice of buprenorphine initiation. This increased in a dose-dependent manner (1 exposure: hazard ratio [HR], 1.31; 95% CI, 1.16-1.48; 5 exposures: HR, 2.85; 95% CI, 1.66-4.89; 10 exposures: HR, 3.55; 95% CI, 1.47-8.58). Intervention site status was associated with practice adoption (HR, 1.50; 95% CI, 1.04-2.18). Health care system and clinician role were also associated with practice adoption. In this secondary analysis of a multicenter, cluster randomized trial of a clinical decision support tool for buprenorphine initiation, the number of exposures to ED initiation of buprenorphine and the trial intervention were associated with uptake of ED initiation of buprenorphine. Although systems-level approaches are necessary to increase the rate of buprenorphine initiation, individual clinicians may change practice of those around them. ClinicalTrials.gov Identifier: NCT03658642.

Optimal planning of safety improvements on road sites belonging to different categories within large networks: An integrated multi-layer framework

Planning road safety interventions on large road networks implies several layers of complexity in the decision-making process. In fact, the following simultaneous problems should be addressed: estimating safety performances on the different road elements of the network, identifying sites showing high potential for improvement with respect to reference values, defining the possible types of safety measures to be implemented and their anticipated effect on traffic safety, limiting the number of interventions given fixed budget constraints.This study proposes an integrated multi-layer framework which takes into account the above-defined problems into a single optimization procedure which provides the number and type of safety interventions to be implemented over a wide road network composed of different categories of road elements. The proposed framework is based on the following peculiar aspects: the potential for safety improvement is quantitatively assessed based on the estimation of safety performances for each road category, a bi-level thresholding process integrated in the optimization process is used to highlight sites for interventions, the anticipated outcome of safety measures is quantitatively assessed as well through available crash reduction factors.The proposed methodology is applied to a case study which analyzes a sample of real roads belonging to a province-wide road network composed of various road elements (i.e., different categories of segments and intersections), under different budget constraints. Results demonstrate the applicability and flexibility of the proposed approach, which could be used for planning purposes, independently of the particular geographic location. Clearly, the approach is valid at the planning stage, given that several details of the different layers of analysis are necessarily simplified, while they should be studied in detail at the single intervention project stage.

Impact of ambulance paramedics missing STEMI diagnosis on subsequent management

Abstract Background/introduction Acute ST elevation myocardial infarction (STEMI) is defined by acute changes in the electrocardiograph (ECG) reflecting acute occlusion of a coronary artery. Rapid and complete reperfusion of the culprit lesion improves immediate mortality and long-term outcomes. Systems of care have been developed to optimise recognition and management of acute STEMI to facilitate the best possible patient outcomes. Pre-hospital diagnosis by ambulance paramedics and activation of Code STEMI teams has been shown to significantly impact treatment times and patient outcomes. But what is the outcome if the diagnosis is missed? Methods We studied 559 consecutive STEMI cases presenting to our health network with two 24/7 interventional sites over a three-year period (2020-2022 inclusive), comparing the impact of arrival by ambulance or self-presentation. Ambulance arrival cases were further stratified by whether Code STEMI was activated prior to hospital arrival or afterwards. Patients who developed STEMI after presentation to hospital or who were transferred from another institution were excluded from this analysis. Only patients proceeding to percutaneous intervention of the culprit lesion were included. First medical contact (FMC) is either hospital door time or time of ambulance paramedic arrival at patient. ECG time reflects first recorded ECG, either by ambulance paramedic or hospital emergency department. Results Results are depicted in the table below. Patients with STEMI had similar FMC to treatment times if diagnosed pre-hospital by the ambulance paramedic or after self-presentation to the emergency department. Interestingly, patients self-presenting to the emergency department had a longer symptom duration, perhaps reflecting uncertainty regarding the cause for symptoms and the rationale for not utilising ambulance services. Patients presenting via ambulance, where the diagnosis and activation of Code STEMI did not occur prior to hospital arrival, had less ST elevation and a significant delay in definitive treatment. Conclusion(s) Ambulance paramedics successfully diagnosed 69% of STEMI cases they transported, activating a Code STEMI prior to hospital arrival. Cases that were not pre-notified had less marked ST elevation, potentially creating uncertainty as to the diagnosis. Strategies to enable direct discussion of equivocal ECG changes and symptoms between ambulance paramedics and interventional cardiologists my assist in more complete recognition of all STEMI cases without creating excessive false activations.Table 1:Results

Transulnar artery approach in STEMI - Best alternative to radial?

Abstract Background Transulnar artery approach is a valuable alternative wrist access site for percutaneous coronary interventions. Currently published data about using transulnar approach (TUA) in the STEMI setting are missing. Due to its similarities with transradial approach (TRA), TUA in STEMI (ST segment elevation myocardial infarction) procedures can help in decreasing access site bleeding and vascular complications without sacrificing procedural success. Purpose To assess the success and safety of Transulnar access in STEMI. Materials and Methods In the period from March 2011 until December 2021, 8013 consecutive STEMI patients underwent primary PCI (percutaneous coronary intervention) in our center. All consecutive patients with transulnar approach (TUA) were included in a single center prospective registry of effectiveness and safety. The primary outcome was procedural success through ulnar access. We also examined clinical and procedure characteristics, access site bleeding and ischemic complications and failure mode of initial TUA. Results In this period, 172 STEMI patients (2.1%) underwent PPCI through transulnar approach. Mean age of patients was 60 ± 12 years with 27% females. All procedures were successfully performed through right TUA. There were no STEMI TUA cases with crossover to Transfemoral approach. In 150 patients (87%) TUA was the primary choice of puncture due to no palpable radial artery from previous radial artery occlusion. In 22 patients (12.7%) the reason for crossover from primary TRA to TUA were complex RA anomalies. Type 3 and 4 EASY Score hematoma was present in 4 patients (2.3%). 7% of patients had over 1 access site puncture. UA spasm was registered in 1.7%. Mean procedural time was 32±23 min and fluoroscopy time was 8.5±9.2 min. Ulnar artery anomalies were registered in 1% of patients. There were no ulnar artery occlusions detected at discharge. There were no clinical or ischemic hand complications seen during clinical follow up. Conclusion Transulnar approach is safe and feasible alternative wrist access in the STEMI setting and can further decrease TFA crossover.

Population rates and contemporary outcomes of atrial fibrillation ablation among older adults: a nationwide cohort study

Abstract Background Atrial fibrillation (AF) is the most common sustained arrhythmia, with pulmonary vein isolation (PVI) increasingly recommended as first-line therapy. Limited data suggest increasing use of PVI as well as increasing rates of post-PVI complications, but contemporary real-world outcomes among older adults remain unclear. Purpose To evaluate patient characteristics, population rates and 30-day clinical outcomes for PVI in a nationwide sample of adults aged &amp;gt;65 in the United States. Methods First-time PVIs were identified among US Medicare fee-for-service beneficiaries using CPT procedural codes, and comorbidities were ascertained using ICD-10 diagnosis codes associated with each procedural claim. Study outcomes included rates of PVI use, procedural complications, all-cause re-hospitalizations, and all-cause mortality at 30 days. Results From January 2017 through December 2020, 156,601 patients underwent first-time PVI performed by 2,791 unique operators. The mean patient age was 72.5 ± 5.2 years, 42.6% were female and the majority (92.7%) Caucasian. The rate of PVI increased from 2.48 per 100,000 beneficiaries in the first quarter of 2017 (performed by 2,113 operators) to 3.01 per 100,000 beneficiaries in the last quarter of 2020 (performed by 2,415 operators) – a 4.8% relative increase per year (p=0.02). This growth was driven primarily by outpatient elective procedures, which represented the majority (85.0%) of all PVIs. Concurrent with this increase in PVI use, there was a significant decrease in complication rates (3.9% in 2017 vs 3.1% in 2020, p&amp;lt;.0001) and re-hospitalizations (8.8% vs 7.1%, p&amp;lt;0.001) at 30 days, with no significant change in mortality at 30 days (0.36% vs 0.40%, p=0.38). Bleeding was the most common peri-procedural complication (1.4%), followed by pericardial effusion requiring intervention (1.2%) and access site vascular complications (0.55%). Conclusions This large nationwide cohort study shows that the use of PVI has steadily increased in contemporary clinical practice. Despite the widespread adoption of this procedure by a growing number of operators, cumulative complication and re-hospitalization rates at 30 days have decreased over time, with stable and very low rates of short-term mortality – even among older patients, who are ordinarily considered to be at higher risk. These findings contrast with those from previously published studies of non-representative cohorts. Results from our study should reassure both patients and providers on the overall safety of PVI as an increasingly common first-line procedure for rhythm control. Forthcoming analyses will be finalized by the time of presentation to evaluate whether hospital and operator volume further influence procedural outcomes.Central Figure: PVI Trends and Outcomes

"With group antenatal care, pregnant women know they are not alone": The process evaluation of a group antenatal care intervention in Ghana.

An essential component to improving maternal and newborn outcomes is antenatal care. A trial of group antenatal care was implemented in Ghana where 7 health care facilities were randomized to be intervention sites and 7 control sites continued traditional antenatal care. Group antenatal care, where 10-14 women with similar due dates meet together for visits, includes traditional components such as risk assessment with increased opportunity for education and peer support. The study aim was to assess and report the process evaluation of the implementation of a group antenatal care intervention. Process evaluation data were collected alongside intervention data and included both quantitative and qualitative data sources. Midwives at the health facilities which were randomized as intervention sites completed tracking logs to measure feasibility of the intervention. Research team members traveled to intervention sites where they conducted structured observations and completed fidelity and learning methods checklists to determine adherence to the model of group antenatal care delivery. In addition, midwives facilitating group antenatal care meetings were interviewed and focus groups were conducted with women participating in group antenatal care. In the majority of cases, midwives facilitating group antenatal care completed all components of the meetings with fidelity, following best practices such as sitting with the group rather than standing. Across 7 intervention sites, 7 groups (622 pregnant women) were documented in the tracking logs and of these participants, the majority (74%) attended more than half of the meetings, with 32% attending all 8 group meetings. Three themes were identified in both the midwife interviews and focus groups with pregnant women: 1) information sharing, 2) sense of community, and 3) time management challenges. An additional theme emerged from the focus groups with the women: women who had already given birth noticed a disconnect between what they learned and treatment received during labor and birth. This process evaluation determined that group antenatal care can be implemented with fidelity in low and middle-income countries. Time management was the biggest challenge, however both midwives and pregnant women found the model of care not only acceptable, but preferable to traditional care. The knowledge shared and sense of community built during the meetings was a valuable addition to the individual model of antenatal care.

Before‐after‐control‐impact field experiment shows anti‐predator netting enhances occupancy of the threatened Hungarian meadow viper (Vipera ursinii rakosiensis)

The Hungarian meadow viper is an endangered grassland‐dwelling species, which faces high predation pressure, partially due to avian species that forage in its habitat. Predation pressure by avian predators is caused not only by abundant game species (e.g. hooded crow, Corvus cornix) but also by protected and threatened species (e.g. short‐toed eagle, Cricaetus gallicus; common buzzard, Buteo buteo; roller, Coracias garrulus) in the project area (Felső‐kiskunsági turjánvidék, Hungary). Mark–recapture data of a reintroduced viper population showed a very low, 42% yearly average apparent survival rate. To establish a strong sub‐population we applied anti‐predator netting (APN) by building a 200 × 200 × 3 m (4 ha) totally closed exclusion site with a mesh net, lateral sides boosted with a 1 m high steel field fence to exclude mammals as well as birds. To test the effect of APN we monitored viper occupancy at 50 × 50 m sampling plots in a before–after/control–intervention (BACI) design, where we randomly placed quadrats 0.25 ha (50 × 50 m) to be surveyed, n = 26 at control habitats and n = 4 below the APN enclosure. We collected data across four years (2020–2023), in each year during the spring by 10 surveys replicates in each plot resulting in 1200 surveys to record viper detection/non‐detection data. We applied a multi‐season occupancy model to estimate site occupancy changes to test the effects of the BACI design. Occupancy probabilities were increasing during the four consecutive survey years in both the control and the intervention sites, however except for the initial occupancy, the occupancy probability became significantly higher at APN sites, and the APN intervention had a significant positive effect on viper occupancy, while the distance to APN showed negative effect. Predator exclusion is an effective method to minimise predation pressure and potentially has a deterministic positive demographic outcome, however, due to the high logistical and maintenance costs, this measure can be applied at only a few sites.

Human amniotic membrane inhibits migration and invasion of muscle-invasive bladder cancer urothelial cells by downregulating the FAK/PI3K/Akt/mTOR signalling pathway

Bladder cancer is the 10th most commonly diagnosed cancer with the highest lifetime treatment costs. The human amniotic membrane (hAM) is the innermost foetal membrane that possesses a wide range of biological properties, including anti-inflammatory, antimicrobial and anticancer properties. Despite the growing number of studies, the mechanisms associated with the anticancer effects of human amniotic membrane (hAM) are poorly understood. Here, we reported that hAM preparations (homogenate and extract) inhibited the expression of the epithelial–mesenchymal transition markers N-cadherin and MMP-2 in bladder cancer urothelial cells in a dose-dependent manner, while increasing the secretion of TIMP-2. Moreover, hAM homogenate exerted its antimigratory effect by downregulating the expression of FAK and proteins involved in actin cytoskeleton reorganisation, such as cortactin and small RhoGTPases. In muscle-invasive cancer urothelial cells, hAM homogenate downregulated the PI3K/Akt/mTOR signalling pathway, the key cascade involved in promoting bladder cancer. By using normal, non-invasive papilloma and muscle-invasive cancer urothelial models, new perspectives on the anticancer effects of hAM have emerged. The results identify new sites for therapeutic intervention and are prompt encouragement for ongoing anticancer drug development studies.

Successful Implementation Trial to Improve Stroke Risk (TCD) Screening in Children with Sickle Cell Anemia: A Roadmap to Care Enhancement

Stroke remains a devastating complication of sickle cell anemia (SCA). The STOP (Stroke Prevention Trial in Sickle Cell Anemia) protocol adopted in 2014 by the National Heart Lung and Blood Institute (NHLBI) guidelines includes stroke-risk screening using transcranial Doppler ultrasound (TCD) and prevention with chronic red cell transfusion therapy (CRCT). Theserecommendations were reinforced by the American Society of Hematology guidelines.However, despite the evidence supporting TCD screening in stroke prevention, the DISPLACE study (Dissemination and Implementation of Stroke Prevention Looking at the Care Environment) showed that real-world implementation was insufficient. To evaluate and improve sickle stroke screening, we conducted the NHLBI-funded multi-center DISPLACE study to identify barriers to TCD implementation and test novel methods for improving outcomes. DISPLACE is a 4-part study: 1) Retrospective calculation of TCD screening rates; 2) Assessment of barriers and facilitators; 3) Implementation trial to improve TCD screening and 4) Comparison of implementation sites to controls. Importantly, DISPLACE is the largest prospective study of children with SCA. This study employed a multi-level, multi-faceted cluster-randomized study of interventions to improve implementation rates of TCD. Methods: DISPLACE is a 28-center US consortium representing a range of: regions (urban vs rural), size (patient number), and institution type (academic vs community). In Part 1, sites performed a rigorous retrospective review of TCD screening from 2012-2016 to collect baseline rates. Part 2 included a barriers and facilitators assessment to TCD screening to inform the trial interventions: 1) Re-branding TCD as Sickle Stroke Screen, a meaningful name for SCD stakeholders; 2) Using a Single Coordinator (SC) for each site's TCD scheduling, and follow-up; 3) A custom designed provider-focused application, ProviderMinder TM (PM) created to remind providers to track TCD appointments and follow-up on results. When a TCD was due, PM alerted the provider to enter scan results or reason(s) missed. Once the TCD results (normal/conditional/abnormal) were entered in PM, providers were prompted to enter the next TCD date and/or intervention plan (if not normal). If a result was not entered, PM alerted the provider q3 days until the TCD was recorded as completed or rescheduled. The implementation trial (parts 3 and 4 of DISPLACE) included 16 sites that had the lowest TCD rates in part 1. The implementation trial included children with SCA aged 2-7 years (the group at highest risk for an abnormal TCD). Cluster randomization was used to allocate sites to PM alone (8 sites) or PM + SC (8 sites). The primary outcome was comparison of TCD rates between PM and PM+SC sites. Secondary outcomes included comparisons between 1) Part 3 sites' TCD rates and Part 1 baseline rates 2) Part 3 sites and control sites (to assess the impact of the educational rebranding of TCD). Results: Part 1 included 28 centers with 5246 children with SCA. Of the 16 intervention sites, 3 sites could not implement the interventions due to administrative issues but remained in the study and were re-designated as “control sites” and a 4th control site was added (they were not informed prospectively to avoid bias). Thus, there were 13 evaluable sites for the primary endpoint including 776 patients; 484 in sites using PM and 292 in sites using PM+SC. Control sites included 185 patients. The trial demonstrated superiority of the PM arm compared to the PM + SC arm (P&amp;lt;.0001 year 1 and p=0.002 year 2) in both years of implementation and in comparison, to the control sites (P&amp;lt;.0001 year 1, p=.009 year 2) with an overall improvement in mean TCD screening from part 1 by 25% (table 1). Conclusions: This was a highly successful implementation study in SCA. This study emphasizes the importance of performing barrier and facilitator assessments when introducing new guideline-recommended screenings into clinical practice. These findings also highlight the importance of ongoing quality assurance in SCA to ensure prevention practices are maintained. Despite the benefit of TCD (sickle stroke screening) in children with SCA, implementation was poor prior to these interventions. Results from this study will guide ongoing optimization of TCD screening and demonstrate the importance of adopting these interventions in the real world.

A quasi-experimental study of effects of community health workers’ incentivisation on uptake of maternal, newborn and child health services in Lamu County, Kenya

Background: Community health workers (CHWs) are known as the ‘gate keepers’ of good health in the community. Being the first contact with the patients at the community level, they can help improve the maternal, newborn and child health (MNCH) indicators if they are well motivated to conduct their day-to-day work. At the same time, MNCH indicators are negatively affected by hard-to-reach health facilities and cultural factors thus the CHWs can help improve the health status in this category. Methods: The study utilized a quasi-experimental study design with an intervention and a control site in both Lamu West and Lamu East Sub Counties. Purposive sampling used to select study population and study site. Study period was (August 2018-March 2022). Mixed methods approach was used with both quantitative and qualitative methodologies of data collection to enable data triangulation. Questionnaires were used to collect data from CHWs, focused group discussions with caregivers and In-depth Interviews conducted with key informants from the Ministry of Health- Lamu County and the implementing partner-PharmAccess. Results: The study established that 78% of the CHWs were selected by the community members. Most of the CHWs in the intervention site had attended other trainings after the initial capacity development program, had at least one supervision in the last month preceding evaluation, were satisfied with the community and county appreciation. The difference between control and intervention site had a statistical significance (p&lt;0.05) for report writing during home visits, cross-referencing of reports before submission, attendance of refresher courses, loss of interest to work as a CHW and referral of patients to link facilities. Conclusions: CHWs need motivation in delivering their services. This can be done in form of incentives (both monitory and non-monitory), refresher trainings and supportive supervision.

The progranulin cleavage product granulin 3 exerts a dominant negative effect on animal fitness.

Progranulin is an evolutionarily conserved protein that has been implicated in human neurodevelopmental and neurodegenerative diseases. Human progranulin is comprised of multiple cysteine-rich, biologically active granulin peptides. Granulin peptides accumulate with age and stress, however their functional contributions relative to full-length progranulin remain unclear. To address this, we generated C. elegans strains that produced quantifiable levels of both full-length progranulin/PGRN-1 protein and cleaved granulin peptide. Using these strains, we demonstrated that even in the presence of intact PGRN-1, granulin peptides suppressed the activity of the lysosomal aspartyl protease activity, ASP-3/CTSD. Granulin peptides were also dominant over PGRN-1 in compromising animal fitness as measured by progress through development and stress response. Finally, the degradation of human TDP-43 was impaired when the granulin to PGRN-1 ratio was increased, representing a disease-relevant downstream impact of impaired lysosomal function. In summary, these studies suggest that not only absolute progranulin levels, but also the balance between full-length progranulin and its cleavage products, is important in regulating lysosomal biology. Given its relevance in human disease, this suggests that the processing of progranulin into granulins should be considered as part of disease pathobiology and may represent a site of therapeutic intervention.

Localising aid: Urban displacement, contested public authority and legitimacy in Jordan and Lebanon

AbstractGlobally, tens of millions of forcibly displaced people live in informal urban neighbourhoods. Although critical sites for humanitarian and development intervention, municipal authorities may have only a limited presence. Especially in conflict and post‐conflict settings, other non‐state actors emerge to compete for public authority. While the localisation agenda of international donors seeks to better engage local governance actors, little is known about how aid donors take account of non‐state public authority actors as they seek to achieve stability, state building, security and refugee resilience objectives. Accordingly, this study adopts a qualitative methodology to analyse how, why and to what effect donors conceive of and seek to address the legitimacy of state and non‐state urban public authority actors in their response to urban displacement. Analysis of the Syrian refugee crisis in Jordan and Lebanon shows that municipalities remain the focus, as donors hold three key assumptions that inform their interventions. Adopting sophisticated tools for understanding non‐state actors' pursuit of public authority, donor interventions seek to undergird, shift, work around, blank or ban their legitimacy‐making practices. We conclude that while donors embrace empirical legitimacy approaches, development and humanitarian responses to urban protracted displacement in marginal urban neighbourhoods are restricted by powerful normative legitimacy approaches rooted in foreign policy objectives.

Process evaluation of The Breastfeeding Trial. What factors impact the intervention delivery?

Abstract Background Breastmilk is the ideal nutrition for infants, and breastfeeding is an important health promoting behaviour. In Denmark, most mothers initiate breastfeeding but many cease within the first months resulting in just 14% reaching the World Health Organization recommendation of six months exclusive breastfeeding. A large-scaled, cluster-randomized intervention study implemented in the Danish health visiting programme aimed to extent the duration of breastfeeding and reduce social inequality. To elucidate how the intervention was implemented, a process evaluation of the intervention was conducted. Methods Following the MRC guidelines for process evaluation, we used a mixed methods approach to assess the delivery of the intervention, and facilitators and barriers in the context that affected the implementation. Data from questionnaires distributed to the health visiting managers of 21 Danish municipalities and 242 health visitors employed there, and data from three focus groups with health visitors and eight individual interviews with mothers in the intervention informed the process evaluation. Results Preliminary findings from questionnaires imply that the training program slightly enhanced health visitors’ breastfeeding support competencies. However, health visitors explained in the focus groups that they provided support as usual. A contextual factor hindering the implementation was change of personnel. Having had favourable experiences with the intervention acted as facilitator. Findings from interviews with mothers indicated a high fidelity in the distribution of intervention materials and partner involvement. Conclusions Preliminary findings of this study show variability in how the intervention was implemented throughout the intervention sites. This evaluation will assist in the interpretation of the results of the effectiveness study and inform policy makers about if and how this intervention could be scaled up. Key messages • Health visitors in intervention clusters seemed to have gained competencies in breastfeeding support; however, expressed that they provided support ‘as usual’. • Change of personnel acted as a barrier, while having had positive experiences with the intervention acted as a facilitator.

Stakeholder engagement to assess the transferability of vaccination interventions in Greece

Abstract Background Due to political instability, poverty and war Greece has been witness, over the last decade, to continuous migrant and refugee flows which enter the country mainly on their way to Northern Europe. Through the RIVER-EU project in Greece we aim to identify and tailor successful interventions that can address health system barriers to MMR/HPV vaccination for this group. Methods RIVER-EU adopts participatory action research (PAR) in order to give voice to all involved groups. The main aim of the focus groups (FGs) and the interviews was to explore transferability. We aimed to discuss how promising interventions could be transferred to the Greek reality and discussed barriers and facilitators. Results FGs were conducted with migrant/refugee parents (mainly mothers), adolescents (boys and girls) and other stakeholders such as health professionals and policy makers. The main challenge in Greece is the diversity of the target group (migrants/refugees), as people who arrive to Greece come from different countries have different cultural and religious backgrounds and have fled their countries for different reasons (war, poverty, financial problems). Possible solutions were discussed such as schools as an intervention site. An additional problem identified was access to vaccination services (for HPV/MMR) and the need to create synergies with local health organizations. Finally, it was evident that adolescents as a group, although from different cultural backgrounds, share common values and norms. Conclusions The RIVER-EU project has implemented an innovative approach to explore barriers and facilitators of transferability and tailor the intervention to the specific circumstances of the situation in Greece. Through the PAR the target groups were able to voice their beliefs about what should be implemented in which way and able to discuss possible solutions. Agreement about the importance of HPV/MMR vaccination for migrants/refugees in Greece was established.

Evaluation of the Effect of a Safe Medication Strategy on Potentially Inappropriate Medications, Polypharmacy and Anticholinergic Burden for People with Dementia: An Intervention Study.

People with dementia (PWD) are at risk for medication-related harm due to their impaired cognition and frequently being prescribed many medications. This study evaluated a medication safety intervention (including pharmacist medication reconciliation and review) for PWD during an unplanned admission to hospital. This article reports the effect of the intervention on polypharmacy, potentially inappropriate medications (PIMs), and anticholinergic burden scores for PWD. A pre-post design using an intervention site and a control site was conducted in 2017-2019, in a regional area in New South Wales, Australia. Polypharmacy, PIMs, and anticholinergic burden were measured at admission, discharge, and three months after discharge. There were 628 participants including 289 at the control site and 339 at the intervention site. Polypharmacy was 95% at admission and 90% at discharge. PIMs at admission were 95-98% across timepoints and decreased significantly at discharge. The mean anticholinergic score decreased significantly between admission (2.40-3.15) and discharge (2.01-2.57). Reduced PIMs at discharge were correlated with reduced anticholinergic burden (rho = 0.48-0.55, p < 0.001). No significant differences were identified between the study and control sites for Polypharmacy, PIMs, and anticholinergic burden rates and scores. High rates of polypharmacy and PIMs in this study indicate a study population with multiple comorbidities. This intervention was feasible to implement but was limited due to difficulty recruiting participants and deaths during the study. Future multisite studies should be designed to recruit larger study samples to evaluate interventions for improving medication safety for PWD and improve outcomes for these vulnerable people.

Integrating Clinical Decision Support Into Electronic Health Record Systems Using a Novel Platform (EvidencePoint): Developmental Study.

Through our work, we have demonstrated how clinical decision support (CDS) tools integrated into the electronic health record (EHR) assist providers in adopting evidence-based practices. This requires confronting technical challenges that result from relying on the EHR as the foundation for tool development; for example, the individual CDS tools need to be built independently for each different EHR. The objective of our research was to build and implement an EHR-agnostic platform for integrating CDS tools, which would remove the technical constraints inherent in relying on the EHR as the foundation and enable a single set of CDS tools that can work with any EHR. We developed EvidencePoint, a novel, cloud-based, EHR-agnostic CDS platform, and we will describe the development of EvidencePoint and the deployment of its initial CDS tools, which include EHR-integrated applications for clinical use cases such as prediction of hospitalization survival for patients with COVID-19, venous thromboembolism prophylaxis, and pulmonary embolism diagnosis. The results below highlight the adoption of the CDS tools, the International Medical Prevention Registry on Venous Thromboembolism-D-Dimer, the Wells' criteria, and the Northwell COVID-19 Survival (NOCOS), following development, usability testing, and implementation. The International Medical Prevention Registry on Venous Thromboembolism-D-Dimer CDS was used in 5249 patients at the 2 clinical intervention sites. The intervention group tool adoption was 77.8% (4083/5249 possible uses). For the NOCOS tool, which was designed to assist with triaging patients with COVID-19 for hospital admission in the event of constrained hospital resources, the worst-case resourcing scenario never materialized and triaging was never required. As a result, the NOCOS tool was not frequently used, though the EvidencePoint platform's flexibility and customizability enabled the tool to be developed and deployed rapidly under the emergency conditions of the pandemic. Adoption rates for the Wells' criteria tool will be reported in a future publication. The EvidencePoint system successfully demonstrated that a flexible, user-friendly platform for hosting CDS tools outside of a specific EHR is feasible. The forthcoming results of our outcomes analyses will demonstrate the adoption rate of EvidencePoint tools as well as the impact of behavioral economics "nudges" on the adoption rate. Due to the EHR-agnostic nature of EvidencePoint, the development process for additional forms of CDS will be simpler than traditional and cumbersome IT integration approaches and will benefit from the capabilities provided by the core system of EvidencePoint.