Home-monitoring for neovascular age-related macular degeneration in older adults within the UK: the MONARCH diagnostic accuracy study.

Background: Most neovascular age-related macular degeneration treatments involve long-term follow-up of disease activity. Home monitoring would reduce the burden on patients and those they depend on for transport, and release clinic appointments for other patients. The study aimed to evaluate three home-monitoring tests for patients to use to detect active neovascular age-related macular degeneration compared with diagnosing active neovascular age-related macular degeneration by hospital follow-up. Objectives: There were five objectives: Estimate the accuracy of three home-monitoring tests to detect active neovascular age-related macular degeneration. Determine the acceptability of home monitoring to patients and carers and adherence to home monitoring. Explore whether inequalities exist in recruitment, participants' ability to self-test and their adherence to weekly testing during follow-up. Provide pilot data about the accuracy of home monitoring to detect conversion to neovascular age-related macular degeneration in fellow eyes of patients with unilateral neovascular age-related macular degeneration. Describe challenges experienced when implementing home-monitoring tests. Design: Diagnostic test accuracy cohort study, stratified by time since starting treatment. Setting: Six United Kingdom Hospital Eye Service macular clinics (Belfast, Liverpool, Moorfields, James Paget, Southampton, Gloucester). Participants: Patients with at least one study eye being monitored by hospital follow-up. Reference standard: Detection of active neovascular age-related macular degeneration by an ophthalmologist at hospital follow-up. Index tests: KeepSight Journal: paper-based near-vision tests presented as word puzzles. MyVisionTrack®: electronic test, viewed on a tablet device. MultiBit: electronic test, viewed on a tablet device. Participants provided test scores weekly. Raw scores between hospital follow-ups were summarised as averages. Results: Two hundred and ninety-seven patients (mean age 74.9 years) took part. At least one hospital follow-up was available for 317 study eyes, including 9 second eyes that became eligible during follow-up, in 261 participants (1549 complete visits). Median testing frequency was three times/month. Estimated areas under receiver operating curves were < 0.6 for all index tests, and only KeepSight Journal summary score was significantly associated with the lesion activity (odds ratio = 3.48, 95% confidence interval 1.09 to 11.13, p = 0.036). Older age and worse deprivation for home address were associated with lower participation (χ2 = 50.5 and 24.3, respectively, p < 0.001) but not ability or adherence to self-testing. Areas under receiver operating curves appeared higher for conversion of fellow eyes to neovascular age-related macular degeneration (0.85 for KeepSight Journal) but were estimated with less precision. Almost half of participants called a study helpline, most often due to inability to test electronically. Limitations: Pre-specified sample size not met; participants' difficulties using the devices; electronic tests not always available. Conclusions: No index test provided adequate test accuracy to identify lesion diagnosed as active in follow-up clinics. If used to detect conversion, patients would still need to be monitored at hospital. Associations of older age and worse deprivation with study participation highlight the potential for inequities with such interventions. Provision of reliable electronic testing was challenging. Future work: Future studies evaluating similar technologies should consider: Independent monitoring with clear stopping rules based on test performance. Deployment of apps on patients' own devices since providing devices did not reduce inequalities in participation and complicated home testing. Alternative methods to summarise multiple scores over the period preceding a follow-up. Trial registration: This trial is registered as ISRCTN79058224. Funding: This award was funded by the National Institute of Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 15/97/02) and is published in full in Health Technology Assessment; Vol. 28, No. 32. See the NIHR Funding and Awards website for further award information.

Treatment for neovascular age-related macular degeneration, the most common cause of sight loss in those over 50 years, involves regular eye injections and frequent follow-up appointments. This is inconvenient for patients and causes capacity issues in the hospital eye service. Finding tests that could be undertaken at home that could detect if a further injection and hospital appointment was required or not would increase capacity to see those at highest risk of sight loss and also reduce the burden on patients and their carers. We investigated three different visual function tests, one paper-based and two applications on an iPod Touch_TM tablet (Apple, Cupertino, CA, USA). We wanted to see if they could detect an increase in disease activity that would require treatment, compared to the decision by a retinal specialist at a traditional hospital eye outpatient visit based on clinical examination and retinal imaging. To encourage those without a smartphone or home internet to participate, we provided both an iPod Touch and Mobile Wireless-Fidelity device with a mobile contract. None of the tests performed well enough to safely monitor patients at home. Those who were willing to participate tended to be younger, had previous experience of using smartphones, sending e-mail and internet access and were more well-off than those who chose not to participate. Some participants also experienced difficulties with the devices provided and successfully uploading the data which were not related to the extent of previous information technology experience. There were also significant technical challenges for the research team. The study helpline was used heavily, considerably more than we anticipated. These tests are not ready to be used in this context. Future studies involving mobile health technology need to carefully consider how to reach those unlikely to participate and provide sufficient technical support to support long-term follow-up.

Acceptability of Home Monitoring for Neovascular Age-Related Macular Degeneration Reactivation: A Qualitative Study.

This study formed part of a diagnostic test accuracy study to quantify the ability of three index home monitoring (HM) tests (one paper-based and two digital tests) to identify reactivation in Neovascular age-related macular degeneration (nAMD). The aim of the study was to investigate views about acceptability and explore adherence to weekly HM. Semi-structured interviews were held with 98 patients, family members, and healthcare professionals. A thematic approach was used which was informed by theories of technology acceptance. Various factors influenced acceptability including a patient's understanding about the purpose of monitoring. Training and ongoing support were regarded as essential for overcoming unfamiliarity with digital technology. Findings have implications for implementation of digital HM in the care of older people with nAMD and other long-term conditions.

Evaluation of a novel sub-acute Hospital in the Home model for providing inpatient geriatric and rehabilitation services.

ObjectiveTo report on the development and implementation of a multidisciplinary, sub-acute Geriatric Evaluation and Management Rehabilitation Hospital in the Home (GEMRHITH) model of care with the initial 2years' service outcome data (October 2019 - September 2021).MethodsA retrospective analysis was conducted using hospital centralised data, and the GEMRHITH internal service database. Descriptive statistics were used to describe the patient population. Student's t-test was used for comparative data.ResultsOver 2years, GEMRHITH admitted 617 patients (13%, n=82 directly from the emergency department). Median age was 82years (range, 32-102 years), with 60.5% (n=373) being female and 39.5% (n=244) presenting with moderate frailty. Most patients (79.6%, n=491) entered from a medical speciality (28.5%, n=178 from neurology). Average GEMRHITH stay was 6days (range, 1-33 days). Average bed occupancy was 5.3 virtual beds. There was an average of 26 discharges per month with 97% of patients (n=598) discharged to their own home. Transfers back to the emergency department with the same diagnosis-related group were low (3.6%). The 7-28day re-admission rate was 2.3%. Service safety was high, with only eight hospital-acquired complications reported in seven patients. Significant improvements were noted for total and sub-scale Functional Independence Measure scores (P<0.001).ConclusionsThe addition of rehabilitation and geriatric care to traditional HITH services provides opportunities for multidisciplinary teams to support a larger cohort of patients with various medical and surgical conditions and functional abilities, to efficiently transition home from hospital settings. There were minimal complications and occupied bed stays were saved within a hospital.

Home-Monitoring Vision Tests to Detect Active Neovascular Age-Related Macular Degeneration.

Importance: Most neovascular age-related macular degeneration (nAMD) treatments involve long-term follow-up of disease activity. Home-monitoring would reduce the burden on patients and their caregivers and release clinic capacity. Objective: To evaluate 3 vision home-monitoring tests for patients to use to detect active nAMD compared with diagnosing active nAMD at hospital follow-up during the after-treatment monitoring phase. Design, Setting, and Participants: This was a diagnostic test accuracy study wherein the reference standard was detection of active nAMD by an ophthalmologist at hospital follow-up. The 3 home-monitoring tests evaluated included the following: (1) the KeepSight Journal (KSJ [International Macular and Retinal Foundation]), which contains paper-based near-vision tests presented as word puzzles, (2) the MyVisionTrack (mVT [Genentech]) vision-monitoring mobile app, viewed on an Apple mobile operating system-based device, and (3) the MultiBit (MBT [Visumetrics]) app, viewed on an Apple mobile operating system-based device. Participants were asked to test weekly; mVT and MBT scores were transmitted automatically, and KSJ scores were returned to the research office every 6 months. Raw scores between hospital follow-ups were summarized as averages. Patients were recruited from 6 UK hospital eye clinics and were 50 years and older with at least 1 eye first treated for active nAMD for at least 6 months or longer to a maximum of 42 months before approach. Participants were stratified by time since starting treatment. Study data were analyzed from May to September 2021. Exposures: The KSJ, mVT, and MBT were compared with the reference standard (in-hospital ophthalmologist examination). Main Outcomes and Measures: Estimated area under receiver operating characteristic curve (AUROC). The study had 90% power to detect a difference of 0.06, or 80% power to detect a difference of 0.05, if the AUROC for 2 tests was 0.75. Results: A total of 297 patients (mean [SD] age, 74.9 [6.6] years; 174 female [58.6%]) were included in the study. At least 1 hospital follow-up was available for 312 study eyes in 259 participants (1549 complete visits). Median (IQR) home-monitoring testing frequency was 3 (1-4) times per month. Estimated AUROC was less than 0.6 for all home-monitoring tests, and only the KSJ summary score was associated with lesion activity (odds ratio, 3.48; 95% CI, 1.09-11.13; P = .04). Conclusions and Relevance: Results suggest that no home-monitoring vision test evaluated provided satisfactory diagnostic accuracy to identify active nAMD diagnosed in hospital eye service follow-up clinics. Implementing any of these evaluated tests, with ophthalmologists only reviewing test positives, would mean most active lesions were missed, risking unnecessary sight loss.

Experiences of Allied Health Clinicians Accessing a Pilot Project ECHO® Program to Support Learning in Pediatric Feeding.

INTRODUCTION: Pediatric feeding disorder is increasing in prevalence, yet low clinician confidence regarding its management is a barrier to care. Targeted clinician training is needed as traditional didactic training programs are limited in both their accessibility and capacity to provide opportunities for the application of theory-based learning. METHODS: This study examined the experiences of a group of clinicians involved in a multidisciplinary PedFeed ECHO® network, a virtual community of practice established to support speech pathologists, occupational therapists, dieticians, and psychologists in Queensland, Australia, working with children with pediatric feeding disorder. Sixteen clinicians (34% of the total PedFeed ECHO network) from different professional backgrounds, clinical settings, and locations participated in semistructured interviews three months post completion of eight ECHO sessions. RESULTS: Inductive thematic analysis revealed three themes: (1) broad-ranging outcomes of PedFeed ECHO, (2) participant experiences of PedFeed ECHO, and (3) facilitators for future success. PedFeed ECHO was viewed very positively and provided participants with a valuable opportunity for information sharing and collaboration as a multidisciplinary team. Participants described impacts on their professional practice, knowledge, confidence, and professional isolation, as well as service and patient-level impacts. Several facilitators for the success of future PedFeed ECHO cohorts were provided. DISCUSSION: Insights from participants will serve to improve the design and delivery of ECHO training for future cohorts. Monitoring clinical skill development over a longer period of time and exploring clinician perceptions regarding direct impact on patient care are needed to further validate the impact of ECHO.

Inequalities in Uptake and Use of Digital Applications for Home-Monitoring of Neovascular Age-Related Macular Degeneration in an Elderly Visually Impaired Population: The MONARCH Study.

Purpose: To describe inequalities in the Monitoring for Neovascular Age-related Macular Degeneration Reactivation at Home (MONARCH) diagnostic test accuracy study for: recruitment; participants' ability to self-test; and adherence to testing using digital applications during follow-up. Methods: Home-monitoring vision tests included two tests implemented as software applications (apps: MyVisionTrack and MultiBit) on an iPod Touch device. Patients were provided with all hardware required to participate (iPod and MIFI device) and trained to use the apps. Regression models estimated associations of age, sex, Index of Multiple Deprivation, strata of time since first diagnosis, and baseline visual acuity at study entry on outcomes of willingness to participate, ability to perform tests, and adherence to weekly testing. Results: A minority of patients who were approached were willing-in-principle to participate. Increasing age was associated with being unwilling-in-principle to participate. Patients from the most deprived areas had a 47% decrease in odds of being willing compared to those from the middle quintile deprived areas (odds ratio, 0.53; 95% confidence interval = 0.32, 0.88). Increasing age and worse deprivation were not consistently associated either with ability to self-monitor with the index tests, or adherence to weekly testing. Conclusions: Associations of increasing age and worse deprivation index were associated with unwillingness-in-principle to participate despite the provision of hardware' highlighting the potential for inequality with interventions of the kind evaluated. Translational Relevance: The clear evidence of inequalities in participation should prompt future research on ways to encourage adoption of mobile health technologies by underserved populations.

'The big value of it is getting the patient seen by the right person at the right time': clinician perceptions of the value of allied health primary contact models of care.

Allied health primary contact clinic models of care have increasingly been used as a strategy to increase public health service capacity. A recent systematic review found little consistency or agreement on how primary contact clinics are evaluated. The concept of value of primary contact clinics, which has important implications for evaluation, has not yet been explored in-depth. To explore allied health clinicians' perceptions of the value of allied health primary contact clinics, with the goal of informing an evaluation framework, a descriptive qualitative approach utilizing semi-structured interviews was employed. Participants included allied health staff embedded in clinical lead roles within primary contact clinics across four acute care hospitals in a metropolitan health service located in South-East Queensland, Australia. Lead staff from 30 identified primary contact clinic models in the health service were approached to take part via email. All eligible participants who provided consent were included. An inductive thematic analysis approach was used. A total of 23 clinicians (n = 23) representing 22 diverse models of primary contact clinics participated. Most participants were physiotherapists, dietitians, or occupational therapists, although speech pathology, audiology, and podiatry were also represented. Participant perceptions of the 'value' of PCCs were a highly complex phenomenon, comprising five intersecting domains: (i) patient satisfaction; (ii) clinical outcomes; (iii) care pathway and resource use; (iv) health service performance; and (v) staff satisfaction and professional standing. These five core value domains were positively or negatively influenced by 12 perceived benefits and 8 perceived drawbacks, respectively. Value domains were also highly interrelated and impacted upon each other. The concept of 'value' relating to primary contact clinics involves multiple intersecting domains encompassing different perspectives. This study highlighted potential benefits and drawbacks of primary contact clinics that have not yet been measured or explored in the literature, and as such may be useful for healthcare administrators to consider. The findings of this study will inform an evaluation framework including health economics calculator for primary contact clinics.

Using concept mapping to guide dysphagia service enhancements in Singapore: Recommendations from the speech-language pathology workforce.

PURPOSE: Optimising dysphagia service delivery is crucial to minimise personal and service impacts associated with dysphagia. However, limited data exist on how to achieve this in Singapore. This study aimed to develop prioritised enhancements that the speech-language pathology workforce perceived as needed to improve dysphagia services in Singapore. METHOD: Using a concept mapping approach, 19 speech-language pathologists (SLPs) and 10 managers listed suggestions for dysphagia service optimisation. Within their groups, the collated suggestions were sorted based on similarity, and individually rated on a 5-point scale based on importance and changeability. Using cluster and bivariate analysis, clusters of similar suggestions and prioritised suggestions for service optimisation were identified. RESULT: The SLPs and managers proposed 73 and 51 unique suggestions respectively. Six clusters were identified for each group, with similar themes suggesting agreement of service improvements. All clusters were rated as more important than changeable. The managers perceived services as easier to change. The SLPs and managers rated 37% (27/73) and 43% (22/51) of suggestions, respectively, as high priority, with similarities relating to workforce capacity and capability, support and services access, care transitions, and telehealth services. CONCLUSION: Prioritised enhancements identified by SLPs and managers provide direction for dysphagia service optimisation in Singapore.

A systematic review of synchronous telepharmacy service models for adult outpatients with cancer.

BACKGROUND: Telephone and videoconsults are known synchronous telepharmacy modalities being used to respond to the demand for outpatient pharmacy services. However, little is known about the evidence for cancer telepharmacy service models. OBJECTIVES: To review existing evidence regarding synchronous telepharmacy service models for adult outpatients with cancer, with a secondary focus on outcomes, enablers, and barriers. METHODS: A PROSPERO registered systematic review was conducted using PubMed, CINAHL, and EMBASE in March 2023. Key search terms included pharmacy, telepharmacy, and outpatient. During article selection in Covidence, an extra inclusion criterion of synchronous cancer-focused services was applied; data extraction and narrative analysis were then performed. RESULTS: From 2129 non-duplicate articles, 8 were eligible for inclusion, describing 7 unique patient populations. The service models included pre-treatment medication history taking, adherence monitoring, toxicity assessment, and discharge follow-up. Studies found synchronous telepharmacy services can improve timeliness of care, optimise workload management, and provide individualised and convenient efficacy monitoring and counselling. One study of 177 patients on immune checkpoint inhibitors found 38% of the 726 telephone consults involved at least one intervention. When videoconsults were compared directly with telephone consults for pre-treatment medication history, it was found scheduled videoconsults had a significantly higher success rate than unscheduled telephone consults, and that videoconsults also represented increased funding and equivalent time efficiency. When telephone follow-up was compared to no follow-up, improved treatment adherence was seen, and progression-free survival was significantly higher for the telephone group (6.1 months vs 3.7 months, p = 0.001). Reported enablers included physician buy-in, staff resources, and correct utilisation of technology, while identified barriers included time investment required and technical issues. CONCLUSION: Both telephone and videoconsult modalities are being used to deliver synchronous telepharmacy services across a range of outpatient services. Although more evidence is needed, data to date supports positive service benefits and enhanced care.

Dysphagia Management in the Emergency Department: Using Concept Mapping to Identify Actionable Change to Improve Services.

BACKGROUND: Integrated speech-language pathology (SLP) services within the emergency department (ED) may facilitate timely dysphagia management. However, there are multiple patient and logistical factors specific to the ED that challenge the delivery of optimal dysphagia referral and management practices within this setting. The aim of the current study was to engage a stakeholder group to identify prioritised, actionable goals that could help enhance dysphagia management within the ED. METHODS AND PROCEDURES: Applying concept mapping methodology, 16 ED stakeholders from SLP, medical, nursing, and leadership participated in semi-structured interviews to develop action statements which were sorted and ranked for importance and changeability. Multidimensional scaling and hierarchical cluster analysis were used to organise data in clusters with unifying themes before statements were ranked by importance and changeability. OUTCOMES AND RESULTS: Stakeholders identified 53 unique statements, grouped into 8 clusters. Review of the 8 clusters identified 3 overarching aspects for change: (a) Improving processes related to identification and referral of patients as well as communication; (b) Teamwork and collaboration amongst the ED multidisciplinary team and SLP; and (c) Improving staffing and access to training resources for SLP and nursing teams. Seventeen statements were within the Go-zone rated highest for importance and changeability) with the highest rated statement being: Clear documentation by SLP re: recommendations. CONCLUSION: The current data identified multiple aspects of service provision that require change to facilitate improved dysphagia referral and management services in the ED. Collaborative actions are required by both SLP and the ED multidisciplinary team to help optimise dysphagia services.

Nature and timeliness of dysphagia management within an emergency setting.

PURPOSE: To examine referral pathways, clinical demographics, and timeliness of dysphagia management within an emergency department (ED) setting utilising both ED staff and speech-language pathology (SLP) initiated referral pathways. METHOD: Six-month retrospective service review of patients who received dysphagia assessment by SLP within a major Australian ED. Data were collected on demographics, referral information, and SLP assessment and service outcomes. RESULT: Three hundred and ninety-three patients were assessed by SLP staff in the ED, consisting of 200 stroke and 193 non-stroke referrals. In the stroke cohort, 57.5% of referrals were initiated by ED staff, while 42.5% were SLP initiated. ED staff initiated 91% of non-stroke referrals, with few (9%) proactively identified by SLP staff. SLP staff identified a higher proportion of non-stroke patients within 4 hr of presentation compared to ED staff. Stroke patients identified by SLP staff were more likely to have assessments completed within 8 hr compared to the ED referral pathway. Collectively, 51% of patients required ongoing dysphagia management following initial assessment. CONCLUSION: Findings provide an overview of SLP services and referral pathways in an ED context. The SLP initiated referral pathway facilitated early assessment of stroke patients, and collaboration with ED staff was integral in referring other at risk populations. SLP/ED synergy is needed for appropriate and timely dysphagia management practices in an ED.

Feeding Characteristics in Children With Food Allergies: A Scoping Review.

BACKGROUND: Food allergy (FA) affects approximately 8% of children and may be immunoglobulin E (IgE)-mediated or non-IgE-mediated. It is recognized clinically that children with both subtypes of FA may present with features of pediatric feeding disorder (PFD); however, there is currently a limited detail of presenting characteristics. OBJECTIVE: The objective of this study was to synthesize the current evidence regarding the feeding characteristics of children with FA, with a focus on the feeding skills and psychosocial domains of PFD. METHOD: This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. Papers published between 2001 and 2022 describing feeding characteristics in the feeding skills and psychosocial domains in children with FA/history of FA were included. Papers that focused solely on characteristics from the medical or nutritional domains were excluded. Descriptive information regarding demographics, methodology, allergy profile and history, and the characteristics of PFD observed was extracted using a preconceived data extraction form. RESULTS: Overall, 40 papers contained descriptions of feeding characteristics of children with non-IgE-mediated FA (n = 22) and IgE-mediated FA (n = 11), while four were nonspecific. In the psychosocial domain, food refusal/aversion, anxiety with eating, and poor intake were the most frequently reported, regardless of FA subtype. Less information was reported regarding feeding skills, although slowness in eating, immature diet, and delays in oral sensory-motor skills were described. CONCLUSIONS: Children with FA/history of FA may present with a range of characteristics that map across the feeding skill and psychosocial domains of PFD. Systematic research is needed to fully describe the feeding characteristics of children with FA. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.24562732.

Patient and multidisciplinary health professional perceptions of an Australian geriatric evaluation and management and rehabilitation hospital in the home service.

OBJECTIVES: Hospital in the Home models are rapidly expanding in response to increasing bed pressures. This study examined patient and multidisciplinary health professional perceptions of a new geriatric evaluation and management and rehabilitation hospital in the home service in Australia. The service was unique, as adults of all ages with a variety of rehabilitation or geriatric evaluation and management needs were within scope. METHODS: A qualitative descriptive approach was used with a consumer co-researcher and a consumer advisor being integral to decision-making. Patient feedback was collected via a paper-based patient satisfaction survey between August 2020 and February 2022. Additionally, interviews with current and past staff were conducted from July to November 2021. Reflexive thematic analysis was conducted for qualitative data and descriptive statistics used for quantitative data. RESULTS: Patient surveys were analysed (n = 199, 42.2% response rate) with 60.8% of participants aged 75 years or over and 26.6% speaking a language other than English. High satisfaction was expressed. Feelings of comfort, familiarity, convenience, and reassurance were voiced. A person-centred approach enhanced involvement in care. Challenges included carer burden and clear communication. Sixteen staff (33% response rate) were interviewed. In general, staff said the service was inclusive and responsive, and the home environment beneficial, particularly for patients from culturally diverse backgrounds. A strong hospital partnership and comprehensive multidisciplinary approach were vital. Challenges included fragmentation due to part-time roles and combining with a pre-existing acute hospital in the home service. CONCLUSIONS: This qualitative exploration of staff and patients' perceptions of a geriatrician-led, multidisciplinary geriatric evaluation and management and rehabilitation hospital in the home service demonstrated that it was person-centred and optimised patients' control and ownership of care. The inclusive service parameters ensured responsiveness to diverse needs whilst allowing earlier return home from hospital, both of which are vital for quality patient care.

Speech pathology assessment of dysphagia post endotracheal extubation: A service-model evaluation.

BACKGROUND: As postextubation dysphagia (PED) is correlated with pneumonia, feeding-tube placement, and in-hospital mortality, early identification is paramount. Endotracheal intubation duration of ≥48 h is independently predictive for PED. Therefore, a blanket intensive care unit (ICU) referral protocol was implemented to conduct PED assessment of patients intubated for ≥48 h. OBJECTIVES: The objective of this study was to review outcomes of an established blanket referral model for PED assessment in patients intubated for ≥48 h. Outcomes of the model were examined over a 2-year period (June 2015-June 2017) for (i) numbers and clinical characteristics of patients meeting criteria and referred for speech pathology (SP) assessment; (ii) frequency identified with PED on clinical swallow examination; (iii) severity and duration of PED; and (iv) SP management within the ICU. RESULTS: There was 96% adherence to the pathway with 108 participants (68% male) assessed. Median intubation duration was 142 h (mode = 61; interquartile range [IQR] = 131.75), and median ICU admission was 9 days (mode = 8; IQR = 6.75). SP referral occurred at a median of 19.5 h (mode = 4; IQR = 18.75) after extubation. Dysphagia assessment occurred at a median of 22 h (mode = 4; IQR = 19), with 34% assessed on the same day and 77% within 24 h of extubation. PED was observed in 89%, with 26% exhibiting profound PED. Dysphagia recovery occurred at a median of 7 days (mode = 2; IQR = 11). Dysphagia severity was associated with duration to swallow recovery (p = 0.001). A median of two occasions of service and 90 min clinical time was spent by the speech pathologist in the ICU. CONCLUSION: The blanket referral model enabled timely triage and assessment of dysphagia in a patient cohort at high risk of PED in our facility.

Examining the Outcomes of Project ECHO® as an Interprofessional Community of Practice for Pediatric Feeding Clinicians.

Project ECHO® is a virtual, interprofessional, cased-based peer-learning model. To date, no studies have explored ECHO as a model for pediatric feeding education. This study examined the outcomes of establishing a pediatric feeding ECHO network. Using a prospective, mixed-methods design, two cohorts of allied health professionals were recruited. Each cohort participated in eight, 90-min videoconference sessions incorporating a didactic presentation and clinical case presentation. The case was presented by a participant, with questions and recommendations provided by the ECHO network. Participants completed: (1) a learning needs analysis before the ECHO series, (2) a self-reported confidence questionnaire pre, post, and 3-month post, (3) a satisfaction questionnaire after each session, and (4) an overall satisfaction questionnaire post-ECHO series. Time spent by hospital allied health clinicians providing impromptu phone/email feeding support to external clinicians was recorded for 8 weeks prior to and 8 weeks during the ECHO series. Forty-seven participants were included in the study, attending an average of 5.8 sessions. Significant improvements in self-reported confidence were observed across the three time points (p < 0.01) with less experienced participants demonstrating greater improvements. Participants reported high satisfaction with ECHO, with 93% (40/43) wanting continued access to ECHO in future. The multidisciplinary format, interactivity, structure, and case-based nature of ECHO were considered beneficial. A 75% reduction in requests for support from clinicians in the same catchment area was noted during the ECHO series. Results demonstrated that Project ECHO is a viable model for pediatric feeding education for clinicians working in the field. Further research is needed to investigate the long-term effects and impacts on clinical care.

Implementing flexible endoscopic evaluation of swallow screening within annual cancer surveillance appointments to monitor for late-stage radiation-induced dysphagia: A feasibility study.

BACKGROUND: Late-stage progressive decline of swallowing function after radiotherapy for head and neck cancer (HNC) is often difficult to monitor. This study examined the feasibility and clinical outcomes of speech-language pathology implementing flexible endoscopic evaluation of swallow (FEES) screening during annual cancer surveillance visits to monitor late-stage swallowing function. METHODS: Patients >2 years post treatment who attended routine oncological visits underwent FEES screening. Feasibility (service data, stakeholder survey) and swallowing outcomes (oral intake, secretions, internal lymphedema, penetration-aspiration, and residue) were collected. RESULTS: Screening was completed with 70% (50/71) of eligible patients. Medical staff and speech-language pathologists indicated the protocol was worthwhile and achievable to incorporate into practice. Almost all patients were willing to complete the protocol annually. FEES outcomes identified 84% with dysphagia versus only 26% self-reported dysphagia. CONCLUSION: Findings indicate FEES screening incorporated into annual oncological reviews is feasible and effective at monitoring late-stage swallowing function following HNC.

Identifying prioritised actions for improving dysphagia services in Singapore: Insights from concept mapping with patients and caregivers.

BACKGROUND: Person-centred services are inherently related to patients/caregivers' needs. However, the extent to which dysphagia services within Singapore meet consumer needs is largely unknown. Involving patients/caregivers in service evaluation/redesign deepens the understanding of consumer needs. This process also increases the success of implementing service enhancements through relevant and meaningful change. AIM: This study aimed to identify aspects of dysphagia services, within acute and subacute settings in Singapore, perceived as highly important and easy to change by patients/caregivers. METHODS & PROCEDURES: Using concept mapping methodology, 5 patients and 11 caregivers reflected on their experiences of receiving dysphagia care and proposed 59 unique suggestions to improve dysphagia services within Singapore. Then, each individual sorted the suggestions into groups based on similarity and rated each statement for its perceived importance and changeability for service enhancement. Data were analysed using multidimensional scaling, hierarchical cluster analysis, and bivariate analysis to generate clusters of conceptually similar suggestions and a prioritised list of suggestions for service enhancement. RESULTS: Twelve clusters were identified, with most rated as more important than changeable for service improvement. Participants prioritised 23 (39%) of the suggestions as highly important and easy to change, and these focused on ensuring effective communication among consumers and healthcare team, enhancing patients and carers' access to support at home, increasing patients and carers' access to educational resources, and improving service quality and access through technology. CONCLUSION: These findings provide future directions on how to develop and implement dysphagia services in Singapore to better meet the needs of patients/caregivers. WHAT THIS PAPER ADDS: What is already known on this subject Little is known about patients and caregivers' experiences and expectations of receiving dysphagia services in Singapore. Consulting them in service review and improvement deepens understanding of their needs and increases the success of implementing meaningful service enhancements. What this study adds to existing knowledge This study shows that patients and caregivers in Singapore identified a wide range of dysphagia service issues and prioritised a list of suggestions for service improvement. They prioritised four key areas for service optimisation: ensuring effective communication among consumers and healthcare team, enhancing patients and carers' access to support at home, increasing patients and carers' access to educational resources, and improving service quality and access through technology. What are the clinical implications of this work? This research highlights the importance of considering the consumers' perspectives in service review and redesign. Patients and caregivers in Singapore identified four prioritised areas for service enhancements. These findings provide future directions on how to develop and implement dysphagia services in Singapore to better meet the needs of patients and caregivers.

Outcomes of a first point of contact speech language therapy clinic for patients requiring vocal cord check pre and post thyroid/parathyroid surgery.

INTRODUCTION: Speech Language Therapy First Point of Contact Clinic (SLT-FPOCC) models can assist assessment of low-risk patient populations referred to ear, nose and throat (ENT) services. To further improve ENT waitlist management and compliance with best-practice care, consideration of other low-risk populations that could be safely managed through this service model is needed. The aims of this paper are to evaluate the clinical and service outcomes of completing vocal cord check (VCC) assessments for patients' pre and post thyroid/parathyroid surgery within an SLT-FPOCC model and examine consumer perceptions. METHODS & PROCEDURES: The service followed existing SLT-FPOCC procedures, with ENT triaging referrals, then SLT completing pre- and postoperative VCC assessment (interview, perceptual assessment, flexible nasendoscopy), with assessment data later reviewed by ENT to diagnose laryngeal pathology. Clinical and service outcomes were collected prospectively. Patients completed an anonymous post-service satisfaction survey. RESULTS: Of the first 100 patients referred for preoperative VCCs, SLT assessment identified 42 with dysphonia and 30 reporting dysphagia, while ENT confirmed 9 with significant preoperative anatomical findings. Eighty-three underwent surgery, with 63 (95 nerves at surgical risk) returning for a postoperative VCC. Postoperative VCC identified three temporary neuropraxias (3.2%) and three unilateral vocal fold paresis (3.2%). Patients were highly satisfied with the service. All 163 pre-/postoperative VCCs were completed with no adverse events. CONCLUSION & IMPLICATIONS: The current data support SLT-FPOCC service expansion to include pre and post thyroid/parathyroid surgery VCC checks, with positive consumer perception. The model supports delivery of best practice management (i.e., pre- and postoperative VCC) for patients receiving surgery for thyroid/parathyroid dysfunction, and associated efficiencies for ENT services. WHAT THIS PAPER ADDS: What is already known Assessment of laryngeal function via flexible nasoendoscopy is recommended best practice for patients pre and postthyroid/parathyroid surgery, as recurrent laryngeal nerve injury is a low incidence (<10%), yet well-recognised risk of these surgeries. Traditionally, general surgeons refer presurgical patients to ear, nose and throat (ENT) for vocal cord check (VCC) assessment. However, with access to specialist outpatient services under increasing pressure, there is growing support for utilisation of other health professionals, such as speech-language therapists working in first point of contact (FPOCC) models, to assist with the administration of pre- and postsurgical assessments of such low-risk populations. What this study adds This work expands on the emerging body of evidence for speech language therapy (SLT) led FPOCC models within ENT outpatient services, providing clinical and service outcomes to support the safety of a new model designed to administer VCCs for patients pre and post thyroid/parathyroid surgery. Adopting a similar model to a prior published SLT-led FPOCC model, the trained SLT completes the pre- and postsurgical VCC including flexible nasoendoscopy and videostroboscopy, with images and clinical information then presented to ENT for diagnosis and management planning. This study also provides the first data on consumer perceptions of this type of service model. Clinical implications of this study Data on 100 consecutive presurgical patients revealed positive service findings, supporting the safety of this model. Nature and incidence of clinical findings pre and post surgery were consistent with previously published studies using traditional models of care (i.e., ENT completing the flexible nasendoscopy). Consumer perception was positive. This model enables delivery of pre-and postsurgical assessments for patients receiving thyroid/parathyroid surgery, consistent with best practice care, and reduces burden on ENT services. In total 163 ENT appointments were avoided with this model, with positive implications for ENT waitlist management.

The tumor microenvironment state associates with response to HPV therapeutic vaccination in patients with respiratory papillomatosis.

Recurrent respiratory papillomatosis (RRP) is a rare, debilitating neoplastic disorder caused by chronic infection with human papillomavirus (HPV) type 6 or 11 and characterized by growth of papillomas in the upper aerodigestive tract. There is no approved medical therapy, and patients require repeated debulking procedures to maintain voice and airway function. PRGN-2012 is a gorilla adenovirus immune-therapeutic capable of enhancing HPV 6/11-specific T cell immunity. This first-in-human, phase 1 study (NCT04724980) of adjuvant PRGN-2012 treatment in adult patients with severe, aggressive RRP demonstrates the overall safety and clinically meaningful benefit observed with PRGN-2012, with a 50% complete response rate in patients treated at the highest dose. Responders demonstrate greater expansion of peripheral HPV-specific T cells compared with nonresponders. Additional correlative studies identify an association between reduced baseline papilloma HPV gene expression, greater interferon responses and expression of CXCL9 and CXCL10, and greater papilloma T cell infiltration in responders. Conversely, nonresponders were characterized by greater HPV and CXCL8 gene expression, increased neutrophilic cell infiltration, and reduced T cell papilloma infiltration. These results suggest that papilloma HPV gene expression may regulate interferon signaling and chemokine expression profiles within the tumor microenvironment that cooperate to govern clinical response to therapeutic HPV vaccination in patients with respiratory papillomatosis.

Research Recommendations for Selected IARC-Classified Agents: Impact and Lessons Learned.

BACKGROUND: The International Agency for Research on Cancer (IARC) Monographs program assembles expert working groups who publish a critical review and evaluation of data on agents of interest. These comprehensive reviews provide a unique opportunity to identify research needs to address classification uncertainties. A multidisciplinary expert review and workshop held in 2009 identified research gaps and needs for 20 priority occupational chemicals, metals, dusts, and physical agents, with the goal of stimulating advances in epidemiological studies of cancer and carcinogen mechanisms. Overarching issues were also described. OBJECTIVES: In this commentary we review the current status of the evidence for the 20 priority agents identified in 2009. We examine whether identified Research Recommendations for each agent were addressed and their potential impact on resolving classification uncertainties. METHODS: We reviewed the IARC classifications of each of the 20 priority agents and identified major new epidemiological and human mechanistic studies published since the last evaluation. Information sources were either the published Monograph for agents that have been reevaluated or, for agents not yet reevaluated, Advisory Group reports and literature searches. Findings are described in view of recent methodological developments in Monographs evidence evaluation processes. DISCUSSION: The majority of the 20 priority agents were reevaluated by IARC since 2009. The overall carcinogen classifications of 9 agents advanced, and new cancer sites with either "sufficient" or "limited" evidence of carcinogenicity were also identified for 9 agents. Examination of published findings revealed whether evidence gaps and Research Recommendations have been addressed and highlighted remaining uncertainties. During the past decade, new research addressed a range of the 2009 recommendations and supported updated classifications for priority agents. This supports future efforts to systematically apply findings of Monograph reviews to identify research gaps and priorities relevant to evaluation criteria established in the updated IARC Monograph Preamble. https://doi.org/10.1289/EHP12547.