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Joshua Barnett,1 Sofia Pappa1,2 1Department of Mental Health, West London NHS Trust, London, UK; 2Department of Brain Sciences, Imperial College London, London, UKCorrespondence: Joshua Barnett, Department of Mental Health, West London NHS Trust, 43– 47 Avenue Road, London, W38NJ, UK, Tel +44 20 84831792, Email joshua.barnett2@nhs.netIntroduction: Poor adherence to antipsychotic medication is common in the treatment of schizophrenia and other psychotic disorders. Paliperidone palmitate 3-monthly (PP3M) is the first long-acting injectable (LAI) antipsychotic to allow for only four medication administrations per year, and although there is sufficient information available about the clinical effects, there is relatively limited insight into the subjective experience of people with lived experience.Methods: This descriptive, cross-sectional survey explored patient’s satisfaction and perspectives on the advantages and disadvantages of switching from monthly to 3-monthly paliperidone while also reporting on perceived levels of safety with regard to the reducing dose regimen during the Covid-19 pandemic. Information on discontinuation and hospitalisation rates at one year was also collected from the electronic records.Results: Of the 46 patients included in the study, the vast majority reported feeling satisfied (89.2%) and safer (93.5%) after switching to the three-monthly formulation. Participants highlighted several advantages of changing to PP3M, most notably convenience (93.5%), improved quality of life (58.7%), decreased stigma (39.1%) and better adherence (28.3%). Furthermore, 93.5% of respondents experienced no disadvantages, while 6.5% described worsening side effects or symptoms. In fact, only one patient discontinued PP3M at one year with the overall number of hospitalisations also reducing in the same period compared to the year before switching.Discussion: Our findings add to the small, but growing, body of evidence supporting patient satisfaction and acceptance with the use of PP3M and may reinforce the use of less frequent LAIs in clinical practice to enhance individual experience and treatment persistence and decrease levels of stigmatisation.Keywords: schizophrenia, paliperidone, long-acting injectable, patient satisfaction

Alan W Kong,1 Tessnim R Ahmad,2 Marcus L Turner,1 Jackson Barnett,1 Gurbani Kaur,1 Neel D Pasricha,2,3 Maanasa Indaram2 1School of Medicine, University of California San Francisco, San Francisco, CA, USA; 2Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA; 3Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA, USACorrespondence: Maanasa Indaram, Department of Ophthalmology, University of California San Francisco, 490 Illinois Street, San Francisco, CA, 94158, USA, Email maanasa.indaram@ucsf.eduPurpose: To describe trends in the use of corneal topography and tomography for the management of keratoconus patients at a single academic institution and to identify how these trends may be associated with different procedural interventions.Patients and Methods: In this retrospective cohort study, keratoconus patients treated from 2012 to 2019 were identified. The electronic health record was reviewed for the presence of corneal topography or tomography imaging completed within seven days of the first visit and the highest level of intervention at the first and most recent visit. Patients were grouped as pediatric (< 18 years) or adult (≥ 18 years). Chi-square tests and linear regressions were used to evaluate trends and to determine which factors were predictive for receiving corneal collagen cross-linking (CXL) versus other surgical interventions (intrastromal corneal ring segments, lamellar keratoplasty, or penetrating keratoplasty) by the most recent visit.Results: A total of 873 keratoconus patients met inclusion criteria. The use of corneal topography at the first visit remained relatively consistent from 2012 to 2019, while corneal tomography usage at the first visit increased from 3.9% in 2015, when corneal tomography was introduced, to 52.8% in 2019. Each year was associated with an 11.2% ± 1.9% increase in the use of corneal tomography at the first visit in pediatric patients and 6.7% ± 0.5% in adult patients. Use of corneal tomography at the first visit was a significant predictor for receiving CXL procedures (P < 0.001) and a negative predictor for requiring other surgical interventions (P = 0.032) when controlling for the year of the first visit.Conclusion: Obtaining corneal tomography at the first visit has become the standard of care in keratoconus, especially for pediatric patients. Moreover, the increase in corneal tomography imaging has coincided with an increase in CXL procedures and decrease in other surgical interventions.Keywords: keratoconus, topography, tomography, corneal collagen cross-linking, keratoplasty

Quincy K Tran,1,2 Jeremy Barnett,3 Francis O’Connell,3 Brian D’Anza,4 Ali Pourmand3 1Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; 2Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA; 3Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA; 4Department of Otolaryngology - Head and Neck Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USACorrespondence: Quincy K Tran Email qtran@som.umaryland.eduAbstract: We performed a narrative review of epistaxis management in the emergency department. First, we examined the pathophysiology, the current types of treatment that are available to emergency clinicians. When nasal packing is indicated, we examined the efficacy of nasal packing in addition to other topical treatment such as tranexamic acid and the evidence of prophylactic antibiotics. We detailed current studies involving tranexamic acid and prophylactic antibiotics for nasal packing. Finally, we introduced an epistaxis clinical care pathway, based on current evidence, to aid emergency clinicians with their clinical decision-making processes.Keywords: epistaxis, tranexamic acid, nasal packing, clinical care pathway

Alessandra N Bazzano,1 Lauren Cenac,1 Amelia J Brandt,1 Josephine Barnett,2 Shelley Thibeau,3 Katherine P Theall1 1Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, 2City University of New York, CUNY Graduate Center, New York, NY, 3Ochsner Clinic Foundation, New Orleans, LA, USA Abstract: An increase in the marketing and use of herbal galactagogues among breastfeeding mothers in the US has raised the issue of how best to provide support and information on the use of these products, particularly in light of limited availability of certified lactation counselors and continued suboptimal rates of breastfeeding globally. Currently, no cross-sectional data are available on the experiences and attitudes of mothers regarding the use of herbal and pharmaceutical galactagogues for lactation in the US. The findings of an online survey of 188 breastfeeding mothers on experiences with and sources of information on galactagogues are presented. Most mothers (76%) reported that while breastfeeding, they felt as though they were not making enough milk to meet the needs of their child, and yet 54% also indicated that they had not supplemented with formula. A large proportion of respondents reported utilizing galactagogues to increase lactation and finding them useful. The results indicated that most women learned about galactagogues from the Internet or by word of mouth through friends. Lactation consultants were the third-most reported sources of information on these products. While many respondents reported perceiving galactagogues as innocuous, more evidence on safety and efficacy is needed to support women properly who seek out and use them. Large-scale studies of the prevalence of galactagogue use in the US and rigorous evaluation of use globally are needed to ensure that mothers who choose to breastfeed may safely avail themselves of all options when counseling support is insufficient. Keywords: galactagogue, breastfeeding, lactation, lactation support

Syed Ghulam Sarwar Shah,1 Julie Barnett,1 Jasna Kuljis,2 Kate Hone,2 Richard Kaczmarski31Multidisciplinary Assessment of Technology Centre for Healthcare, 2Department of Information Systems and Computing, Brunel University London, Uxbridge, Middlesex, UK; 3Department of Haematology, Hillingdon Hospital, Uxbridge, Middlesex, UKPurpose: To identify factors that determine patients' intentions to use point-of-care medical devices, ie, portable coagulometer devices for self-testing of the international normalized ratio (INR) required for ongoing monitoring of blood-coagulation intensity among patients on long-term oral anticoagulation therapy with vitamin K antagonists, eg, warfarin.Methods: A cross-sectional study that applied the technology-acceptance model through a self-completed questionnaire, which was administered to a convenience sample of 125 outpatients attending outpatient anticoagulation services at a district general hospital in London, UK. Data were analyzed using descriptive statistics, factor analyses, and structural equation modeling.Results: The participants were mainly male (64%) and aged ≥ 71 years (60%). All these patients were attending the hospital outpatient anticoagulation clinic for INR testing; only two patients were currently using INR self-testing, 84% of patients had no knowledge about INR self-testing using a portable coagulometer device, and 96% of patients were never offered the option of the INR self-testing. A significant structural equation model explaining 79% of the variance in patients’ intentions to use INR self-testing was observed. The significant predictors that directly affected patients' intention to use INR self-testing were the perception of technology (β = 0.92, P < 0.001), trust in doctor (β = −0.24, P = 0.028), and affordability (β = 0.15, P = 0.016). In addition, the perception of technology was significantly affected by trust in doctor (β = 0.43, P = 0.002), age (β = −0.32, P < 0.001), and affordability (β = 0.23, P = 0.013); thereby, the intention to use INR self-testing was indirectly affected by trust in doctor (β = 0.40), age (β = −0.29), and affordability (β = 0.21) via the perception of technology.Conclusion: Patients’ intentions to use portable coagulometers for INR self-testing are affected by patients' perceptions about the INR testing device, the cost of device, trust in doctors/clinicians, and the age of the patient, which need to be considered prior to any intervention involving INR self-testing by patients. Manufacturers should focus on increasing the affordability of INR testing devices for patients’ self-testing and on the potential role of medical practitioners in supporting use of these medical devices as patients move from hospital to home testing.Keywords: oral anticoagulation, INR self-testing, technology-acceptance model, trust in doctor, home testing, affordability, structural equation modeling

Abstract Background Earlier diagnosis followed by multi-factorial cardiovascular risk intervention may improve outcomes in Type 2 Diabetes Mellitus (T2DM). Latent phase identification through screening requires structured, appropriately targeted population-based approaches. Providers responsible for implementing screening policy await evidence of clinical and cost effectiveness from randomised intervention trials in screen-detected T2DM cases. UK South Asians are at particularly high risk of abnormal glucose tolerance and T2DM. To be effective national screening programmes must achieve good coverage across the population by identifying barriers to the detection of disease and adapting to the delivery of earlier care. Here we describe the rationale and methods of a systematic community screening programme and randomised controlled trial of cardiovascular risk management within a UK multiethnic setting (ADDITION-Leicester). Design A single-blind cluster randomised, parallel group trial among people with screen-detected T2DM comparing a protocol driven intensive multi-factorial treatment with conventional care. Methods ADDITION-Leicester consists of community-based screening and intervention phases within 20 general practices coordinated from a single academic research centre. Screening adopts a universal diagnostic approach via repeated 75g-Oral Glucose Tolerance Tests within an eligible non-diabetic population of 66,320 individuals aged 40-75 years (25-75 years South Asian). Volunteers also provide detailed medical and family histories; complete health questionnaires, undergo anthropometric measures, lipid profiling and a proteinuria assessment. Primary outcome is reduction in modelled Coronary Heart Disease (UKPDS CHD) risk at five years. Seven thousand (30% of South Asian ethnic origin) volunteers over three years will be recruited to identify a screen-detected T2DM cohort (n = 285) powered to detected a 6% relative difference (80% power, alpha 0.05) between treatment groups at one year. Randomisation will occur at practice-level with newly diagnosed T2DM cases receiving either conventional (according to current national guidelines) or intensive (algorithmic target-driven multi-factorial cardiovascular risk intervention) treatments. Discussion ADDITION-Leicester is the largest multiethnic (targeting >30% South Asian recruitment) community T2DM and vascular risk screening programme in the UK. By assessing feasibility and efficacy of T2DM screening, it will inform national disease prevention policy and contribute significantly to our understanding of the health care needs of UK South Asians. Trial registration Clinicaltrial.gov (NCT00318032).

Novel metal oxide films and new metal gates are currently being developed for future generations of Si based field-effect transistors as the SiO2 gate dielectric and polycrystalline Si gate electrode are reaching scaling limits. These gate stacks are often comprised of sub-nanometer layers. Device properties are increasingly controlled by the complex structure and chemistry of interfaces between the layers. Electron energy-loss spectroscopy (EELS) in scanning transmission electron microscopy (STEM) is capable of providing insights into interfacial chemistry and local atomic structure with a spatial resolution unmatched by any other technique. Using gate stacks with Hf-silicate dielectrics as examples, we demonstrate the capabilities of STEM/EELS for analyzing the interfacial chemistry of novel gate stacks. We show that a priori unknown reaction layers of a few A thickness can be detected and identified even in the presence of substantial interfacial roughness that may obscure such layers in a high-resolution image. We discuss some experimental aspects of STEM/EELS chemical profiling applied to gate stacks and the factors affecting the interpretation. In particular, the effects of interfacial roughness, beam spreading, elemental analysis in a heavily scattering matrix, and the interpretation of the EELS core-loss fine-structures from ultrathin layers are discussed. (c) 2004 Elsevier B.V. All rights reserved.