Flow Mediated Dilatation and Progression of Abdominal Aortic Aneurysms

Objective/Background

Biomarker(s) for prediction of the future progression rate of abdominal aortic aneurysms (AAA) may be useful to stratify the management of individual patients. AAAs are associated with features of systemic inflammation and endothelial dysfunction. Flow mediated dilatation (FMD) of the brachial artery is a recognised non-invasive measurement for endothelial function. We hypothesised that FMD is a potential biomarker of AAA progression and reflects the temporal changes of endothelial function during AAA progression.

Methods

In a prospectively recruited cohort of patients with AAAs (Oxford Abdominal Aortic Aneurysm Study), AAA size was recorded by antero-posterior diameter (APD) (outer to outer) on ultrasound. Annual AAA progression was calculated by (ΔAPD/APD at baseline)/(number of days lapsed/365 days). FMD was assessed at the same time as AAA size measurement. Analyses of data were performed in the overall cohort, and further in subgroups of AAA by size (small: 30–39 mm; moderate: 40–55 mm; large: > 55 mm).

Results

FMD is inversely correlated with the diameter of AAAs in all patients (n = 162, Spearman’s r = −.28, p < .001). FMD is inversely correlated with AAA diameter progression in the future 12 months (Spearman’s r = −.35, p = .001), particularly in the moderate size group. Furthermore, FMD deteriorates during the course of AAA surveillance (from a median of 2.0% at baseline to 1.2% at follow-up; p = .004), while surgical repair of AAAs (n = 50 [open repair n = 22, endovascular repair n = 28)] leads to an improvement in FMD (from 1.1% pre-operatively to 3.8% post-operatively; p < .001), irrespective of the type of surgery.

Conclusion

FMD is inversely correlated with future AAA progression in humans. FMD deteriorates during the natural history of AAA, and is improved by surgery. The utility of FMD as a potential biomarker in the context of AAA warrants further investigation.

Evaluating the role of soluble aluminum in manganese removal via MnOx(s)-coated filtration media in drinking water treatment

The Mn oxide (MnO_x(s)) surfaces of water treatment filtration media are known to aid in the capture of dissolved Mn species, but the discovery of significant deposits of Al within these coatings (Tobiason et al., 2008) raised certain questions about the possible role of Al in soluble Mn removal and the formation of the MnO_x(s) surface on the media. This phenomenon was addressed by conducting a series of bench-scale column studies that involved the application of solutions containing varying amounts of soluble Al and Mn to MnO_x(s)-coated media. The experimental results confirmed that soluble Al was removed in significant amounts by adsorption onto the MnO_x(s) media surface. The deposition of soluble Al onto the media surface did not have any significant effect on its ability to remove soluble Mn. Likewise, the relative amounts of Al incorporated into the media coating suggested that uptake of soluble Al alone cannot fully explain the levels of Al often found in real-world, MnO_x(s)-coated filter media; instead, the incorporation of particulate forms of Al (routinely found in water treatment plant situations) must contribute to the formation of the MnO_x(s) coatings on these media.

Orthopaedic surgical site infection surveillance in NHS England: national audit of current practice

AIMS

The importance of accurate identification and reporting of surgical site infection (SSI) is well recognised but poorly defined. Public Health England (PHE) mandated collection of orthopaedic SSI data in 2004. Data submission is required in one of four categories (hip prosthesis, knee prosthesis, repair of neck of femur, reduction of long bone fracture) for one quarter per year. Trusts are encouraged to carry out post-discharge surveillance but this is not mandatory. Recent papers in the orthopaedic literature have highlighted the importance of SSI surveillance and the heterogeneity of surveillance methods. However, details of current orthopaedic SSI surveillance practice has not been described or quantified.

PATIENTS AND METHODS

All 147 NHS trusts in England were audited using a structured questionnaire. Data was collected in the following categories: data collection; data submission to PHE; definitions used; resource constraints; post-discharge surveillance and SSI rates in the four PHE categories. The response rate was 87.7%.

RESULTS

Variation in practice was clear in all categories in terms of methods and timings of data collection and data submission. There was little agreement on SSI definitions. At least six different definitions were used, some trusts using more than one definition. Post-discharge surveillance was carried out by 62% of respondents but there was again variation in both the methods and staff used. More than half of the respondents felt that SSI surveillance in their unit was limited by resource constraints. SSI rates ranged from 0% to 10%.

CONCLUSION

This paper quantifies the heterogeneity of SSI surveillance in England. It highlights the importance of adequate resourcing and the unreliability of relying on voluntary data collection and submission. Conformity of definitions and methods are recommended to enable meaningful SSI data to be collated. Cite this article: Bone Joint J 2017;99-B:171-4.

Metallosis following implantation of magnetically controlled growing rods in the treatment of scoliosis: a case series

AIMS

We present a case series of five patients who had revision surgery following magnetic controlled growing rods (MGCR) for early onset scoliosis. Metallosis was found during revision in four out of five patients and we postulated a mechanism for rod failure based on retrieval analysis.

PATIENTS AND METHODS

Retrieval analysis was performed on the seven explanted rods. The mean duration of MCGR from implantation to revision was 35 months (17 to 46). The mean age at revision was 12 years (7 to 15; four boys, one girl).

RESULTS

A total of six out of seven rods had tissue metallosis and pseudo-capsule surrounding the actuator. A total of four out of seven rods were pistoning. There were two rods which were broken. All rods had abrasive circumferential markings. A significant amount of metal debris was found when the actuators were carefully cut open. Analytical electron microscopy demonstrated metal fragments of predominantly titanium with a mean particle size of 3.36 microns (1.31 to 6.61).

CONCLUSION

This study highlights concerns with tissue metallosis in MCGR. We recommend careful follow-up of patients who have received this implant. Cite this article: Bone Joint J 2016;98-B:1662-7.

Representation of people of South Asian origin in cardiovascular outcome trials of glucose-lowering therapies in Type 2 diabetes

AIMS

Our aim was to investigate the proportional representation of people of South Asian origin in cardiovascular outcome trials of glucose-lowering drugs or strategies in Type 2 diabetes, noting that these are among the most significant pieces of evidence used to formulate the guidelines on which clinical practice is largely based.

METHODS

We searched for cardiovascular outcome trials in Type 2 diabetes published before January 2015, and extracted data on the ethnicity of participants. These were compared against expected values for proportional representation of South Asian individuals, based on population data from the USA, from the UK, and globally.

RESULTS

Twelve studies met our inclusion criteria and, of these, eight presented a sufficiently detailed breakdown of participant ethnicity to permit numerical analysis. In general, people of South Asian origin were found to be under-represented in trials compared with UK and global expectations and over-represented compared with US expectations. Among the eight trials for which South Asian representation could be reliably estimated, seven under-represented this group relative to the 11.2% of the UK diabetes population estimated to be South Asian, with the representation in these trials ranging from 0.0% to 10.0%.

CONCLUSIONS

Clinicians should exercise caution when generalizing the results of trials to their own practice, with regard to the ethnicity of individuals. Efforts should be made to improve reporting of ethnicity and improve diversity in trial recruitment, although we acknowledge that there are challenges that must be overcome to make this a reality.

Review of research grant allocation to psychosocial studies in diabetes research

AIMS

To estimate and discuss the allocation of diabetes research funds to studies with a psychosocial focus.

METHODS

Annual reports and funded-research databases from approximately the last 5 years (if available) were reviewed from the following representative funding organizations, the American Diabetes Association, the Canadian Diabetes Association, Diabetes Australia, Diabetes UK, the Dutch Diabetes Research Foundation and the European Foundation for the Study of Diabetes, in order to estimate the overall proportion of studies allocated research funding that had a psychosocial focus.

RESULTS

An estimated mean of 8% of funded studies from our sample were found to have a psychosocial focus.

CONCLUSIONS

The proportion of funded studies with a psychosocial focus was small, with an estimated mean ratio of 17:1 observed between funded biomedical and psychosocial studies in diabetes research. While several factors may account for this finding, the observation that 90% of funded studies are biomedical may be partly attributable to the methodological orthodoxy of applying biomedical reductionism to understand and treat disease. A more comprehensive and systemic whole-person approach in diabetes research that resembles more closely the complexity of human beings is needed and may lead to improved care for individuals living with diabetes or at risk of diabetes.

Use of programme budgeting and marginal analysis as a framework for resource reallocation in respiratory care in North Wales, UK

Background

Since the global financial crisis, UK NHS spending has reduced considerably. Respiratory care is a large cost driver for Betsi Cadwaladr University Health Board, the largest health board in Wales. Under the remit of ‘prudent healthcare’ championed by the Welsh Health Minister, a Programme Budgeting Marginal Analysis (PBMA) of the North Wales respiratory care pathway was conducted.

Methods

A PBMA panel of directors of medicines management, therapies finance, planning, public health and healthcare professionals used electronic voting to establish criteria for decision-making and vote on candidate interventions in which to disinvest and invest.

Results

A sum of £86.9 million was spent on respiratory care in 2012–13. Following extensive discussion of 13 proposed candidate interventions facilitated by a chairperson, 4 candidates received recommendations to disinvest, 7 to invest and 2 to maintain current activity. Marginal analysis prioritized mucolytics and high antibiotic prescribing as areas for disinvestment, and medicines waste management and pulmonary rehabilitation for investment.

Conclusions

This exercise demonstrates the potential for health boards to use evidence-based approaches to reach potentially controversial disinvestment and investment decisions. Initial progress has begun with communication from the Medical Director in relation to the disinvestment in mucolytics prescribing and possible redirection of funding options being explored.

Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer

BACKGROUND

Robust data on patient-reported outcome measures comparing treatments for clinically localized prostate cancer are lacking. We investigated the effects of active monitoring, radical prostatectomy, and radical radiotherapy with hormones on patient-reported outcomes.

METHODS

We compared patient-reported outcomes among 1643 men in the Prostate Testing for Cancer and Treatment (ProtecT) trial who completed questionnaires before diagnosis, at 6 and 12 months after randomization, and annually thereafter. Patients completed validated measures that assessed urinary, bowel, and sexual function and specific effects on quality of life, anxiety and depression, and general health. Cancer-related quality of life was assessed at 5 years. Complete 6-year data were analyzed according to the intention-to-treat principle.

RESULTS

The rate of questionnaire completion during follow-up was higher than 85% for most measures. Of the three treatments, prostatectomy had the greatest negative effect on sexual function and urinary continence, and although there was some recovery, these outcomes remained worse in the prostatectomy group than in the other groups throughout the trial. The negative effect of radiotherapy on sexual function was greatest at 6 months, but sexual function then recovered somewhat and was stable thereafter; radiotherapy had little effect on urinary continence. Sexual and urinary function declined gradually in the active-monitoring group. Bowel function was worse in the radiotherapy group at 6 months than in the other groups but then recovered somewhat, except for the increasing frequency of bloody stools; bowel function was unchanged in the other groups. Urinary voiding and nocturia were worse in the radiotherapy group at 6 months but then mostly recovered and were similar to the other groups after 12 months. Effects on quality of life mirrored the reported changes in function. No significant differences were observed among the groups in measures of anxiety, depression, or general health-related or cancer-related quality of life.

CONCLUSIONS

In this analysis of patient-reported outcomes after treatment for localized prostate cancer, patterns of severity, recovery, and decline in urinary, bowel, and sexual function and associated quality of life differed among the three groups. (Funded by the U.K. National Institute for Health Research Health Technology Assessment Program; ProtecT Current Controlled Trials number, ISRCTN20141297 ; ClinicalTrials.gov number, NCT02044172 .).

Telehealth: Acceptability, clinical interventions and quality of life in peritoneal dialysis

INTRODUCTION

Telehealth technologies are being widely adopted across the globe for management of long-term conditions. There are limited data on its use, effectiveness and patient experience in end-stage renal disease. The aim of this pilot project was to explore patient acceptability of technology and evaluate its effect on clinical interventions and quality of life in patients undergoing peritoneal dialysis.

METHODS

Peritoneal dialysis patients were provided with computer tablets (PODs). PODs contained a knowledge database with treatment- and symptom-based questionnaires that generated alerts for the clinical team. Alerts were reviewed daily and followed up by a telephone call or clinic visit. Interventions were at the discretion of clinicians. Data were recorded prospectively and quality of life and Quebec User Evaluation of Satisfaction with assistive Technology questionnaires evaluated at the start and end of the programme.

RESULTS

In all, 22 patients have participated over 15 months. The mean age was 61.6 years and PODs were utilised for an average of 341.9 days with 59.1% choosing to continue beyond the study period. We received a total of 1195 alerts with an average of 2.6 alerts per day. A total of 36 admissions were avoided and patients supported to self-manage on 154 occasions. Quebec User Evaluation of Satisfaction with assistive Technology scores remained high throughout the programme although no improvement in quality of life was seen.

DISCUSSION

Telehealth is useful to monitor patients with renal failure on peritoneal dialysis. It is acceptable across age groups and provides an additional resource for patients to self-manage. Satisfaction scores and retention rates suggest a high level of acceptability.

Ultrasound Practitioner Master's Degree Curriculum and Questionnaire Response by the SDMS Membership

Following publication of the ultrasound practitioner (UP) master's degree educational proposal in August 1999, the UP Commission published a questionnaire to obtain feedback from SDMS membership to the UP concept. This article contains the results of that data collection. Additionally, as progress has been made in the development of UP programs around the country, refinement of the curriculum, as originally proposed, has begun. This article contains a breakdown of required didactic and clinical education for the midlevel provider in diagnostic ultrasound.

Effect of recommended positioning on stroke outcome at six months: a randomized controlled trial

Objective: To evaluate the effect on patient outcome of a teaching package for nurses designed to improve the positioning of stroke patients.

Design: Cluster randomized controlled trial with six-month follow-up.

Setting: Ten stroke rehabilitation hospital units located within one UK inner city region. These were randomized to control or intervention group.

Subjects: A sample of 120 patients admitted within four weeks of a first stroke and with a hemiplegia. No eligible patient refused to participate. Eighty-three (69%) completed the study.

Intervention: All nursing staff on the intervention units received a group teaching package to improve their clinical practice in patient positioning.

Main outcome measure: Rivermead Mobility Index (RMI) at six months post stroke. Patient's position was recorded using an established observational tool.

Results: After the teaching there was some evidence of better positioning in the intervention than the control group (difference in percentage of correct positions per patient 4.9%, 95% confidence interval (CI-0.1% to 9.9%, p-0.055). There was no evidence of differences between the two groups in any of the outcome measures at six months although there was a trend towards increased elbow flexor tone in the control group.

Conclusions: A teaching intervention to improve patient positioning made no significant impact on outcome at six months post stroke. However, following the teaching there was only a slightly higher incidence of recommended patient positioning within the intervention group. Thus, a teaching package may not be powerful enough to enable any effect on patient outcome to be measured.

Meta-analysis of executive functioning in ecstasy/polydrug users

Ecstasy/3,4-methylenedioxymethamphetamine (MDMA) use is proposed to cause damage to serotonergic (5-HT) axons in humans. Therefore, users should show deficits in cognitive processes that rely on serotonin-rich, prefrontal areas of the brain. However, there is inconsistency in findings to support this hypothesis. The aim of the current study was to examine deficits in executive functioning in ecstasy users compared with controls using meta-analysis. We identified k = 39 studies, contributing 89 effect sizes, investigating executive functioning in ecstasy users and polydrug-using controls. We compared function-specific task performance in 1221 current ecstasy users and 1242 drug-using controls, from tasks tapping the executive functions - updating, switching, inhibition and access to long-term memory. The significant main effect demonstrated overall executive dysfunction in ecstasy users [standardized mean difference (SMD) = -0.18, 95% confidence interval (CI) -0.26 to -0.11, Z = 5.05, p < 0.001, I 2 = 82%], with a significant subgroup effect (χ 2 = 22.06, degrees of freedom = 3, p < 0.001, I 2 = 86.4%) demonstrating differential effects across executive functions. Ecstasy users showed significant performance deficits in access (SMD = -0.33, 95% CI -0.46 to -0.19, Z = 4.72, p < 0.001, I 2 = 74%), switching (SMD = -0.19, 95% CI -0.36 to -0.02, Z = 2.16, p < 0.05, I 2 = 85%) and updating (SMD = -0.26, 95% CI -0.37 to -0.15, Z = 4.49, p < 0.001, I 2 = 82%). No differences were observed in inhibitory control. We conclude that this is the most comprehensive analysis of executive function in ecstasy users to date and provides a behavioural correlate of potential serotonergic neurotoxicity.

Using CRP to predict anastomotic leakage after open and laparoscopic colorectal surgery: is there a difference?

AIM

C-reactive protein (CRP) has proven to be a useful adjunct in early diagnosis of anastomotic leak (AL) after colorectal surgery. It would be of considerable value to examine whether modality of surgery has influence upon postoperative CRP serum levels and their predictive value in the diagnosis of AL.

METHODS

All patients undergoing elective colorectal surgery with anastomosis were enrolled into a prospective database between 2011 and 2014. AL was defined with strict operative and radiological criteria. Outcomes between open and laparoscopic resections were assessed statistically and Receiver Operating Characteristic (ROC) curve analysis performed.

RESULTS

Seven hundred twenty-seven patients with an intestinal anastomosis were identified including 468 laparoscopic procedures (468/727; 64 %). There were 58 anastomotic leaks (58/727; 7.9 %) of which 29 (6.2 %) were laparoscopic and 29 (11.2 %) were open. Mean CRP levels were significantly higher in patients after open surgery compared with laparoscopic both with AL (p = 0.013), and without (p = 0.02). ROC curve analysis revealed postoperative day 3 (cut-off CRP 209) and day 4 (cut-off CRP 123.5) to be most predictive of leak in the open group with an area under the curve (AUC) 0.794 (sensitivity 80 %, specificity 80 %) and AUC 0.806 (sensitivity 94 %, specificity 60 %), respectively. In the laparoscopic group, day 2 proved to be the most accurate day for detection of leak with a cut-off CRP of 146.5 showing 75 % sensitivity and a 70 % specificity (AUC 0.766).

CONCLUSION

CRP levels are higher after open surgery compared with laparoscopic surgery, both with and without AL. AL generates a significant detectable increase in CRP within 2-4 days after surgery.

Abstract P5-12-13: What goes through your mind when you think about your medication? Thoughts about endocrine medication and treatment adherence

Hormonal therapy in women with breast cancer is an important part of long-term treatment, conferring significant survival benefits. However, a substantial proportion of women are non-adherent to endocrine therapy. Patients' beliefs about their illness and subsequent thoughts about whether the treatment is appropriate for their condition are important factors in treatment adherence. We sought to investigate the thoughts that breast cancer patients have about their endocrine medication and how these thoughts are related to adherence to treatment. Methods: Women with breast cancer were recruited from the Army of Women research registry. Women were asked what thoughts go through their mind when they think about the endocrine medication they were taking. Open-ended responses were coded reliably into 9 independent categories. Adherence to endocrine therapy, using an adapted version of the Morisky Medication Adherence Scale, as well as demographic and medical information was collected. Analysis of covariance (ANCOVA) was used to investigate the relation of treatment-related thoughts with adherence. Results: 1371 women were included in this analysis, mean age 56 years; 76.4% married, 57% currently working full or part-time. Mean years since breast cancer diagnosis was 5.1 years, and most women had early stage breast cancer (87%). With regard to endocrine therapy, 36.3% of participants were taking Arimidex (anastrazole), 29.6% Nolvadex (tamoxifen), 21.5% Femara (letrozole), and 12.5% Aromasin (exemestane). Of the 1371 participants, 1058 responses were able to be coded into 1 of the 9 categories. The most frequent category of thoughts reported was concern about side effects (19%) followed by the drug preventing cancer recurrence (18%), worry about future effects (13%), hope the drug is working (13%), dislike taking the drug (9%), time remaining on treatment (9%), grateful that drug exists (8%), and the drug is saving my life (6%). Treatment-related thoughts were related significantly to self-reported adherence to endocrine medication, F(8, 1013) = 5.97, p &lt; .001, partial η2 = .05. Women who reported thinking that they don't like taking their medication were the least adherent to treatment (M = 7.01, 95%CI[6.60, 7.42]). This group reported significantly lower adherence than participants who reported feeling protected (M = 5.79, 95%CI[5.22, 6.37], p = .025), those who thought about their medication saving their lives (M = 5.88, 95%CI[5.40, 6.35], p = .014), preventing recurrence (M = 5.98, 95%CI[5.70, 6.26], p = .002), those who reported feeling grateful for treatment (M = 6.00, 95%CI[5.59, 6.42], p = .024), and those who thought about their hope that the treatment is working (M = 6.01, 95%CI[5.69, 6.34], p = .006). Women who were worried about the possible long-term effects of the treatment or were concerned about side effects were also significantly less adherent to treatment.

Conclusions: The thoughts that patients with breast cancer have about their medication are significantly related to adherence to endocrine therapy. This simple open-ended question may be useful to assess patients' experiences of their medication and identify cognitions that can be targeted in interventions to improve adherence.

Citation Format: Partridge AH, Fasse K, Stanton AL, Jones A, Bright E, Petrie KJ. What goes through your mind when you think about your medication? Thoughts about endocrine medication and treatment adherence. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-12-13.