Effects of grazing platform stocking rate on productivity and profitability of pasture-based dairying in a fragmented farm scenario

The area adjacent to the milking parlor, accessible for grazing by lactating dairy cows (i.e., the grazing platform [GP]), can be limited on fragmented pasture-based dairy farms. Such farms, with a moderate overall farm stocking rate, typically have a much higher stocking rate of dairy cows on the GP. This study quantified the effects of farm fragmentation on milk and herbage production and profitability in a whole-farm systems-scale study over 3 yr (2017-2019). Four systems, each with an overall farm stocking rate of 2.5 cows/ha but with different grazing platform stocking rates (GPSR), were examined. The proportions of the overall farm area within the GP were 100%, 83%, 71%, and 63% in each of the 4 systems, respectively. Hence, the 4 systems had a GPSR of 2.5, 3.0, 3.5, and 4.0 cows/ha. The GP was used for grazing and silage (ensiled herbage) production, and the non-GP portion of each GPSR system was used solely for silage production. Concentrate supplementation per cow was the same across all GPSR systems; approximately 10% of the annual feed budget. All systems were compact spring-calving with 24 cows per system. We discovered a lower proportion of grazed herbage in the diet with higher GPSR. All silage produced on the non-GP areas was required to support higher GPSR on each of the systems. Annual herbage production and milk production per cow were not different between GPSR systems, resulting in similar milk production per hectare of the overall system area. The economic implications of different GPSR on fragmented farms were modeled in 2 scenarios: (1) quantifying the cost associated with different levels of farm area fragmentation; (2) investigating the optimum GPSR on fragmented pasture-based dairy farms, depending on variable criteria. A greater level of farm fragmentation lowered the profitability of pasture-based dairy production. Costs of production increased with higher GPSR and longer distances between GP and non-GP areas. At a fixed GP area, it was most profitable to increase GPSR up to 4 cows/ha on the GP when milk price was high, land rental price was low, and shorter distance existed between GP and non-GP areas.

POS1411 ARTIFICIAL INTELLIGENCE FOR IDENTIFYING NEW DISEASE CLUSTERS IN PATIENTS WITH PSORIATIC ARTHRITIS/PSORIASIS: A PROOF-OF-CONCEPT STUDY

Background

Psoriatic arthritis (PsA)/Psoriasis (PsO) patients present with multiple long-term conditions (MLTCs), and more than half of PsA patients have ≥1 LTC, which have an impact on the quality of life. We used the Clinical Practice Research Datalink (CPRD) in the UK to determine multimorbidity in patients with PsA/PsO. CPRD is a database of routinely collected UK patient data that can be used to examine multimorbidity over the life course of the disease. A understanding of clusters and timing may allow the development of tailored programmes for surveillance and early interventions to reduce MLTcs in PSA/PO.

Objectives

The overall objective of our study was to use CPRD to identify and interpret new and frequently-occurring disease clusters in the PsA/PsO population.

Methods

We identified PsA/PsO patients from the CPRD GOLD for the UK from 2009 to 2018 with at least one year of follow up but excluded patients in practices that had migrated to Aurum, a different electronic health record system held by CPRD. All patients were matched to controls at a 1: 4 ratio by age, sex, practice. We analysed 40 common MLTCs outlined by Barnett et al. to identify and interpret multimorbidity clusters. Multimorbidity clusters were identified using the network bi-clustering. Our methodology can be divided into three steps- (a) Separate the “case” and the “control” population, (b) Create a patient-condition matrix for each of “case” and “control” population and (c) From the patient-condition matrix in each case use a the Euclidean distance criterion to compute a similarity matrix of all the possible conditions among those patients.

Results

We identified 67,827 incident or prevalent PsA/PsO patients aged 20 years and above who were matched to 271,308 controls by age, sex and practice (Table 1). The median number of long-term conditions (LTCs) was higher in the cases than in the controls.

Table 1.CharacteristicCASE, N = 67,827CONTROL, N = 271,308Age Group, n (%)<206,491 (9.6%)27,897 (10%)20-5442,357 (62.4%)169,008(62.3%)55 and above19,148 (28.2%)74,403 (27.4%)Ethnicity, n (%)White28,200 (41.6%)93,485 (34.5%)Black, S.Asian and other956 (1.4%)3,735 (1.4%)Unknown38,671 (57%)174,088(64.2%)Sex, n (%)F35,431 (52%)141,724 (52%)BMI category, n (%)20 to <2511,183 (16.5%)43,240 (15.9%)25 to <3013,565 (20%)45,783 (16.9%)30 to <357,584 (11.2%)22,690 (8.4%)35 to 403,048 (4.5%)8,172 (3.0%)Alcohol status, n (%)Non-drinker/ Ex-drinker8,649/2,159 (15.9%)33,983/7,579 (15.3%)Drinker/Heavy drinker47,316/3,030 (74.2%)180,888/8,831 (69.9%)Smoking status, n (%)Ex-smoker/Non-smoker14,137/29,289 (64%)48,110/142,295 (70.2%)Smoker24,018 (35%)71,779 (26%)Long term condition, Median (IQR)1.00 (0.00, 3.00)1.00 (0.00, 2.00)

We present the results obtained via spectral clustering on the similarity matrix obtained in each “case” and “control” population via Euclidean distance. There are 40 LTCs which are represented via two clusters in the “case” and the “control” population network (Figure 1). The LTCs in the same cluster are strongly connected within themselves compared to those in the other cluster. The noticeable part was clustering of diabetes, hypertension and chronic heart diseases in one group, especially in the “case” population over the “control” population. Interestingly depression, dementia and chronic heart diseases were in the same group in the clustering results for both the “case” and the “control” population. There are a central group of diseases (HYP, DEM, DIV, CHD etc.) in Figure 1, which seems to be connected with both sets of clusters. As mentioned earlier, diabetes has connections with these central groups of diseases, and it tends to be more pronounced in the “case” population.

Figure 1.

Conclusion

MLTCs including diabetes, hypertension, chronic kidney disease and heart disease occurred together more commonly in patients with PsA/PsO than those without PsA/PsO.

The future goal is to identify frequently occurring clusters of MLTCs in the immune-mediated inflammatory disease population.

Disclosure of Interests

Prasad Nishtala: None declared, Neil McHugh: None declared, William Tillett Speakers bureau: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Pfizer and UCB, Consultant of: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Pfizer and UCB, Grant/research support from: Abbvie, Celgene, Eli-Lilly, Janssen, and UCB, Sarah Skeoch: None declared, Jenny Humphreys: None declared, John Pauling: None declared, Olga Isupova: None declared, Anita McGROGAN: None declared, Julia Snowball: None declared, Sandipan Roy: None declared

POS0591 TREATMENTS TO PREVENT RHEUMATOID ARTHRITIS IN FIRST DEGREE RELATIVES: DEMOGRAPHIC AND PSYCHOLOGICAL PREDICTORS OF RISK TOLERANCES

Background

There is a growing research focus on the development of interventions to reduce risk of rheumatoid arthritis (RA) in at-risk groups.(1) RA patients’ first-degree relatives (FDRs) have an elevated risk of developing RA and are potential candidates for preventive interventions. Recent studies have quantified the preferences of at risk groups for preventive treatments.(2-4) Little is known about predictors of preference heterogeneity in this context.

Objectives

Assess the extent to which FDR characteristics and beliefs predict risk tolerances for preventive treatments.

Methods

Adult FDRs of patients with confirmed RA in the UK were invited to take part in a web-based survey. FDRs enrolled in a UK prospective cohort (PREVeNT-RA) were also invited. Survey development, including attribute selection and presentation, was informed by qualitative research, ranking surveys, literature review, and expert opinion including patient research partners. Respondents received information about RA, questions to check comprehension, and an introduction to the survey. Participants were asked to imagine they were experiencing arthralgia and had positive autoantibody tests indicating a 60% chance of developing RA within two years. Using a probabilistic threshold technique, participants made choices between no treatment (no benefit and no risks) or a preventive treatment option. Treatment options were defined by a fixed level of benefit (reduction in risk of RA from 60% to 20%) and varying levels of risks (Table 1). For each treatment risk, participants made a series of choices where the risk was systematically increased or decreased until they switched their choice. This procedure was repeated for each of the remaining risks. Participants also completed items assessing demographics, perceived risk of developing RA, health literacy, subjective numeracy, the Brief Illness Perception Questionnaire (IPQ) and the Beliefs about Medicines Questionnaire General (BMQ-G). The maximum acceptable risk (MAR) respondents were willing to accept for a 40% (60% to 20%) point risk reduction in developing RA was summarized across participants using descriptive statistics. Associations between MARs and participants’ characteristics and illness/medication beliefs were assessed using interval regression. Independent variables were dichotomized and effects coded.

Table 1.

Attributes and levels of treatment options

Treatment attributeLevels describing no treatment optionLevels describing treatment optionChance of developing RA60%20%Chance of mild side effects0%2%; 4%; 5%; 7% or 10%Chance of a serious infection due to treatment0%1%; 1.5%; 2%; 3% or 5%Chance of a serious side effect that is potentially irreversible0%0.001%; 0.01%; 0.02%; 0.05% or 0.1%

Results

289 FDRs (80 male) responded. The mean (SE) MAR for mild side effects, serious infection, and serious side effects was 29.08 (1.52), 9.09 (0.60) and 0.85 (0.27), respectively. Participants aged over 60 years were less tolerant of risk of serious infection than average (mean MAR - 2.06 (0.78)) and younger participants were more tolerant of risk of serious infection than average (mean MAR + 2.06 (0.78)). Risk of mild side effects was less acceptable to participants who perceived they were likely/very likely to develop RA (mean MAR - 3.34 (1.55)) than to those who did not (mean MAR + 3.34 (1.55)). Education level, health literacy, numeracy, IPQ and BMQ-G subscales were not predictors of risk tolerance.

Conclusion

Age and perceived risk of RA had a significant impact on FDRs’ tolerance for specific, but not all, included risks. Cognitive ability and beliefs about RA/medicine did not explain preference heterogeneity. This is informative for drug development and the development of tailored risk communication resources to support preventive approaches.

References

[1]Mankia et al. Ann Rheum Dis. 2021;80(10):1286-98.

[2]Simons et al. Ann Rheum Dis. 2021;80:96-7.

[3]Harrison et al. Plos One. 2009; 14(4): e0216075.

[4]Finckh et al. Curr Rheumatol Rep. 2016;18: 51.

Acknowledgements

On behalf of the PREFER project. PREFER received funding from the IMI 2 Joint Undertaking (grant No. 115966), which receives support from the EU’s Horizon 2020 research and innovation program and European Federation of Pharmaceutical Industries and Associations (EFPIA). K. Raza is supported by the NIHR Birmingham Biomedical Research Centre.

Disclosure of Interests

Gwenda Simons: None declared, Ellen Janssen Shareholder of: Johnson & Johnson, Employee of: Janssen Research and Development, Jorien Veldwijk: None declared, Rachael DiSantostefano Shareholder of: Johnson & Johnson, Employee of: Janssen Research and Development, Matthias Englbrecht Speakers bureau: Abbvie, Chugai, Eli Lilly, Novartis, Roche, Sanofi, Mundipharma, Paid instructor for: Abbvie, Chugai, Roche, Consultant of: Abbvie, Novartis, Roche, Sanofi, Grant/research support from: Roche, Chugai, Christine Radawski Shareholder of: Eli Lilly, Employee of: Eli Lilly, Larissa Valor: None declared, Jenny Humphreys: None declared, Ian N. Bruce: None declared, Brett Hauber Shareholder of: Pfizer Inc., Employee of: Pfizer Inc., Karim Raza Consultant of: Abbvie, Sanofi, Grant/research support from: Bristol Myers Squibb, Marie Falahee: None declared.

POS0325 THE ASSOCIATION BETWEEN OBESITY, SOCIOECONOMIC POSITION AND KNEE JOINT REPLACEMENT SURGERY IN PATIENTS WITH OSTEOARTHRITIS: RESULTS FROM THE ENGLISH LONGITUDINAL STUDY OF AGEING

Background

Evidence suggests that associations of lower socioeconomic position (SEP) with increased incidence of osteoarthritis (OA) are partially mediated by obesity. Obesity and lower SEP are also associated with increased symptoms in OA (i.e. pain/function). However, few studies have investigated whether obesity and lower SEP are also associated with increased risk of knee joint replacement surgeries (kJRS).

Objectives

To investigate the relationships of obesity and SEP at time of diagnosis with kJRS at follow-up in people with knee OA (kOA).

Methods

The English Longitudinal Study of Ageing is a nationally representative panel study of adults aged ≥50 years with biannual waves of data collection (2002–2019). Participants who self-reported OA diagnosis for the first time in waves 2–8 and knee pain in the same or previous wave of diagnosis were defined as having kOA (baseline). Participants with at least one body mass index (BMI) measurement and one follow-up assessment were included. Underweight/normal weight, overweight and obesity were defined using BMI <25 kg/m2, 25–30 kg/m2 and ≥30kg/m2, respectively. Education, occupation (current or last occupation if retired), wealth quintiles (all individual-based) and index of multiple deprivation quintiles (area-based) were used as SEP indicators. Outcome was the first self-reported kJRS (left or right knee) in waves 3–9. Cox proportional hazards models were used to investigate the associations of obesity and SEP with kJRS, controlling for baseline covariates. Person year follow up was calculated from baseline to either a) date of self-reported kJRS, b) loss to follow-up, c) end of follow-up (wave 9).

Results

The analysis sample included 1499 people who reported kOA and had ≥1 BMI measure (62.3% female; mean age 66.5y (SD 9.4); 96% white; 47.4% obese). Number of person-years included in the analysis was 8427. Over a mean follow-up of 4.7 years (SD 2.8), 144 (9.6%) reported having kJRS. Obese kOA patients were more likely to report kJRS than non-obese patients (adjHR 1.89 (95% CI 1.33, 2.68)), independent of age, gender, SEP, cardiovascular disease (self-reported) and HbA1c values (measured from collected blood samples). Education and occupation were not associated with kJRS. However, those living in the most deprived areas and with the least amount of wealth were less likely to undergo kJRS compared with the least deprived and wealthiest (HRs adjusted for age and gender 0.37 (95% CI 0.19, 0.73) and 0.55 (95% CI 0.33, 0.93), respectively). There was no evidence of interactions between obesity and SEP indicators.

Conclusion

Obesity increased the likelihood of undergoing kJRS in kOA patients. Therefore, reducing obesity in kOA patients may help to reduce the need for kJRS. Area-deprivation and lower wealth were associated with lower likelihood of kJRS. Taken together with findings from other studies which report associations between lower SEP and worse OA symptoms, our results suggest that there may be social inequalities in the provision of kJRS in England.

Table 1.

The relationships between obesity at baseline and rates of knee joint replacement surgery over a mean of 4.7 (SD 2.8) years in follow-up in those with knee OA at baseline in the English Longitudinal Study of Ageing

PredictorsHR (95% CI)UnadjustedAdjusted for age and genderAdjusted for age, gender and SEPAdjusted for age, gender, SEP, CVD and HbA1cObesity1.56 (1.12, 2.17)1.63 (1.17, 2.28)1.77 (1.26, 2.50)1.89 (1.33, 2.68)Non-obesityrefrefrefrefObesity3.53 (1.77, 7.02)3.58 (1.80, 7.12)4.01 (2.01, 8.03)4.35 (2.16, 8.74)Overweight2.91 (1.43, 5.91)2.81 (1.38, 5.73)2.93 (1.44, 5.98)2.98 (1.46, 6.09)Underweight/normal weightrefrefrefrefBMI per 1 kg/m2 increment1.05 (1.02, 1.07)1.05 (1.03, 1.08)1.06 (1.04, 1.09)1.07 (1.04, 1.10)

HR, hazard ratio; CI, confidence interval; SEP, socioeconomic position; CVD, cardiovascular disease; ref, reference category; BMI, body mass index.

Disclosure of Interests

None declared

OP0276 PREFERENCES FOR TREATMENTS TO PREVENT RHEUMATOID ARTHRITIS: DISCRETE CHOICE SURVEY OF RHEUMATOID ARTHRITIS PATIENTS’ FIRST-DEGREE RELATIVES IN THE UNITED KINGDOM AND GERMANY

Background

There is a growing research focus on the development of interventions to reduce risk of rheumatoid arthritis (RA) in at-risk individuals.(1) A recent survey of the general population asked to assume a 60% risk of RA established that hypothetical preventive treatments were acceptable to most participants.(2) However the preferences of individuals who actually have an elevated risk of RA, such as first-degree relatives (FDRs) of RA patients, are not well understood.

Objectives

To quantify FDRs’ preferences for preventive treatments for RA.

Methods

Adult FDRs in the UK and Germany were invited to take part in a web-based survey via patients with clinician-confirmed RA either during a rheumatology clinic visit or by mail. In addition, FDRs taking part in a UK-based prospective cohort (PREVeNT-RA) were invited via email. Participants received information about RA followed by questions to check comprehension, and an introduction to the survey including warm-up questions. They were asked to imagine they were experiencing arthralgia and had positive autoantibody tests indicating a 60% chance of developing RA in the next two years. Using a discrete choice experiment, participants were offered a series of 15 choices between no treatment and two unlabeled hypothetical treatments to reduce risk of RA. Treatments were defined by six attributes with varying levels, describing benefits, risks, and frequency/route of administration (Table 1). Attribute selection and presentation was informed by qualitative research, ranking surveys, systematic literature review, and expert opinion. Survey layout was informed by patient research partners and qualitative pre-testing. A two-class latent class analysis was used to estimate preferences and calculate relative importance of treatment attributes and predicted uptake. A panel mixed logit model was used to obtain maximum acceptable risk estimates.

Table 1.

Treatment attributes and levels

AttributeLevelsChance of developing RA reduced from 60% to10%; 20%; 30%; 40%How the treatment is takenA shallow injection under the skinA drip into the veinOne or two tabletsHow often the medication has to be takenDailyWeeklyMonthlyEvery 6 monthsChance of mild side effects2%; 5%; 10%Chance of a serious infection due to treatment0%; 1%; 5%Chance of a serious side effect that is potentially irreversible1 in 100,000 people20 in 100,000 people100 in 100,000 people

Results

356 FDRs (252 female, 289 in the UK) responded. While treatment effectiveness was the most important attribute in both classes (Figure 1), the importance of other attributes differed between classes, with method and frequency of treatment administration being more important in class 2 and risk of mild side effects only impacting treatment choice in class 1. Perceived risk of developing RA predicted class assignment; those with higher perceived risk were more likely to belong to class 1. On average, the predicted uptake of treatment profiles estimating prevention candidates: abatacept; atorvastatin; hydroxychloroquine; tolerogenic cell-based therapy; and no treatment would be 50%, 15%, 9%, 18% and 0%, respectively. Finally, the maximum acceptable risk participants were willing to accept were 81%, 25% and 3% point increases in risk of mild side effects, serious infection, and serious side effects, respectively, for medicines that would reduce their risk of developing RA in the upcoming two years from 60% to 20%.

Conclusion

Effective preventive treatments for RA were acceptable to FDRs asked to assume a 60% chance of developing RA. Mode and frequency of treatment administration had a greater impact on treatment choices for participants with a lower perceived risk of RA. These findings are informative for target product profile development, endpoint selection, benefit-risk assessment, regulatory approval, and development of informational resources for those at risk of RA.

References

[1]Mankia et al. Ann Rheum Dis. 2021;80(10):1286-98.

[2]Simons et al. Ann Rheum Dis. 2021;80:96-7.

Acknowledgements

On behalf of the PREFER project. PREFER received funding from the IMI 2 Joint Undertaking (grant No. 115966), which receives support from the EU’s Horizon 2020 research and innovation program and European Federation of Pharmaceutical Industries and Associations (EFPIA). This abstract and its contents reflect the view of the presenter and not the view of PREFER, IMI, the European Union or EFPIA. K. Raza is supported by the NIHR Birmingham Biomedical Research Centre.

Disclosure of Interests

Gwenda Simons: None declared, Jorien Veldwijk: None declared, Rachael DiSantostefano Shareholder of: Johnson & Johnson, Employee of: Janssen Research and Development, Matthias Englbrecht Speakers bureau: Abbvie, Chugai, Eli Lilly, Novartis, Roche, Sanofi, Munidpharma, Paid instructor for: Abbvie, Chugai, Roche, Consultant of: Abbvie, Novartis, Roche, Sanofi, Grant/research support from: Roche, Chugai, Christine Radawski Shareholder of: Eli Lilly & Company, Employee of: Eli Lilly & Company, Larissa Valor: None declared, Jenny Humphreys: None declared, Ian N. Bruce: None declared, Karim Raza Consultant of: Abbvie, Sanofi, Grant/research support from: Bristol Myers Squibb, Marie Falahee: None declared

Examining area-level variation in service organisation and delivery across the breadth of primary healthcare. Usefulness of measures constructed from routine data

Background

Australia has a universal healthcare system, yet organisation and delivery of primary healthcare (PHC) services varies across local areas. Understanding the nature and extent of this variation is essential to improve quality of care and health equity, but this has been hampered by a lack of suitable measures across the breadth of effective PHC systems. Using a suite of measures constructed at the area-level, this study explored their application in assessing area-level variation in PHC organisation and delivery.

Methods

Routinely collected data from New South Wales, Australia were used to construct 13 small area-level measures of PHC service organisation and delivery that best approximated access (availability, affordability, accommodation) comprehensiveness and coordination. Regression analyses and pairwise Pearson’s correlations were used to examine variation by area, and by remoteness and area disadvantage.

Results

PHC service delivery varied geographically at the small-area level–within cities and more remote locations. Areas in major cities were more accessible (all measures), while in remote areas, services were more comprehensive and coordinated. In disadvantaged areas of major cities, there were fewer GPs (most disadvantaged quintile 0.9[SD 0.1] vs least 1.0[SD 0.2]), services were more affordable (97.4%[1.6] bulk-billed vs 75.7[11.3]), a greater proportion were after-hours (10.3%[3.0] vs 6.2[2.9]) and for chronic disease care (28%[3.4] vs 17.6[8.0]) but fewer for preventive care (50.7%[3.8] had cervical screening vs 62.5[4.9]). Patterns were similar in regional locations, other than disadvantaged areas had less after-hours care (1.3%[0.7] vs 6.1%[3.9]). Measures were positively correlated, except GP supply and affordability in major cities (-0.41, p < .01).

Implications

Application of constructed measures revealed inequity in PHC service delivery amenable to policy intervention. Initiatives should consider the maldistribution of GPs not only by remoteness but also by area disadvantage. Avenues for improvement in disadvantaged areas include preventative care across all regions and after-hours care in regional locations.

The effect of fertilizer nitrogen input to grass-clover swards and calving date on the productivity of pasture-based dairy production

The objective of this systems-scale study was to investigate grazing season timeframes on pasture and milk production and on milk processability of dairy systems with compact spring-calving dairy cows grazing white clover (Trifolium repens L.) based grassland. Fifty-four primiparous and multiparous Holstein-Friesian dairy cows were used in a one-factor study with 3 systems (n = 18) and repeated over 2 yr (2008/09 and 2009/10). The 3 systems were: early spring calving with annual fertilizer N input of 100 kg·ha^-1 applied in spring (ES100N; 2.1 cows·ha^-1; grazing February to November), early spring calving without fertilizer N (ES0N; 1.6 cows·ha^-1; grazing February to November) and late spring calving without fertilizer N (LS0N; 1.53 cows·ha^-1; grazing April to January). Annual pasture production was affected by an interaction between grazing system and year: Mean annual pasture yields for 2008 and 2009 were ES100N; 10.35 and 9.88, ES0N; 8.88 and 8.63, LS0N; 9.18 and 10.31 t of dry matter (DM)·ha^-1 (SEM 0.39). LS0N had higher pasture DM yield in 2009 due to higher clover DM production and biological N fixation compared with the other systems. Clover stolon and root mass in the following February was correlated with stolon and root mass in the previous November with 64% of stolon mass present on LS0N in February (R² = 0.84). There were no detectable differences in per-lactation milk yield (6,335 kg·cow^-1), fat, protein and lactose yields (271, 226, 297 kg·cow^-1, respectively), cow liveweight (585 kg) or body condition score (3.02). Although winter grazing favored subsequent clover DM production, biological N fixation and pasture DM production, delaying calving date in spring and extending lactation into the following winter led to inefficient use of this pasture by the grazing herd and lowered the quality of late-lactation milk for processing purposes. Hence, a mean calving date in mid- to late-February is recommended for zero-fertilizer N input clover-based grassland.

SAT0065 TIMING OF PNEUMOCOCCAL VACCINATIONS IN RELATION TO STARTING DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS IN RHEUMATOID ARTHRITIS

Background:

Pneumococcal vaccinations are recommended for patients with rheumatoid arthritis (RA). There is evidence that pneumococcal vaccinations are less effective when administered after starting conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs). Vaccination guidelines have changed over time, since 1992 UK guidelines recommend pneumococcal vaccination for the immunocompromised, and in 2003 was expanded to all individual’s age ≥65 years. Guidelines from British Society of Rheumatology (2011) and EULAR (2019) advise to vaccinate prior to starting csDMARDs where possible. There is little evidence about whether these guidelines are being followed.

Objectives:

The aims of this study were to explore the timing of pneumococcal vaccination in patients with RA in relation to starting csDMARDs and examine whether this has changed over time.

Methods:

This was a cross-sectional study using UK electronic health records from primary care between 1st January 2000 and 31st December 2018. To be included in the study patients needed to 1) have a diagnosis of RA, 2) be prescribed csDMARDs up to 3 months prior to, or after RA diagnosis date and 3) have received a pneumococcal vaccination. Index date was considered the start of csDMARDs and vaccinations were required to be up to 5 years prior to the index date or after index date until leaving the practice, death or the end of the study period. For each patient it was determined if the first vaccination was prior to starting csDMARDs. For those vaccinated up to 3 years prior to, or up to 3 years after starting csDMARDs, the time between vaccination and starting csDMARDs in months was determined and this distribution was plotted in a bar chart. To explore how timing of vaccination has changed over time the proportion (with 95% confidence intervals (CI)) of people vaccinated prior to starting csDMARDs was plotted by year.

Results:

Of 21461 people with RA identified who were prescribed their first csDMARD on or after 1st January 2000, there were 8205 (38.2%) patients vaccinated and eligible to be included in the study. The cohort had a mean age 62 years, 66.4% were female. There were 2997 (36.5%) patients vaccinated prior to starting csDMARDs. Those vaccinated prior to starting csDMARDs were older, with 72% (n=2168) being aged 65 years or over vs 28% (n=1465) in those vaccinated after starting csDMARDs. 5358 (65.3%) were vaccinated up to 3 years prior to, or up to 3 years after starting csDMARDs. The distribution showed that the most frequent time of vaccination was in the 3 months after starting csDMARDs and the frequency was higher in the months after starting csDMARDs than in the months preceding (Figure 1). Of those vaccinated outside these times, 1000 (12.2%) were vaccinated >3 years prior and 1844 (22.5%) were vaccinated >3 years after starting csDMARDs. The proportion vaccinated prior to starting csDMARDs has increased over time from a minimum of 17.2% in 2001 to a maximum of 55.6% in 2016. The greatest increases were seen between 2003 and 2007 (Figure 2).

Figure 1.

Time between starting csDMARDs and pneumococcal vaccination

Figure 2.

Proportion and 95% confidence interval of those vaccinated prior to starting csDMARDs by year.

Conclusion:

This study shows that timing of pneumococcal vaccination is improving with a trend towards increasing vaccination prior to starting csDMARDs and a high proportion of patients were vaccinated around the time of csDMARD initiation. However, just over a fifth (22.5%) were vaccinated more than 3 years after starting csDMARDs. Rheumatologists need to continue to work to raise awareness of the importance of vaccinations through better communications to patients and primary care physicians, to ensure best practice is being followed.

Disclosure of Interests:

Ruth E Costello: None declared, Jenny Humphreys: None declared, Kevin Winthrop Grant/research support from: Bristol-Myers Squibb, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Galapagos, Gilead, GSK, Pfizer Inc, Roche, UCB, William Dixon Consultant of: Bayer and Google

THU0551 SOCIAL CARE USE IN PEOPLE WITH CHRONIC PAIN IN THE UNITED KINGDOM

Background:

Chronic pain is a common and disabling health problem and those affected may need support with their activities of daily living (ADLs). Currently there are no data quantifying how much social care support people with chronic pain need.

Objectives:

To describe formal and informal social care use in people with chronic pain

Methods:

Between June-July 2019, previous participants of theCloudy with a Chance of Painstudy were invited to take part in an online survey, adapted from a validated Personal Social Services Research Unit interview survey. It collected data on whether participants with chronic pain needed help with ADLs, how frequently help was needed and who provided it (formal and informal social care). Additional data was collected on demographics, employment status, pain diagnosis, and comorbidities. Descriptive statistics described the burden of social care need and multivariable logistic regression identified factors associated with social care need.

Results:

There were 981 respondents; 791 (81%) were female, median age 59 years (table 1). In the last month 527(61%) respondents reported needing help with ADLs. Over three-quarters of help was provided informally by family and friends (408 (77%)). For 309 (59%) respondents, help was needed at least daily. In the multivariable logistic regression model, needing help was lower with older age, (OR (95% CI) 0.96 (0.94-0.98), but higher in female gender (OR (95% CI) 1.96 (1.27-3.01), fibromyalgia (OR(95% CI) 2.75(2.53-5.54)), osteoarthritis (OR (95% CI) 1.56 (1.11-2.19)) and multi-morbidity OR (95% CI) 2.13 (1.51-3.01)). Compared to full-time work, respondents who were retired or unable to work were also significantly more likely to need help with ADLs, respective OR (95% CI) 2.16 (1.21-3.84) and 6.98 (3.72-13.08).

Table 1.All respondentsn=981Need help$n=527No help$n=337MissingAge med (IQR)59 (50-66)57 (47-64)61 (52-68)5Female n (%)791 (81)452 (86)251 (74)11Employment statusn (%)FTPTSelf-employedStudentHomemakerRetiredUnable to workUnemployed134 (14)169 (17)50 (5)7 (0.7)23 (2)360 (37)221 (23)16 (1.6)54 (10)79 (15)26 (5)4 (0.8)12 (2)151 (29)188 (36)12 (2)70 (21)69 (20)19 (6)2 (0.6)10 (3)143 (42)21 (6)3 (0.9)1Diagnosis reportedn (%)*OsteoarthritisFibromyalgiaRheumatoid arthritisArthritis (type not specified)Ankylosing SpondylitisGoutMigraine/chronic headacheNeuropathic painOther (inc Psoriatic arthritis, hypermobility)929 (95)482 (49)265 (27)205 (21)128 (15)56 (6)18 (2)115 (13)155 (18)272 (29)516 (98)269 (51)207 (39)115 (22)73 (14)33 (6)13 (2)82 (16)120 (23)209 (39)313 (93)160 (47)40 (12)73 (22)55 (16)23 (7)5 (1)33 (10)35 (10)63 (19)11Any MSk diagnosisn (%)828 (95)460 (87)279 (83)64Multi-morbidity∞n (%)712 (82)473 (90)54 (36)0

med - median, IQR - interquartile range, MSk – musculoskeletal

$117 respondents did not answer the question about whether they did or did not need help with ADLs

*some participants reported more than one diagnosis for their pain

includes MSK diseases above and the following chronic diseases listed in questionnaire: angina, heart attack, stroke, COPD, diabetes, cancer, parkinson’s, multiple sclerosis, depression, other (participants asked to specify)

Conclusion:

A high proportion of people with chronic pain needed support with ADLs; for more than half, on a daily or more frequent basis. Interestingly, younger patients were more likely to need help which may reflect responder bias (younger patients with severe pain potentially more likely to respond than those with milder pain). The majority of support was provided informally, and this could be for a number of reasons. For example, lack of awareness/not meeting eligibility/unable to afford formal social care, or preference to be cared for by familiar persons. This should be explored in future research. These results demonstrate the burden of social care may be significantly greater than government and social care organisations are aware, with important implications for policy and planning.

Disclosure of Interests:

Jenny Humphreys: None declared, Katy Dempsey: None declared, Ollie Phelan: None declared, Laura Boothman: None declared, Louise Cook: None declared, William Dixon Consultant of: Bayer and Google

Phosphorus and nitrogen losses from temperate permanent grassland on clay-loam soil after the installation of artificial mole and gravel mole drainage

Mole (M) and gravel-mole (GM) drainage systems improve the permeability of soils with high clay contents. They collect and carry away infiltrating water during episodic rainfall events. Characterisation of nutrient fluxes (concentration and flows) in overland flow (OF) and in mole drain flow (MF) across sequential rainfall events is important for environmental assessment of such drainage systems. The objective of this study is to assess the impact of drainage systems on soil nutrient losses. Three treatments were imposed on grazed permanent grassland on a clay loam soil in Ireland (52°30'N, 08°12'W) slope 1.48%: undrained control (C), mole drainage (M) and gravel mole drainage (GM). Plots (100 m × 15 m) were arranged in a randomized complete block design with four replicated blocks. Nitrogen (N) and phosphorus (P) concentrations in OF, MF and groundwater (GW) were measured from each plot over 15 consecutive rainfall events. The results showed that M and GM (P < 0.05) deepened the watertable depth and decreased OF. M and GM increased losses of nitrate-N (22%) and ammonium-N (14%) in GW. Nitrate-N concentrations from all the flow pathways (mean and standard error (s.e.): 0.99 s.e. 0.10 mg L^-1) were well below the 11.3 mg L^-1 threshold for drinking water. Ammonium-N concentrations from all the flow pathways (mean: 0.64 s.e. 0.14 mg L^-1) exceeded drinking water quality standards. On the other hand M and GM lowered total P losses (mean annual losses from C, M and GM: 918, 755 and 853 s.e. 14.1 g ha^-1 year^-1) by enhancing soil P sorption. Hence M and GM can be implemented on farms under similar management to that described in the present study with a minor impact on N (increased concentration on averaged 18% to GW) and P (reduced by on avenged 114 g ha^-1 year^-1).

A Retrospective Evaluation of A Paediatric Consult Clinic Serving Uninsured Children in Canada

BACKGROUND: Children new to Canada may not have health insurance which limits access to health care and increases their vulnerability to poorer health outcomes. As part of a resident advocacy initiative, a monthly pediatric consult clinic was created within a community health clinic to serve uninsured children living in a suburb of a major Canadian city. At the time of its inception in 2009, 35% of patients seen in the health clinic did not have provincial health insurance and an additional 35-40% did not receive Interim Federal Health (IFH) that they were otherwise entitled to (Denburg et al., 2010).

OBJECTIVES: To describe the demographics and health issues of uninsured immigrant children referred to a pediatric consult clinic.

DESIGN/METHODS: This study is a retrospective chart review characterizing the patients seen from 2009 – 2013. We collected demographic information, presenting symptoms, diagnoses and clinical outcomes. After REB approval, 180 patients were identified and 159 charts were found. Data was extracted from each chart and coded into a database. Of these files, 38 were removed because of duplicate entries or if they were not seen in the clinic. A total of 121 charts were included in the final analysis. An audit was performed by a blinded reviewer to identify any discrepancies in transcription prior to descriptive analysis.

RESULTS: Over half (52.1%) of patients seen in our clinic were landed immigrants or Canadians, while 19.8% had refugee status. 49.3% of patients were in a 3-month waiting period for provincial health insurance, while 12.6% had IFH, 11.6% had OHIP and 21.5% had no insurance at all. Only 34% spoke English as their primary language. The top three presenting complaints were developmental, dermatologic and respiratory. The most common final diagnoses were psychiatric and behavioural, dermato-logic and nutritional. The majority of patients required counselling (67%), with 14% prescribed a short medication course and 20% requiring ongoing medication.

CONCLUSION: Almost 70% of patients seen had no insurance at the time of their visit, with most in the mandatory 3-month wait for provincial health coverage. Our study suggests that children still need access to health care during this period. The most common diagnoses related to mental health and development suggesting a high prevalence in immigrants and supporting the need to screen for these issues when caring for children new to Canada.

Viewpoint: effective stakeholder communication in agriculture: together we stand, divided we fall!

Substantial improvements of agricultural systems are necessary to meet the future requirements of humanity. However, current agricultural knowledge and information systems are generally not well suited to meet the necessary improvements in productivity and sustainability. For more effective application of research output, research producers and research consumers should not be considered as separate individuals in the knowledge chain but as collaborating partners creating synergy. The current paper investigates the relationships between scientists and stakeholders and identifies approaches to increase the effectiveness of their communication. On-farm research has proven to be an effective means of improving exploitation of research output at farm level because it connects all relevant partners in the process. Furthermore, pilot farms can act as an effective platform for communication and dissemination. Regional networks of pilot farms should be established and connected across regions.

Energy demand on dairy farms in Ireland

Reducing electricity consumption in Irish milk production is a topical issue for 2 reasons. First, the introduction of a dynamic electricity pricing system, with peak and off-peak prices, will be a reality for 80% of electricity consumers by 2020. The proposed pricing schedule intends to discourage energy consumption during peak periods (i.e., when electricity demand on the national grid is high) and to incentivize energy consumption during off-peak periods. If farmers, for example, carry out their evening milking during the peak period, energy costs may increase, which would affect farm profitability. Second, electricity consumption is identified in contributing to about 25% of energy use along the life cycle of pasture-based milk. The objectives of this study, therefore, were to document electricity use per kilogram of milk sold and to identify strategies that reduce its overall use while maximizing its use in off-peak periods (currently from 0000 to 0900 h). We assessed, therefore, average daily and seasonal trends in electricity consumption on 22 Irish dairy farms, through detailed auditing of electricity-consuming processes. To determine the potential of identified strategies to save energy, we also assessed total energy use of Irish milk, which is the sum of the direct (i.e., energy use on farm) and indirect energy use (i.e., energy needed to produce farm inputs). On average, a total of 31.73 MJ was required to produce 1 kg of milk solids, of which 20% was direct and 80% was indirect energy use. Electricity accounted for 60% of the direct energy use, and mainly resulted from milk cooling (31%), water heating (23%), and milking (20%). Analysis of trends in electricity consumption revealed that 62% of daily electricity was used at peak periods. Electricity use on Irish dairy farms, therefore, is substantial and centered around milk harvesting. To improve the competitiveness of milk production in a dynamic electricity pricing environment, therefore, management changes and technologies are required that decouple energy use during milking processes from peak periods.

Life cycle assessment of milk production from commercial dairy farms: the influence of management tactics

Little consideration has been given to how farm management, specifically tactics used to implement the management strategy, may influence the carbon footprint (CF) and land use for milk produced on commercial farms. In this study, the CF and land use of milk production from 18 Irish commercial dairy farms were analyzed based on foreground data from a 12-mo survey capturing management tactics and background data from the literature. Large variation was found in farm attributes and management tactics; for example, up to a 1.5-fold difference in fertilizer nitrogen input was used to support the same stocking density, and up to a 3.5-fold difference in concentrate fed for similar milk output per cow. However, the coefficient of variation for milk CF between farms only varied by 13% and for land use by 18%. The overall CF and overall land use of the milk production from the 18 dairy farms was 1.23±0.04kg of CO2 Eq and 1.22±0.05 m(2) per kilogram of energy-corrected milk. Milk output per cow, economic allocation between exports of milk and liveweight, and on-farm diesel use per ha were found to be influential factors on milk CF, whereas the fertilizer N rate, milk output per cow, and economic allocation between exports of milk and liveweight were influential on land use. Effective sward management of white clover within a few farms appeared to lower the CF but increased on-farm land use. It was concluded that a combination of multiple tactics determines CF and land use for milk production on commercial dairy farms and, although these 2 measures of environmental impact are correlated, a farm with a low CF did not always have low land use and vice versa.

N leaching to groundwater from dairy production involving grazing over the winter on a clay-loam soil

This study investigated concentrations of various N species in shallow groundwater (<2.2m below ground level) and N losses from dairy production involving grazing over the winter period on a clay loam soil with a high natural attenuation capacity in southern Ireland (52°51'N, 08°21'W) over a 2-year period. A dense network of shallow groundwater piezometers was installed to determine groundwater flow direction and N spatial and temporal variation. Estimated vertical travel times through the unsaturated zone (<0.5 yr, time lag) allowed the correlation of management with groundwater N within a short space of time. There was a two way interaction of the system and sampling date (P<0.05) on concentrations of DON, oxidised N and NO(3)(-)-N. In contrast, concentrations of NH(4)(+)-N and NO(2)(-)-N were unaffected by the dairy system. Grazing over the winter had no effect on N losses to groundwater. Mean concentrations of DON, NH(4)(+)-N, NO(2)(-)-N and NO(3)(-)-N were 2.16, 0.35, 0.01 and 0.37 mg L(-1) respectively. Soil attenuation processes such as denitrification and DNRA resulted in increased NH(4)(+)-N levels. For this reason, DON and NH(4)(+)-N represented the highest proportion of N losses from the site. Some of the spatial and temporal variation of N concentrations was explained by correlations with selected chemical and hydro-topographical parameters (NO(3)(-)-N/Cl(-) ratio, distance of the sampling point from the closest receptor, watertable depth, depth of sampling piezometer, DOC concentration). A high explanatory power of NO(3)(-)-N/Cl(-) ratio and the distance of the sampling point from the closest receptor indicated the influence of point sources and groundwater-surface water interactions.

Analysis of breeding and pathology helps refine management practices of a large-scale N'-ethyl-N'-nitrosourea mouse mutagenesis programme

N'-ethyl-N'-nitrosourea (ENU) is a powerful germline mutagen used in conjunction with phenotype-driven screens to generate novel mouse mutants. ENU also induces genetic lesions in somatic cells and dosage requires optimization between maximum germline mutation rate versus induced sterility and tumourigenesis that compromise the welfare and fecundity of the ENU-treated males. Here, we present our experience with BALB/cAnNCrl and C57BL/6J mice in terms of the pathology induced by ENU and its impact on breeding. In both mouse strains, morbidity and mortality rises with ENU dose. In more than 75% of C57BL/6J males, morbidity and mortality were attributable to the development of malignant T-lymphoblastic lymphoma. Approximately 50% of ENU-treated BALB/cAnNCrl males develop early malignant T-lymphoblastic lymphoma, but the cohort that survives develops late-onset lung carcinoma. Within strains, the latency of these clinically important tumour(s) was not dosage-dependent, but the proportion of mice developing tumours and consequently removed from the breeding programme increased with ENU dosage. The median number of offspring per ENU-treated C57BL/6J male in standard matings with C3H/HeH females decreased with increasing dosage. The two most important underlying causes for lower male fecundity were increased infertility in the highest dosage group and reduced numbers of litters born to the remaining fertile C57BL/6J males due to a higher incidence of morbidity. These findings have allowed us to refine breeding strategy. To maximize the number of offspring from each ENU-treated male, we now rotate productive males between two cages to expose them to more females. This optimizes the number of mutation carrying offspring while reducing the number of ENU-treated males that must be generated.

A changing climate for grassland research

Here, we review the current genetic approaches for grass improvement and their potential for the enhanced breeding of new varieties appropriate for a sustainable agriculture in a changing global climate. These generally out-breeding, perennial, self-incompatible species present unique challenges and opportunities for genetic analysis. We emphasise their distinctiveness from model species and from the in-breeding, annual cereals. We describe the modern genetic approaches appropriate for their analysis, including association mapping. Sustainability traits discussed here include stress resistance (drought, cold and pathogeneses) and favourable agronomic characters (nutrient use efficiency, carbohydrate content, fatty acid content, winter survival, flowering time and biomass yield). Global warming will predictably affect temperature-sensitive traits such as vernalisation, and these traits are under investigation. Grass biomass utilisation for carbon-neutral energy generation may contribute to reduced atmospheric carbon emissions. Because the wider potential outcomes of climate change are unpredictable, breeders must be reactive to events and have a range of well-characterised germplasm available for new applications.

Microarray comparative genomic hybridisation analysis of intraocular uveal melanomas identifies distinctive imbalances associated with loss of chromosome 3

Defining regions of genomic imbalance can identify genes involved in tumour development. Conventional cytogenetics has identified several nonrandom copy number alterations (CNA) in uveal melanomas (UVM), which include monosomy 3, chromosome 6 abnormalities and gain of 8q. To gain further insight into the CNAs and define the regions involved more precisely we analysed 18 primary UVMs using 1 Mb BAC microarray comparative genomic hybridisation (CGH). Our analysis showed that the most common genomic imbalances were 8q gain (78%), 6p gain (67%) and monosomy 3 (56%). Two distinct CGH profiles could be delineated on the basis of the chromosome 3 status. The most common genetic changes in monosomy 3 tumours, in our study, were gain of 8q11.21-q24.3, 6p25.1-p21.2, 21q21.2-q21.3 and 21q22.13-q22.3 and loss of 1p36.33-p34.3, 1p31.1-p21.2, 6q16.2-q25.3 and 8p23.3-p11.23. In contrast, disomy 3 tumours showed recurrent gains of only 6p25.3-p22.3 and 8q23.2-q24.3. Our approach allowed definition of the smallest overlapping regions of imbalance, which may be important in the development of UVM.

Engagement of Toll-like receptors by mycoplasmal superantigen: downregulation of TLR2 by MAM/TLR4 interaction

Mycoplasma arthritidis mitogen (MAM) is a superantigen (SAg) from M. arthritidis, an agent of murine toxic shock syndrome and arthritis. We previously demonstrated that C3H/HeJ and C3H/HeSnJ mice that differ in expression of TLR4 differed in immune reactivity to MAM. We show here that MAM directly interacts with TLR2 and TLR4 by using monoclonal antibodies to TLR2 and TLR4 which inhibit cytokine responses of THP-1 cells to MAM. Also, using macrophages from C3H substrains and TLR2-deficient mice, we confirmed that both TLR2 and TLR4 are used by MAM. Levels of IL-6 in supernatants of MAM-challenged macrophages were higher in mice which expressed only TLR2, lesser with both TLR2 and TLR4, and absent in mice lacking both TLR2 and TLR4. In addition, expression of TLR2 and TLR4 was moderately upregulated in wild-type cells but cells lacking TLR4 showed a fivefold increase in TLR2 expression. Further, blockade of TLR4 on macrophages of C3H/HeN mice with antibody greatly increased expression of TLR2 and release of IL-12p40 in response to MAM. These results indicate that the SAg, MAM, interacts with both TLR2 and TLR4 and that TLR4 signalling might downregulate the MAM/TLR2 inflammatory response.

A randomised controlled trial of empowerment training for Chinese abused pregnant women in Hong Kong

OBJECTIVE

To evaluate the effectiveness of an empowerment intervention in reducing intimate partner violence (IPV) and improving health status.

DESIGN

Randomised controlled trial.

SETTING

Antenatal clinic in a public hospital in Hong Kong.

SAMPLE

One hundred and ten Chinese pregnant women with a history of abuse by their intimate partners.

METHODS

Women were randomised to the experimental or control group. Experimental group women received empowerment training specially designed for Chinese abused pregnant women while the control group women received standard care for abused women. Data were collected at study entry and six weeks postnatal.

MAIN OUTCOMES MEASURES

IPV [on the Conflict Tactics Scale (CTS)], health-related quality of life (SF-36) and postnatal depression [Edinburgh Postnatal Depression Scale (EPDS)].

RESULTS

Following the training, the experimental group had significantly higher physical functioning and had significantly improved role limitation due to physical problems and emotional problems. They also reported less psychological (but not sexual) abuse, minor (but not severe) physical violence and had significantly lower postnatal depression scores. However, they reported more bodily pain.

CONCLUSION

An empowerment intervention specially designed for Chinese abused pregnant women was effective in reducing IPV and improving the health status of the women.

Introgression-mapping of genes for drought resistance transferred from Festuca arundinacea var. glaucescens into Lolium multiflorum

Procedures for the transfer of genes for drought resistance from Festuca glaucescens (2n=4x=28) into Lolium multiflorum (2n=2x=14) are described. Following the initial hybridisation of a synthetic autotetraploid of L. multiflorum (2n=4x=28) with F. glaucescens, the F1 hybrid was backcrossed twice onto diploid L. multiflorum (2n=2x=14) to produce a diploid Lolium genotype with a single F. glaucescens introgression located distally on the nucleolar organiser region arm of chromosome 3. The transmission of F. glaucescens-derived amplified fragment length polymorphisms and a sequence-tagged-site (STS) marker was monitored throughout the breeding programme. Those genotypes of a mapping population of backcross 3 that survived combined severe drought and heat stress all contained the F. glaucescens-derived markers. The STS marker provided a prototype for a PCR-based system for high-throughput screening during cultivar development for the presence of the F. glaucescens-derived genes for drought resistance. The frequency of intergeneric recombination between L. multiflorum and F. glaucescens is described. During the initial stages of the breeding programme, preferential intraspecific chromosome pairing between Lolium homologues and Festuca homoeologues dominated with low frequencies of intergeneric chromosome associations. However, these increased in the backcross 1 due to the absence of opportunities for intraspecific chromosome pairing between homoeologous Festuca chromosomes following the loss of half of the Festuca chromosomes. Once transferred to Lolium, F. glaucescens sequences recombined with Lolium at high frequencies, thereby enabling the loss of potentially deleterious gene combinations that might reduce the forage quality of Lolium.

Fumonisin contamination of a corn sample associated with the induction of hepatocarcinogenesis in rats-role of dietary deficiencies

A corn sample associated with a field outbreak of equine leukoencephalomalacia in Pennsylvania, USA, during 1983/1984 and induced hepatotoxic and hepatocarcinogenic effects when fed to male Fischer rats was analyzed mycologically and chemically for the presence of fumonisins (FB), hydrolysed FB derivatives and aflatoxins (AFB). Fusarium verticillioides was found to be the predominant fungal contaminant in the corn sample but Aspergillus flavus was also present. Trace amounts (0.1 microg/kg) of AFB(1) and AFB(2) and a total FB level of 33.5 mg/kg (FB(1):FB(2):FB(3) ratio of 9:2.3:1) were found. No hydrolysed FB derivatives or AFG(1) and AFG(2) were detected. Based on the chemical stability of the fumonisins in different corn cultures of F. verticillioides kept at 4 degrees C over a period of 13-20 years, a level of approximately 55 mg/kg of total FB is estimated in the original corn sample. A possible role of certain dietary constituents such as the high protein content and deficiencies in certain micronutrients is evaluated to address differences in the organ-specific toxicity of FB(1) in rats using commercial, semi-purified, purified and corn-only diets.

Email triage of new neurological outpatient referrals from general practice

OBJECTIVES

To determine whether an email triage system between general practitioners and a neurologist for new outpatient referrals is feasible, acceptable, efficient, safe, and effective.

METHODS

This was a prospective single cohort study on the interface between primary care practitioners and the neurology clinic of a district general hospital. Seventy six consecutive patients with neurological symptoms from nine GPs, for whom a specialist opinion was deemed necessary, were entered in the study. The number of participants managed without clinic attendance and the reduction in neurologist's time compared with conventional consultation was measured, as was death, other specialist referral, and change in diagnosis in the 6 months after episode completion. The acceptability for GPs was ascertained by questionnaire.

RESULTS

Forty three per cent of participants required a clinic appointment, 45% were managed by email advice alone, and 12% by email plus investigations. GP satisfaction was high. Forty four per cent of the neurologist's time was saved compared with conventional consultation. No deaths or significant changes in diagnosis were recorded during the 6 month follow up period.

CONCLUSIONS

Email triage is feasible, acceptable to GPs, and safe. It has the potential for making the practice of neurologists more efficient, and this needs to be tested in a larger randomised study.

Role of MC1R variants in uveal melanoma

Variants of the melanocortin-1 receptor (MC1R) gene have been linked to sun-sensitive skin types and hair colour, and may independently play a role in susceptibility to cutaneous melanoma. To assess the role of MC1R variants in uveal melanoma, we have analysed a cohort of 350 patients for the changes within the major region of the gene displaying sequence variation. Eight variants were detected – V60L, D84E, V92M, R151C, I155T, R160W, R163Q and D294H – 63% of these patients being hetero- or homozygous for at least one variant. Standard melanoma risk factor data were available on 119 of the patients. MC1R variants were significantly associated with hair colour (P=0.03) but not skin or eye colour. The frequency of the variants detected in the 350 patients was comparable with those in the general population, and comparison of the cumulative tumour distribution by age at diagnosis in carriers and noncarriers provided no evidence that MC1R variants confer an increased risk of uveal melanoma. We interpret the data as indicating that MC1R variants do not appear to be major determinants of susceptibility to uveal melanoma.

Spirituality and distress in sheltered battered women

PURPOSE

To examine the relationship between spiritual beliefs and psychological distress in sheltered battered women.

DESIGN

A convenience sample of 50 ethnically diverse women who had resided for at least 21 days in battered women's shelters participated. Data were obtained over a 7-month period in 1998 and 1999.

METHODS

Participants completed the Spiritual Perspective Scale (SPS), Symptom Checklist-90-Revised (SCL-90), Conflict Tactics Scale, and a demographic data sheet.

RESULTS

These sheltered battered women placed high value on their spiritual beliefs and used a variety of spiritual practices to aid them. The relationship between the Global Severity Index as measured by the SCL-90 and SPS scores approached statistical significance (r = -.27, p = .06). However, a significant inverse relationship was found between the SPS score and the obsessive-compulsive score (r = -.34, p < .05), interpersonal sensitivity score (r = -.31, p < .05), and hostility dimensions score (r = -.37, p < .01) of the SCL-90.

CONCLUSIONS

The findings indicated that, among these sheltered battered women, spirituality may be associated with greater internal resources that buffer distressing feelings and calm the mind. This study shows support of spirituality as a means of reducing distress through greater connection to oneself and higher powers.

Glucocorticoid-induced osteopenia in the mouse as assessed by histomorphometry, microcomputed tomography, and biochemical markers

Glucocorticoids are potent anti-inflammatory molecules used in the treatment of asthma, rheumatoid arthritis, inflammatory bowel disease, and other inflammatory and dermatological diseases, as well as in posttransplantation immunotherapy. Although glucocorticoids have been prescribed for many years, their potential side effects, when administered orally, can prevent their long-term use. The most serious side effect observed in the clinic is glucocorticoid-induced osteoporosis (GIOP). To develop a small animal model to characterize glucocorticoid-induced bone loss, we carried out a series of experiments using BALB/c mice given daily intraperitoneal doses of the synthetic glucocorticoid, dexamethasone. Following dexamethasone treatment, the mice became osteopenic, with highly significant decreases in bone formation rate and mineral apposition rate, as assessed by standard histomorphometry. Moreover, 3 week treatment with dexamethasone resulted in a decrease in trabecular thickness and trabecular number with an increase in surface-to-volume ratio of trabeculae in the distal femur, as measured using microcomputed tomography (micro-CT). The serum bone formation marker, osteocalcin, was dose-dependently decreased in all mice treated with dexamethasone and showed a parallel extent of regulation to the bone formation rate changes. In addition, serum levels of leptin, recently identified as playing a role in the regulation of bone mass, increased following dexamethasone treatment. BALB/c mice therefore represent a useful model system in which the detrimental effects of glucocorticoids on bone can be studied.

A critical review of rural medical workforce retention in Australia

The problem of how best to recruit and retain doctors in rural and remote communities has led governments to adopt a range of medical workforce incentives, including retention grants. A comprehensive literature survey suggests that medical workforce retention has been poorly distinguished from other supply issues such as recruitment, and that its determinants and the process leading to retention are poorly understood. Such a knowledge gap is likely to limit the effectiveness of retention incentives. This article reports the results of this literature review, and advances a conceptual framework as the basis for ongoing research and evaluating how best to deliver effective retention interventions.

Intimate partner violence against women

Intimate partner violence against women has received considerable attention from nurse-researchers over the past 10 years. Although the amount and sophistication of both quantitative and qualitative research have changed over time, nursing research on intimate partner violence against women has not lost its perspective; nurse-researchers have continued to address women survivors' full range of human responses to violence. Research into violence during pregnancy and battered women's psychological responses to abuse have received considerable attention. Research into violence during pregnancy and battered women's psychological responses to abuse have received considerable attention. Research into violence during pregnancy accounts for fully 20% of all the reviewed nursing research. The largely qualitative research into women's psychological responses to violence is particularly rich and remarkably similar across multiple studies. International studies on intimate partner violence are beginning to appear in the literature and research that addresses the unique experience of ethnically diverse women is occurring with greater frequency. The purpose of this chapter is to review nursing research on intimate partner violence against women in the past decade. Future directions for nursing research, practice, and education are included.

Psychological and physical distress of sheltered battered women

We explored the physical and psychological distress of sheltered battered women. A convenience sample of 50 ethnically diverse women was obtained from women who had resided in two shelters for at least 21 days. Participants had experienced multiple traumatic events (8.1+/-4.6); however, only 19 (38.8%) of the participants were diagnosed with posttraumatic stress disorder (PTSD). When we analyzed biopsychosocial variables, we saw beneficial effects of support (financial, social, spiritual). These findings reinforce the need to enhance the resources of battered women, to help them identify existing opportunities, and to fortify self-caring strategies that give them strength.

Advancing the science of symptom management

Since the publication of the original Symptom Management Model (Larson et al. 1994), faculty and students at the University of California, San Francisco (UCSF) School of Nursing Centre for System Management have tested this model in research studies and expanded the model through collegial discussions and seminars.

AIM

In this paper, we describe the evidence-based revised conceptual model, the three dimensions of the model, and the areas where further research is needed.

BACKGROUND/RATIONALE

The experience of symptoms, minor to severe, prompts millions of patients to visit their healthcare providers each year. Symptoms not only create distress, but also disrupt social functioning. The management of symptoms and their resulting outcomes often become the responsibility of the patient and his or her family members. Healthcare providers have difficulty developing symptom management strategies that can be applied across acute and home-care settings because few models of symptom management have been tested empirically. To date, the majority of research on symptoms was directed toward studying a single symptom, such as pain or fatigue, or toward evaluating associated symptoms, such as depression and sleep disturbance. While this approach has advanced our understanding of some symptoms, we offer a generic symptom management model to provide direction for selecting clinical interventions, informing research, and bridging an array of symptoms associated with a variety of diseases and conditions. Finally, a broadly-based symptom management model allows the integration of science from other fields.

Public health implications of dengue in personnel returning from East Timor

In north Queensland the vector of dengue fever (Aedes aegypti) is present; hence any viraemic individual importing dengue has the potential to transmit the disease locally. In early 2000 approximately 2,000 personnel returned from East Timor to Townsville, north Queensland. Seven importations of dengue occurred and individual cases were viraemic for up to 6 days in Townsville. No subsequent local transmission occurred. There were 3 cases each of dengue type 2 and dengue type 3. One case could not be serotyped. A response, including mosquito control measures, was initiated in another 18 cases in which dengue fever was clinically suspected but which subsequently proved not to be dengue. The planning and processes undertaken to prevent local transmission of dengue in Townsville during an intense period are described.