Perinatal mental healthcare in Northern Ireland: challenges and opportunities

Perinatal mental health is a vital component of public mental health. The perinatal period represents the time in a woman's life when she is at the highest risk of developing new-onset psychiatric disorders or relapse of an existing mental illness. Optimisation of maternal mental health in the perinatal period is associated with both short- and long-term benefits not only for the mother, but also for her infant and family. However, perinatal mental health service provision remains variable across the world. At present in Northern Ireland, 80% of women do not have access to specialist community perinatal mental health services, and without access to a mother and baby unit, mothers who require a psychiatric admission in the postnatal period are separated from their baby. However, following successful campaigns, funding for development of specialist perinatal mental health community teams has recently been approved. In this article, we discuss the importance of perinatal mental health from a public health perspective and explore challenges and opportunities in the ongoing journey of specialist service development in Northern Ireland.

Animal board invited review: Opportunities and challenges in using GWP* to report the impact of ruminant livestock on global temperature change

Ruminant livestock is a large contributor of CH4 emissions globally. Assessing how this CH4 and other greenhouse gases (GHG) from livestock contribute to anthropogenic climate change is key to understanding their role in achieving any temperature targets. The climate impacts of livestock, as well as other sectors or products/services, are generally expressed as CO2-equivalents using 100-year Global Warming Potentials (GWP100). However, the GWP100 cannot be used to translate emission pathways of short-lived climate pollutants (SLCPs) emissions to their temperature outcomes. A key limitation of handling long- and short-lived gases in the same manner is revealed in the context of any potential temperature stabilisation goals: to achieve this outcome, emissions of long-lived gases must decline to net-zero, but this is not the case for SLCPs. A recent alternative metric, GWP* (so-called 'GWP-star'), has been proposed to overcome these concerns. GWP* allows for simple appraisals of warming over time for emission series of different GHGs that may not be obvious if using pulse-emission metrics (i.e. GWP100). In this article, we explore some of the strengths and limitations of GWP* for reporting the contribution of ruminant livestock systems to global temperature change. A number of case studies are used to illustrate the potential use of the GWP* metric to, for example, understand the current contribution of different ruminant livestock production systems to global warming, appraise how different production systems or mitigations compare (having a temporal element), and seeing how possible emission pathways driven by changes in production, emissions intensity and gas composition show different impacts over time. We suggest that for some contexts, particularly if trying to directly infer contributions to additional warming, GWP* or similar approaches can provide important insight that would not be gained from conventional GWP100 reporting.

POS0177 HETEROGENOUS CARTILAGE DAMAGE SEEN ON MRI AMONG KNEES WITH KELLGREN-LAWRENCE 2 & 3 OSTEOARTHRITIS: WHAT ARE THE IMPLICATIONS FOR CLINICAL TRIALS?

Background

The most recent update of the Global Burden of Disease figures (GBD 2013) estimated that 242 million people were living in the world with symptomatic and activity-limiting OA of the hip and/or knee. Many potential disease-modifying osteoarthritis drugs (DMOADs) have been investigated, but to date no DMOADs that slow or stop disease progression have been approved by the Food and Drug Administration (FDA) or the European Medicines Agency (EMA). A potential reason for the lack of demonstrated efficacy may be reliance on radiographs for defining structural inclusion and exclusion criteria for clinical trials, such as use of joint space width and Kellgren-Lawrence (KL) grade as surrogates for cartilage damage.

Objectives

To estimate the distribution of cartilage damage seen on knee MRI in a sample of knees with radiographic KL 2 and 3 OA that would potentially qualify for a DMOAD trial.

Methods

We selected knees from the Osteoarthritis Initiative (OAI), a longitudinal cohort study of knees with or at risk of developing symptomatic radiographic OA, that met common structural inclusion criteria for DMOAD trial enrollment at OAI baseline: knees with radiographs centrally graded as KL 2 or 3 and medial minimum joint space width (mJSW) ≥ 1.5mm. A musculoskeletal radiologist with 10 years of experience in semi-quantitative MRI assessment scored knee cartilage damage in the medial and lateral tibiofemoral and patellofemoral compartments using WORMS (Whole-Organ Magnetic Resonance Imaging Score). Coronal intermediate weighted (IW) TSE and sagittal fat-suppressed IW TSE sequences on 3T MRI were used. The WORMS cartilage scores, which are based on both the extent and depth of cartilage damage, were collapsed into 4 categories: no cartilage damage (WORMS 0 and 1), focal partial or full-thickness (PT/FT) cartilage damage (WORMS 2 and 2.5), diffuse partial thickness (PT) cartilage damage (WORMS 3 and 4), and diffuse full-thickness (FT) cartilage damage (WORMS 5 and 6). We estimated the prevalence of each category of cartilage damage in KL2 and KL3 knees; 95% confidence intervals (CI) accounted for clustering at the participant-level since some participants contributed two knees to the analysis.

Results

We identified 2,372 participants contributing 3,446 knees with radiographic OA (KL 2 and 3) and medial mJSW ≥ 1.5mm. There were 2,318 KL2 knees and 1,128 KL3 knees. The distribution of cartilage damage in each compartment by KL grade is presented in Table 1. We found no cartilage damage in any compartments in 9.8% (95%CI: 8.5, 11.1) of KL2 knees and 2.0% (95%CI: 1.1, 2.9) of KL3 knees. Cartilage damage was absent in the medial tibiofemoral compartment in 52.4% (95%CI: 50.1, 54.6) of KL2 knees, and 14.4% (95%CI: 12.2, 16.6) of KL3 knees, versus 61% (95%CI: 58.8, 63.2) of KL2 knees and 53.6% (95%CI: 50.4, 56.7) of KL3 knees in the lateral compartment. When medial and lateral compartments were combined, cartilage damage was absent in 34.8% (95%CI: 32.7, 36.9) of the KL2 knees, and 4.3% (95%CI: 3.0, 5.5) of the KL3 knees. Diffuse FT cartilage lesions in the medial compartment were found in 6.1% (95%CI: 5.0, 7.1) of KL2 knees and 42.5% (95%CI: 39.4, 45.6) of KL3 knees.

Conclusion

MRI screening prior to clinical trial enrollment may identify a substantial percentage of knees with normal cartilage, as well as knees with diffuse FT cartilage lesions that may not be responsive to DMOADs, depending on the mode of action of a given pharmacological compound.

Disclosure of Interests

Mohamed Jarraya: None declared, Frank Roemer Shareholder of: Boston Imaging Core Lab, Consultant of: California Institute of Biomedical Research, Erin Ashbeck: None declared, John Lynch: None declared, C. Kent Kwoh Consultant of: Novartis, Regeneron, LG Chem, Kolon Tissue Gene, Avalor, Grant/research support from: Pfizer, Lilly, Cumberland, Ali Guermazi Shareholder of: Stock options in BICL, Consultant of: Pfizer, TissueGene, MerckSerono, Regeneron, Novartis, AstraZeneca

The politics of ageing: how to get policymakers to support lifecourse policies

Background

Given that there is not much evidence that ageing imperils the finance and provision of health care, why do so many policymakers act like it does?

Methods

We break conventional wisdom down into myths and realities, identifying the evidence against them.

Results

A first myth is that ageing produces unsustainable health care costs, which in turn, creates intergenerational conflict over public policy. A second myth is that older people behave as a single group, always pursuing policies that benefit themselves. The final myth is that decisions about policy are made by politicians who pander to that elderly block. The first reality is that most of the problems ascribed to inequality between generations (intergenerational equity) are actually problems of inequality within society as a whole that span across age groups (intragenerational equity). The second reality is that policies that address these broader inequalities are built on the life-course perspective, which focuses on identifying the policies which can make people happier and healthier at all ages by drawing on the context and circumstances under which aging occurs. The third reality is that it is possible to construct coalitions of politicians and interests that can develop and support sophisticated life-course policies that lessen the burdens of ageing and health on everybody.

Conclusions

Intergenerational inequality is not, and need not be, a significant problem for rich countries. It is substantially a product of current and past intragenerational inequality, and in fact inequality between generations often goes with inequality within generations. Intergenerational conflict is a distraction from policies that promote greater equality within and between generations, and talk of an ageing crisis is frequently just another version of longstanding arguments against public social investment from cradle to grave.

Genetic associations of fatigue and other symptoms following breast cancer treatment: A prospective study

Background

Cancer-related fatigue, mood disturbances, pain and cognitive disturbance are common after adjuvant cancer therapy, but vary considerably between individuals despite common disease features and treatment exposures. A genetic basis for this variability was explored in a prospective cohort.

Methods

Physical and psychological health of women were assessed prospectively following therapy for early stage breast cancer with self-report questionnaires. Participation in a genetic association sub-study was offered. Indices for the key symptom domains of fatigue, pain, depression, anxiety, and neurocognitive difficulties were empirically derived by principal components analysis from end-treatment questionnaires, and then applied longitudinally. Genetic associations were sought with functional single nucleotide polymorphisms (SNPs) in pro- and anti-inflammatory cytokine genes - tumour necrosis factor (TNF)-α (−308 ​GG), interferon (IFN)-ɣ (+874 ​TA), interleukin (IL)-10 (1082 ​GA and −592 CA), IL-6 (−174 ​GC), IL-1β (−511 ​GA).

Results

Questionnaire data was available for 210 participants, of whom 111 participated in the genetic sub-study. As expected, symptom domain scores generally improved over several months following treatment completion. Tumour and adjuvant treatment related factors were unassociated with either severity or duration of the individual symptom domains, but severity of symptoms at end-treatment was strongly associated with duration for each domain (all p ​< ​0.05). In multivariable analyses, risk genotypes were independently associated with: fatigue with IL-6 -174 ​GG/GC and IL-10 -1082 GG; depression and anxiety with IL-10 -1082 AA; neurocognitive disturbance: TNF-α −308 GG; depression IL-1β (all p ​< ​0.05). The identified SNPs also had cumulative effects in prolonging the time to recovery from the associated symptom domain.

Conclusions

Genetic factors contribute to the severity and duration of common symptom domains after cancer therapy.

•

Common symptoms following breast cancer treatment can be grouped into symptom domains.

•

Symptom domains are useful to describe patterns and trajectories of symptoms following breast cancer treatment.

•

Cytokine gene polymorphisms are associated with the severity and duration of symptom domains following cancer treatment.

•

The symptom severity at final treatment predicts the duration of symptoms.

Learning in lockdown: Using the COVID-19 crisis to teach children about food and climate change

Food systems are significant sources of global greenhouse gas emissions (GHGE). Since emission intensity varies greatly between different foods, changing food choices towards those with lower GHGE could make an important contribution to mitigating climate change. Public engagement events offer an opportunity to communicate these multifaceted issues and raise awareness about the climate change impact of food choices. An interdisciplinary team of researchers was preparing food and climate change educational activities for summer 2020. However, the COVID-19 pandemic and lockdown disrupted these plans. In this paper, we report on shifting these events online over the month of June 2020. We discuss what we did and the reception to our online programme. We then reflect on and highlight issues that arose. These relate to: (1) the power dynamics of children, diet and climate change; (2) mental health, diet and COVID-19; (3) engaging the wider science, agriculture and food communities; (4) the benefits of being unfunded and the homemade nature of this programme; (5) the food system, STEAM (science, technology, engineering, arts and mathematics) and diversity; and (6) how our work fits into our ongoing journey of food and climate change education.

Crotonaldehyde-induced vascular relaxation and toxicity: Role of endothelium and transient receptor potential ankyrin-1 (TRPA1)

INTRODUCTION

Crotonaldehyde (CR) is an electrophilic α,β-unsaturated aldehyde present in foods and beverages and is a minor metabolite of 1,3-butadiene. CR is a product of incomplete combustion, and is at high levels in smoke of cigarettes and structural fires. Exposure to CR has been linked to cardiopulmonary toxicity and cardiovascular disease.

OBJECTIVE

The purpose of this study was to examine the direct effects of CR in murine blood vessels (aorta and superior mesenteric artery, SMA) using an in vitro system.

METHODS AND RESULTS

CR induced concentration-dependent (1-300 μM) relaxations (75-80%) in phenylephrine (PE) precontracted aorta and SMA. Because the SMA was 20× more sensitive to CR than aorta (SMA EC50 3.8 ± 0.5 μM; aorta EC50 76.0 ± 2.0 μM), mechanisms of CR relaxation were studied in SMA. The CR-induced relaxation at low concentrations (1-30 μM) was inhibited by: 1) mechanically-impaired endothelium; 2) Nω-Nitro-L-arginine methyl ester hydrochloride (L-NAME); 3) guanylyl cyclase (GC) inhibitor (ODQ); 4) transient receptor potential ankyrin-1 (TRPA1) antagonist (A967079); and, 5) by non-vasoactive level of nicotine (1 μM). Similarly, a TRPA1 agonist, allyl isothiocyanate (AITC; mustard oil), stimulated SMA relaxation dependent on TRPA1, endothelium, NO, and GC. Consistent with these mechanisms, TRPA1 was present in the SMA endothelium. CR, at higher concentrations (100-300 μM), induced tension oscillations (spasms) and irreversibly impaired contractility (a vasotoxic effect enhanced by impaired endothelium).

CONCLUSIONS

CR relaxation depends on a functional endothelium and TRPA1, whereas vasotoxicity is enhanced by endothelium dysfunction. Thus, CR is both vasoactive and vasotoxic along a concentration continuum.

Establishing nationally representative benchmarks of farm-gate nitrogen and phosphorus balances and use efficiencies on Irish farms to encourage improvements

Agriculture faces considerable challenges of achieving more sustainable production that minimises nitrogen (N) and phosphorus (P) losses and meets international obligations for water quality and greenhouse gas emissions. This must involve reducing nutrient balance (NB) surpluses and increasing nutrient use efficiencies (NUEs), which could also improve farm profitability (a win-win). To set targets and motivate improvements in Ireland, nationally representative benchmarks were established for different farm categories (sector, soil group and production intensity). Annual farm-gate NBs (kg ha^-1) and NUEs (%) for N and P were calculated for 1446 nationally representative farms from 2008 to 2015 using import and export data collected by the Teagasc National Farm Survey (part of the EU Farm Accountancy Data Network). Benchmarks for each category were established using quantile regression analysis and percentile rankings to identify farms with the lowest NB surplus per production intensity and highest gross margins (€ ha^-1). Within all categories, large ranges in NBs and NUEs between benchmark farms and poorer performers show considerable room for nutrient management improvements. Results show that as agriculture intensifies, nutrient surpluses, use efficiencies and gross margins increase, but benchmark farms minimise surpluses to relatively low levels (i.e. are more sustainable). This is due to, per ha, lower fertiliser and feed imports, greater exports of agricultural products, and for dairy, sheep and suckler cattle, relatively high stocking rates. For the ambitious scenario of all non-benchmark farms reaching the optimal benchmark zone, moderate reductions in farm nutrient surpluses were found with great improvements in profitability, leading to a 31% and 9% decrease in N and P surplus nationally, predominantly from dairy and non-suckler cattle. The study also identifies excessive surpluses for each level of production intensity, which could be used by policy in setting upper limits to improve sustainability.

Children and adolescents with type 1 and type 2 diabetes mellitus in the Pediatric Diabetes Consortium Registries: comparing clinical characteristics and glycaemic control

AIM

To compare the characteristics of children and adolescents with type 1 vs. type 2 diabetes in the Pediatric Diabetes Consortium (PDC) registries.

METHODS

Participants were 10 to < 21 years of age at diagnosis; there were 484 with type 1 diabetes and 1236 with type 2 diabetes.

RESULTS

Children and adolescents with type 2 diabetes were more likely to be female, overweight/obese, and from low-income, minority ethnic families. Children and adolescents with type 1 diabetes were more likely to present with diabetic ketoacidosis and have higher mean HbA_1c levels at diagnosis. More than 70% in both cohorts achieved target HbA_1c levels < 58 mmol/mol (< 7.5%) within 6 months, but fewer participants with type 1 than type 2 diabetes were able to maintain target HbA_1c levels after 6 months consistently throughout 3 years post diagnosis. Of the 401 participants with type 2 diabetes with ≥ 24 months diabetes duration on enrolment in the registry, 47% required no insulin treatment. Median C-peptide levels were 1.43 mmol/l in the subset of participants with type 2 diabetes in whom it was measured, but only 0.06 mmol/l in the subset with type 1 diabetes.

CONCLUSIONS

Although families of children and adolescents with type 2 diabetes face greater socio-economic obstacles and risk factors for poor diabetes outcomes, the greater retention of residual endogenous insulin secretion likely contributes to the increased ability of children and adolescents with type 2 diabetes to maintain target HbA_1c during the first 3 years of diabetes diagnosis.

Examining Bias and Reporting in Oral Health Prediction Modeling Studies

Recent efforts to improve the reliability and efficiency of scientific research have caught the attention of researchers conducting prediction modeling studies (PMSs). Use of prediction models in oral health has become more common over the past decades for predicting the risk of diseases and treatment outcomes. Risk of bias and insufficient reporting present challenges to the reproducibility and implementation of these models. A recent tool for bias assessment and a reporting guideline—PROBAST (Prediction Model Risk of Bias Assessment Tool) and TRIPOD (Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis)—have been proposed to guide researchers in the development and reporting of PMSs, but their application has been limited. Following the standards proposed in these tools and a systematic review approach, a literature search was carried out in PubMed to identify oral health PMSs published in dental, epidemiologic, and biostatistical journals. Risk of bias and transparency of reporting were assessed with PROBAST and TRIPOD. Among 2,881 papers identified, 34 studies containing 58 models were included. The most investigated outcomes were periodontal diseases (42%) and oral cancers (30%). Seventy-five percent of the studies were susceptible to at least 4 of 20 sources of bias, including measurement error in predictors ( n = 12) and/or outcome ( n = 7), omitting samples with missing data ( n = 10), selecting variables based on univariate analyses ( n = 9), overfitting ( n = 13), and lack of model performance assessment ( n = 24). Based on TRIPOD, at least 5 of 31 items were inadequately reported in 95% of the studies. These items included sampling approaches ( n = 15), participant eligibility criteria ( n = 6), and model-building procedures ( n = 16). There was a general lack of transparent reporting and identification of bias across the studies. Application of the recommendations proposed in PROBAST and TRIPOD can benefit future research and improve the reproducibility and applicability of prediction models in oral health.

Caesarean section and risk of type 1 diabetes: whole-of-population study

AIM

A hypothesized mechanism for increased type 1 diabetes risk among caesarean births is lack of exposure to the vaginal microbiota. Children born by prelabour caesarean are not exposed to the vaginal microbiota, whereas caesarean births during labour (intrapartum) may be exposed. The aim of this study was to estimate type 1 diabetes risk among children born by caesarean compared with normal vaginal delivery.

METHODS

This whole-of-population study linked routinely collected, de-identified administrative data from the South Australian Early Childhood Data Project for all births from 1999 to 2013. Type 1 diabetes cases were identified using inpatient hospitalizations from 2001 to 2014 (ICD-10-AM codes E10-E109). Type 1 diabetes risk for caesarean was assessed by Cox regression using two models: (i) caesarean vs. vaginal and (ii) prelabour or intrapartum caesarean vs. vaginal. Analyses were adjusted for confounding and multiple imputation was used to address missing data.

RESULTS

A total of 286 058 children born between 1999 and 2013 contributed to 2 200 252 person-years, of which 557 had type 1 diabetes. Of all births, 90 546 (31.7%) were caesarean, and of these 53.1% were prelabour and 46.9% intrapartum caesarean. Compared with vaginal delivery, the adjusted hazard ratio for type 1 diabetes was 1.05 [95% confidence interval (CI) 0.86-1.28) for caesarean, 1.02 (95% CI 0.79-1.32) for prelabour caesarean and 1.08 (95% CI 0.82-1.41) for intrapartum caesarean.

CONCLUSION

There may be a small increased type 1 diabetes risk following caesarean, but confidence intervals included the null. The lower estimate for prelabour compared with intrapartum caesarean, and the potential for unmeasured confounding suggest that neonatal vaginal microbiota might not be involved in type 1 diabetes.

Outcome Study of the Pipeline Embolization Device with Shield Technology in Unruptured Aneurysms (PEDSU)

BACKGROUND AND PURPOSE

The recently introduced Pipeline Flex Embolization Device with Shield Technology (Pipeline Shield) is the third generation of Pipeline flow-diverter devices. It has a new stent-surface modification, which reduces thrombogenicity. We aimed to evaluate clinical and radiographic (safety and efficacy) outcomes of the Pipeline Shield.

MATERIALS AND METHODS

The 30-day and 1-year mortality and morbidity rates and the 6- and 18-month radiographic aneurysm occlusion outcomes for procedures performed between March 2016 and January 2018 were analyzed. 3D-TOF-MRA was used for follow-up.

RESULTS

Forty-four attempted Pipeline Shield procedures were performed for 41 patients with 44 target aneurysms (total of 52 aneurysms treated). A total of 88.5% of devices were inserted in the anterior circulation, and 11.5%, in the posterior circulation; 49/52 (94.2%) aneurysms were saccular; and 1/52 (1.9%) was fusiform. One (1.9%) aneurysm was an iatrogenic pseudoaneurysm, and 1 (1.9%) was a dissecting aneurysm. Seventy-one percent (35/49) of the saccular aneurysms were wide-neck (neck, >4 mm), 34.6% (18/52) were large (≥10 mm), and 3.8% (2/52) were giant (≥25 mm). The mean aneurysm sac maximal diameter was 9.0 mm, and the mean neck width was 5.0 mm. The cumulative mortality and morbidity rates were 2.3% and 6.8% at 1 year, respectively. The adequate occlusion rate was 78.8% at 6 months and 90.3% at 18 months.

CONCLUSIONS

In this pragmatic and non-industry-sponsored study, the occlusion rates and safety outcomes were similar to those seen in previously published studies with flow-diverter devices and earlier generation Pipeline Embolization Devices.

Busting the myth of the ‘greedy elderly’

Background

The politics of ageing are both personal, involving judgements about specific family members as well as broad social groups. This chapter evaluates the argument that governments implement packages of policies that are favorable to the elderly, but that are societally sub-optimal, because of political pressure from the elderly. It begins by laying out the core premises of the “greedy geezer” narrative: because pension transfers, high-cost medical care, and policies that protect transferable assets like housing are highly salient to the elderly and their advocates, intense preferences for these types of policies communicated to politicians and policy-makers will eventually crowd out other, more societally-optimal policies.

Methods

Looking at public opinion data on ageing, intergenerational transfers, and the welfare state this chapter wants to understand both how different publics understand and frame ageing and health as well as what priorities these publics identify, and why?

Results

The elderly and their organized representatives (e.g. pensioner parties, pensioner unions, and advocacy groups) in some contexts do push for policies that are “greedy” in the sense of being beneficial for the elderly or their own children, but not for society as a whole. However, this phenomenon is far from universal: It is especially pronounced in the US and the UK, but much less so in other national contexts. Moreover, the policy packages adopted by national governments are generally motivated by concerns other than appeasing the elderly.

Conclusions

Characterizing the elderly as uniformly “greedy” obscures the fact that inequality among the elderly means that many need more support than they actually receive.

From smartphone to bed-side: exploring the use of social media to disseminate recommendations from the National Tracheostomy Safety Project to front-line clinical staff

Traditional methods used to disseminate educational resources to front-line healthcare staff have several limitations. Social media may increase the visibility of these resources among targeted groups and communities. Our project aimed to disseminate key clinical messages from the National Tracheostomy Safety Project to those caring for patients with tracheostomies or laryngectomies. We commissioned an external media company to design educational material and devise a marketing strategy. We developed videos to communicate recommendations from the safety project and used Facebook, Twitter, YouTube and LinkedIn to deliver these to our target users. We recorded 629,270 impressions over a paid 12-week campaign. Our YouTube channel registered more than a five-fold increase in views and watch time during the campaign as compared with the previous year. Around two-thirds of views across all platforms were from peer-to-peer sharing. We spent £4140 on social media advertising, with each view and click costing £0.02 and £0.67, respectively. This intelligence-led approach using social media is an effective and efficient method to disseminate knowledge on the principles of safe tracheostomy care to front-line clinical staff. Similar strategies may be effective for other patient safety topics, especially when targeting groups that do not use medical journals or other traditional means of dissemination.

Signal intensity alteration within infrapatellar fat pad predicts knee replacement within 5 years: data from the Osteoarthritis Initiative

OBJECTIVE

To investigate whether infrapatellar fat pad (IPFP) signal intensity (SI) alteration predicts the occurrence of knee replacement (KR) in knee osteoarthritis (OA) patients over 5 years.

DESIGN

The subjects were selected from Osteoarthritis Initiative (OAI) study. Case knees (n = 127) were defined as those who received KR during 5 years follow-up visit. They were matched by gender, age and radiographic status with control knees (n = 127). We used T2-weighted MR images to measure IPFP SI alteration using a newly developed algorithm in MATLAB. The measurements were assessed at baseline (BL), T0 (the visit just before KR) and 1 year before T0 (T-1). Conditional logistic regression was used to analyse the associations between IPFP SI alterations and the risk of KR.

RESULTS

Participants were mostly female (57%), with an average age of 63.7 years old and a mean body mass index (BMI) of 29.5 kg/m². In multivariable analysis, the standard deviation (SD) of IPFP SI [sDev (IPFP)] and the ratio of high SI region volume to whole IPFP volume [Percentage (H)] measured at BL were significantly associated with increased risks of KR after adjustment for covariates. IPFP SI alterations measured at T-1 including sDev (IPFP), Percentage (H) and clustering effect of high SI [Clustering factor (H)] were significantly associated with higher risks of KR. All measurements were significantly associated with higher risks of KR at T0.

CONCLUSIONS

IPFP SI is associated with the occurrence of KR suggesting it may play a role in end-stage knee OA.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Twice-Daily Insulin Regimens in Management of Severe Diabetes

Diurnal glucose profiles have been compared in ten insulin dependent diabetics receiving, firstly, a twice-daily soluble insulin (SI): isophane insulin (NPHI) regimen containing a high proportion of SI (mean 73%) and, secondly, Mixtard insulin (30% SI, 70% NPHI). For each patient the two regimens gave similar profiles though nocturnal blood glucose control was better on Mixtard. HbA1 values were similar on the two regimens. The findings show that, using highly purified formulations, small changes in insulin proportions in twice-daily SI: NPHI regimens may be irrelevant to diabetic control; they also suggest that highly purified NPHI may have a substantially shorter duration of action than its older counterpart and that the convenient regimen of twice-daily Mixtard is usually as good as any more complicated ‘tailormade’ regimen of highly purified insulins.

Coherency image analysis to quantify collagen architecture: implications in scar assessment

A novel technique for the fast and robust quantification of collagen architecture following scarring.

DXA-derived hip shape is related to osteoarthritis: findings from in the MrOS cohort

OBJECTIVE

Statistical shape modelling (SSM) of radiographs has been used to explore relationships between altered joint shape and hip osteoarthritis (OA). We aimed to apply SSM to Dual-energy X-ray Absorptiometry (DXA) hip scans, and examine associations between resultant hip shape modes (HSMs), radiographic hip OA (RHOA), and hip pain, in a large population based cohort.

METHOD

SSM was performed on baseline hip DXA scans from the Osteoporotic Fractures in Men (MrOS) Study. Associations between the top ten HSMs, and prevalent RHOA from pelvic radiographs obtained 4.6 years later, were analysed in 4100 participants. RHOA was defined as Croft score ≥2. Hip pain was based on pain on walking, hip pain on examination, and Western Ontario and McMaster Universities Arthritis Index (WOMAC).

RESULTS

The five HSMs associated with RHOA showed features of either pincer- or cam-type deformities. HSM 1 (increased pincer-type deformity) was positively associated with RHOA [1.23 (1.09, 1.39)] [odds ratio (OR) and 95% CI]. HSM 8 (reduced pincer-type deformity) was inversely associated with RHOA [0.79 (0.70, 0.89)]. HSM 10 (increased cam-type deformity) was positively associated with RHOA [1.21 (1.07, 1.37)]. HSM 3 and HSM 4 (reduced cam-type deformity) were inversely associated with RHOA [0.73 (0.65, 0.83) and 0.82 (0.73, 0.93), respectively]. HSM 3 was inversely related to pain on examination [0.84 (0.76, 0.92)] and walking [0.88, (0.81, 0.95)], and to WOMAC score [0.87 (0.80, 0.93)].

CONCLUSIONS

DXA-derived measures of hip shape are associated with RHOA, and to a lesser extent hip pain, possibly reflecting their role in the pathogenesis of hip OA.

On the calculation of the reliability of general load sharing systems

Harlow et al. (1983) have given a recursive formula which is fundamental for computing the bundle strength distribution under a general class of load sharing rules called monotone load sharing rules. As the bundle size increases, the formula becomes prohibitively complex and, by itself, does not give much insight into the relationship of the assumed load sharing rule to the overall strength distribution. In this paper, an algorithm is given which gives some additional insight into this relationship. Here it is shown how to explicitly compute the bundle strength survival distribution by using a new type of graph called the loading diagram. The graph is parallel in structure and recursive in nature and so would appear to lend itself to large-scale computation. In addition, the graph has an interesting property (which we refer to as the cancellation property) which is related to the asymptotics of the Weibull as a minimum stable law.

Total Positivity of Markov Chains and the Failure Rate Character of Some First Passage Times

It is shown that totally positive order 2 (TP2) properties of the infinitesimal generator of a continuous-time Markov chain with totally ordered state space carry over to the chain's transition distribution function. For chains with such properties, failure rate characteristics of the first passage times are established. For Markov chains with partially ordered state space, it is shown that the first passage times have an IFR distribution under a multivariate total positivity condition on the transition function.