Colonoscopic cancer detection rate: a new performance measure - is it FIT for purpose?

Introduction

Gastrointestinal symptoms correlate poorly with cancer diagnosis. A faecal immunochemical test (FIT) result of ≥10 µg has high sensitivity and negative predictive value for colorectal cancer (CRC) detection. An FIT-based diagnostic pathway may lead to more effective resource utilisation. We aimed to use National Endoscopy Database (NED) data to create a new colonoscopy performance measure, cancer detection rate (CDR) to assess the appropriate identification of target populations for colonoscopy; then to use CDR to assess the impact of implementing an FIT-based referral pathway locally.

Methods

NED data were analysed to compare local diagnostic colonoscopic CDR in 2019 (prepathway revision) and 2021 (postpathway revision), benchmarked against overall national CDR for the same time frames.

Results

1, 123, 624 NED diagnostic colonoscopies were analysed. Locally, there was a significant increase in CDR between 2019 and 2021, from 3.01% (2.45%-3.47%) to 4.32% (3.69%-4.95%), p=0.003. The CDR increase was due to both a 10% increase in the number of CRCs detected and a 25% reduction in the number of diagnostic colonoscopies performed. Nationally, there was a smaller, but significant, increase in CDR from 2.02% (1.99%-2.07%) to 2.33% (2.29%-2.37%), p<0.001. The rate of increase in CDR% between 2019 and 2021 was significantly different locally compared with nationally.

Conclusion

Our study indicates that the introduction of a robustly vetted FIT-based algorithm to determine whether diagnostic colonoscopy is required, is effective in increasing the colonoscopic CDR. Moreover, CDR appears to be a meaningful performance metric that can be automatically calculated through NED, enabling monitoring of the quality of referral and vetting pathways.

Arrest of mouse preterm labor until term delivery by combination therapy with atosiban and mundulone, a natural product with tocolytic efficacy

There is a lack of FDA-approved tocolytics for the management of preterm labor (PL). In prior drug discovery efforts, we identified mundulone and mundulone acetate (MA) as inhibitors of in vitro intracellular Ca2+-regulated myometrial contractility. In this study, we probed the tocolytic potential of these compounds using human myometrial samples and a mouse model of preterm birth. In a phenotypic assay, mundulone displayed greater efficacy, while MA showed greater potency and uterine-selectivity in the inhibition of intracellular-Ca2+ mobilization. Cell viability assays revealed that MA was significantly less cytotoxic. Organ bath and vessel myography studies showed that only mundulone exerted inhibition of myometrial contractions and that neither compounds affected vasoreactivity of ductus arteriosus. A high-throughput combination screen identified that mundulone exhibits synergism with two clinical-tocolytics (atosiban and nifedipine), and MA displayed synergistic efficacy with nifedipine. Of these combinations, mundulone+atosiban demonstrated a significant improvement in the in vitro therapeutic index compared to mundulone alone. The ex vivo and in vivo synergism of mundulone+atosiban was substantiated, yielding greater tocolytic efficacy and potency on myometrial tissue and reduced preterm birth rates in a mouse model of PL compared to each single agent. Treatment with mundulone after mifepristone administration dose-dependently delayed the timing of delivery. Importantly, mundulone+atosiban permitted long-term management of PL, allowing 71% dams to deliver viable pups at term (>day 19, 4-5 days post-mifepristone exposure) without visible maternal and fetal consequences. Collectively, these studies provide a strong foundation for the development of mundulone as a single or combination tocolytic for management of PL.

Arrest of mouse preterm labor until term delivery by combination therapy with atosiban and mundulone, a natural product with tocolytic efficacy

Currently, there is a lack of FDA-approved tocolytics for the management of preterm labor (PL). In prior drug discovery efforts, we identified mundulone and its analog mundulone acetate (MA) as inhibitors of in vitro intracellular Ca 2+ -regulated myometrial contractility. In this study, we probed the tocolytic and therapeutic potential of these small molecules using myometrial cells and tissues obtained from patients receiving cesarean deliveries, as well as a mouse model of PL resulting in preterm birth. In a phenotypic assay, mundulone displayed greater efficacy in the inhibition of intracellular-Ca 2+ from myometrial cells; however, MA showed greater potency and uterine-selectivity, based IC 50 and E max values between myometrial cells compared to aorta vascular smooth muscle cells, a major maternal off-target site of current tocolytics. Cell viability assays revealed that MA was significantly less cytotoxic. Organ bath and vessel myography studies showed that only mundulone exerted concentration-dependent inhibition of ex vivo myometrial contractions and that neither mundulone or MA affected vasoreactivity of ductus arteriosus, a major fetal off-target of current tocolytics. A high-throughput combination screen of in vitro intracellular Ca 2+ -mobilization identified that mundulone exhibits synergism with two clinical-tocolytics (atosiban and nifedipine), and MA displayed synergistic efficacy with nifedipine. Of these synergistic combinations, mundulone + atosiban demonstrated a favorable in vitro therapeutic index (TI)=10, a substantial improvement compared to TI=0.8 for mundulone alone. The ex vivo and in vivo synergism of mundulone and atosiban was substantiated, yielding greater tocolytic efficacy and potency on isolated mouse and human myometrial tissue and reduced preterm birth rates in a mouse model of PL compared to each single agent. Treatment with mundulone 5hrs after mifepristone administration (and PL induction) dose-dependently delayed the timing of delivery. Importantly, mundulone in combination with atosiban (FR 3.7:1, 6.5mg/kg + 1.75mg/kg) permitted long-term management of PL after induction with 30 μg mifepristone, allowing 71% dams to deliver viable pups at term (> day 19, 4-5 days post-mifepristone exposure) without any visible maternal and fetal consequences. Collectively, these studies provide a strong foundation for the future development of mundulone as a stand-alone single- and/or combination-tocolytic therapy for management of PL.

The Effects of Noninvasive Vagus Nerve Stimulation on Fatigue in Participants With Primary Sjögren's Syndrome

OBJECTIVES

Fatigue is one of the most important symptoms needing improvement in Primary Sjögren's syndrome (PSS). Previous data from our group suggest that noninvasive stimulation of the vagus nerve (nVNS) may improve symptoms of fatigue. This experimental medicine study uses the gammaCore device (electroCore) and a sham device to investigate the relationship between nVNS and fatigue in PSS, and to explore potential mechanisms involved.

MATERIALS AND METHODS

Forty participants with PSS were randomly assigned to use active (n = 20) or sham (n = 20) nVNS devices twice daily for 54 days in a double-blind manner. Patient-reported measures of fatigue were collected at baseline and day 56: Profile of Fatigue (PRO-F)-Physical, PRO-F-Mental and Visual Analogue Scale of abnormal fatigue (fVAS). Neurocognitive tests, immunologic responses, electroencephalography alpha reactivity, muscle acidosis, and heart rate variability were compared between devices from baseline to day 56 using analysis of covariance.

RESULTS

PRO-F-Physical, PRO-F-Mental, and fVAS scores were significantly reduced at day 56 in the active group only (p = 0.02, 0.02, and 0.04, respectively). Muscle bioenergetics and heart rate variability showed no change between arms. There were significant improvements in digit span and a neurocognitive test (p = 0.03), and upon acute nVNS stimulation, frontal region alpha reactivity showed a significant negative relationship with fatigue scores in the active group (p < 0.01).

CONCLUSIONS

We observed significant improvements in three measures of fatigue at day 56 with the active device but not the sham device. Directly after device use, fatigue levels correlate with measures of alpha reactivity, suggesting modulation of cholinergic system integrity as a mechanism of action for nVNS.

Meta-Analysis of Exploring the Effect of Curcumin Supplementation with or without Other Advice on Biochemical and Anthropometric Parameters in Patients with Metabolic-Associated Fatty Liver Disease (MAFLD)

Metabolic (dysfunction)-associated fatty liver disease (MAFLD), previously known as non-alcoholic fatty liver disease (NAFLD), is the most common chronic liver disease. MAFLD is characterized by the excessive presence of lipids in liver cells and metabolic diseases/dysfunctions, e.g., obesity, diabetes, pre-diabetes, or hypertension. Due to the current lack of effective drug therapy, the potential for non-pharmacological treatments such as diet, supplementation, physical activity, or lifestyle changes is being explored. For the mentioned reason, we reviewed databases to identify studies that used curcumin supplementation or curcumin supplementation together with the use of the aforementioned non-pharmacological therapies. Fourteen papers were included in this meta-analysis. The results indicate that the use of curcumin supplementation or curcumin supplementation together with changes in diet, lifestyle, and/or physical activity led to statistically significant positive changes in alanine aminotransferase (ALT), aspartate aminotransferase (AST), fasting blood insulin (FBI), homeostasis model assessment of insulin resistance (HOMA-IR), total triglycerides (TG), total cholesterol (TC), and waist circumference (WC). It appears that these therapeutic approaches may be effective in alleviating MAFLD, but more thorough, better designed studies are needed to confirm this.

An assessment of heart rate and blood pressure asymmetry in the diagnosis of vasovagal syncope in females

Introduction: Heart Rate Asymmetry (HRA) describes a phenomenon of differences between accelerations and decelerations in human heart rate. Methods used for HRA assessment can be further implemented in the evaluation of asymmetry in blood pressure variations (Blood Pressure Asymmetry-BPA). Methods: We have analyzed retrospectively the series of heartbeat intervals extracted from ECG and beat-to-beat blood pressure signals from 16 vasovagal patients (age: 32.1 ± 13.3; BMI: 21.6 ± 3.8; all female) and 19 healthy subjects (age: 34.6 ± 7.6; BMI: 22.1 ± 3.4; all female) who have undergone tilt test (70°). Asymmetry was evaluated with Poincaré plot-based methods for 5 min recordings from supine and tilt stages of the test. The analyzed biosignals were heart rate (RR), diastolic (dBP) and systolic Blood Pressure (sBP) and Pulse Pressure (PP). In the paper we explored the differences between healthy and vasovagal women. Results: The changes of HRA indicators between supine and tilt were observed only in the control group (Porta Index p = 0.026 and Guzik Index p = 0.005). No significant differences in beat-to-beat variability (i.e. spread of points across the line of identity in Poincaré plot-SD1) of dBP was noted between supine and tilt in the vasovagal group (p = 0.433 in comparison to p = 0.014 in healthy females). Moreover, in vasovagal patients the PP was significantly different (supine: 41.47; tilt: 39.27 mmHg) comparing to healthy subjects (supine: 35.87; tilt: 33.50 mmHg) in supine (p = 0.019) and in tilt (p = 0.014). Discussion: Analysis of HRA and BPA represents a promising method for the evaluation of cardiovascular response to orthostatic stressors, however currently it is difficult to determine a subject's underlying health condition based only on these parameters.

Assessing a 12-month course of oral alendronate for adults with avascular necrosis of the hip: MANTIS RCT with internal pilot

Background

People with avascular necrosis of the hip have very limited treatment options currently available to stop the progression of this disease; this often results in the need for a hip replacement. There is some weak evidence that a class of drugs called bisphosphonates may delay the course of the disease, and this trial was commissioned and set up to provide robust evidence regarding the use of bisphosphonates in adults aged ≥ 18 years with this condition.

Objectives

The aim of the Managing Avascular Necrosis Treatments: an Interventional Study (MANTIS) trial was to evaluate the clinical effectiveness and cost-effectiveness of a 12-month course of alendronate in the treatment of avascular necrosis.

Design

This was a 66-month, definitive, multisite, two-arm, parallel-group, placebo-controlled, double-blind, randomised controlled trial, with an internal pilot phase.

Setting

Eight secondary care NHS hospitals across the UK.

Participants

Planned trial size – 280 adult patients with avascular necrosis.

Intervention

Participants in the intervention group received 70 mg of alendronate (an oral bisphosphonate) weekly for 12 months.

Main outcomes

The main outcomes were Oxford Hip Score at 12 months (short-term outcome) and the time to decision that a hip replacement is required at 36 months (long-term outcome).

Results

Twenty-one patients were recruited and randomised to receive either the intervention drug, alendronate, or a placebo-matched tablet.

Limitations

This trial was principally limited by low disease prevalence. Other limitations included the late disease stage at which participants were identified and the rapid progression of the disease.

Future work

This trial was limited by a low recruitment rate. Avascular necrosis of the hip should be treated as a rare disease. Future trials would need to recruit many more sites and recruit over a longer time period, and, for this reason, a registry may provide a more effective means of collecting data pertaining to this disease.

Conclusions

The MANTIS trial was terminated at the end of the pilot phase, because it did not meet its go/no-go criteria. The main issue was a poor recruitment rate, owing to a lower than expected disease prevalence and difficulties in identifying the condition at a sufficiently early stage. Those patients who were identified and screened either were too advanced in their disease progression or were already taking medication. We would not recommend that a short-term interventional study is conducted on this condition until its prevalence, geographic foci and natural history and better understood. The difficulty of acquiring this understanding is likely to be a barrier in most health-care markets. One means of developing this understanding would be the introduction of a database/registry for patients suffering from avascular necrosis of the hip.

Trial registration

The trial is registered as ISRCTN14015902.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 43. See the NIHR Journals Library website for further project information.

One-Year Neurodevelopmental Outcomes After Neonatal Opioid Withdrawal Syndrome: A Prospective Cohort Study

PURPOSE

The aims of this study were, in a cohort of children with neonatal opioid withdrawal syndrome (NOWS), (a) to report 1-year neurodevelopmental outcomes and specifically characterize speech, language, and hearing outcomes and (b) to report the prevalence of cleft lip and/or cleft palate.

METHOD

This prospective observational cohort study includes newborns with confirmed in utero opioid exposure who received pharmacological treatment for NOWS. During 1-year-old developmental visits, we administered standardized assessments (Bayley Scales of Infant and Toddler Development-Third Edition [Bayley-III] or Developmental Assessment of Young Children-Second Edition [DAYC-2]-due to COVID-19 restrictions). We compared Bayley-III scores to standardized population means using one-sample z tests. We report estimates, 95% confidence intervals, and two-sided p values.

RESULTS

We enrolled 202 infants (October 2018 to March 2020). Follow-up at 1-year was 80%. Infants with NOWS had lower Bayley-III scores at 1 year compared to published norms for cognitive, language, and motor domains. One infant with NOWS was diagnosed with isolated cleft palate and Pierre Robin sequence. All infants passed the newborn hearing screen, and 7.5% had a formal hearing evaluation after neonatal intensive care unit discharge, with 40% having abnormal or inconclusive results; middle ear effusion was the leading cause of abnormal hearing (66.7%). Ten percent of children received a speech-language pathology referral prior to 2 years of age. Infants born to mothers with mental health conditions were more likely to have Bayley-III or DAYC-2 scores below 95 in language or motor domains.

CONCLUSIONS

Infants with pharmacologically treated NOWS have significantly lower cognitive, language, and motor scores on standardized developmental testing compared to population means at 1 year of age. Early speech-language pathology referral is frequently necessary to promote optimal development in this population.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20044403.

Cerebral perfusion and neurological examination characterise neonatal opioid withdrawal syndrome: a prospective cohort study

OBJECTIVE

To test the hypothesis that cerebral blood flow (CBF) assessed with arterial spin labelling (ASL) MRI is increased and standardised neurological examination is altered in infants with neonatal opioid withdrawal syndrome (NOWS) compared with those without.

DESIGN

Prospective cohort study.

SETTING

Level IV neonatal intensive care unit and outpatient primary care centre.

PARTICIPANTS

Infants with NOWS receiving pharmacological treatment and unexposed controls matched for gestational age at birth and post-menstrual age at MRI.

MAIN OUTCOMES

CBF assessed by ASL on non-sedated 3-Tesla MRI and standardised Hammersmith Neonatal Neurological Examination (HNNE) within 14 days of birth.

RESULTS

Thirty infants with NOWS and 31 control infants were enrolled and included in the final analysis. Global CBF across the brain was higher in the NOWS group compared with controls (14.2 mL/100 g/min±5.5 vs 10.7 mL/100 g/min±4.3, mean±SD, Cohen's d=0.72). HNNE total optimality score was lower in the NOWS group compared with controls (25.9±3.6 vs 28.4±2.4, mean±SD, Cohen's d=0.81). A penalised logistic regression model including both CBF and HNNE items discriminated best between the two groups.

CONCLUSIONS

Increased cerebral perfusion and neurological examination abnormalities characterise infants with NOWS compared with those without intrauterine drug exposure and suggest prenatal substance exposure affects fetal brain development. Identifying neurological and neuroimaging characteristics of infants with NOWS can contribute to understanding mechanisms underlying later outcomes and to designing potential new treatments.

Effect of moderate to high intensity aerobic exercise on blood pressure in young adults: The TEPHRA open, two-arm, parallel superiority randomized clinical trial

BACKGROUND

Exercise is advised for young adults with elevated blood pressure, but no trials have investigated efficacy at this age. We aimed to determine whether aerobic exercise, self-monitoring and motivational coaching lowers blood pressure in this group.

METHODS

The study was a single-centre, open, two-arm, parallel superiority randomized clinical trial with open community-based recruitment of physically-inactive 18-35 year old adults with awake 24 h blood pressure 115/75mmHg-159/99 mmHg and BMI<35 kg/m². The study took place in the Cardiovascular Clinical Research Facility, John Radcliffe Hospital, Oxford, UK. Participants were randomized (1:1) with minimisation factors sex, age (<24, 24-29, 30-35 years) and gestational age at birth (<32, 32-37, >37 weeks) to the intervention group, who received 16-weeks aerobic exercise training (three aerobic training sessions per week of 60 min per session at 60-80% peak heart rate, physical activity self-monitoring with encouragement to do 10,000 steps per day and motivational coaching to maintain physical activity upon completion of the intervention. The control group were sign-posted to educational materials on hypertension and recommended lifestyle behaviours. Investigators performing statistical analyses were blinded to group allocation. The primary outcome was 24 h awake ambulatory blood pressure (systolic and diastolic) change from baseline to 16-weeks on an intention-to-treat basis. Clinicaltrials.gov registered on March 30, 2016 (NCT02723552).

FINDINGS

Enrolment occurred between 30/06/2016-26/10/2018. Amongst the 203 randomized young adults (n = 102 in the intervention group; n = 101 in the control group), 178 (88%; n = 76 intervention group, n = 84 control group) completed 16-week follow-up and 160 (79%; n = 68 intervention group, n = 69 control group) completed 52-weeks follow-up. There were no group differences in awake systolic (0·0 mmHg [95%CI, -2·9 to 2·8]; P = 0·98) or awake diastolic ambulatory blood pressure (0·6 mmHg [95%CI, -1·4. to 2·6]; P = 0·58). Aerobic training increased peak oxygen uptake (2·8 ml/kg/min [95%CI, 1·6 to 4·0]) and peak wattage (14·2watts [95%CI, 7·6 to 20·9]) at 16-weeks. There were no intervention effects at 52-weeks follow-up.

INTEPRETATION

These results do not support the exclusive use of moderate to high intensity aerobic exercise training for blood pressure control in young adults.

FUNDING

Wellcome Trust, British Heart Foundation, National Institute for Health Research, Oxford Biomedical Research Centre.

Association between hip joint impingement and lumbar disc disease in elite rowers

Objectives

Lumbar disc disease is a known cause of back pain. Increasingly it is thought that cam morphology of the hip may have a causal role in development of lumbar disc disease. The aim of this study was to describe the morphology of the hip and investigate the association of cam morphology with lumbar disc disease observed on MRI in elite rowers.

Methods

Cross-sectional observational study of 20 elite rowers (12 male, 8 female, mean age 24.45, SD 2.1). Assessment included clinical examination, questionnaires, 3T MRI scans of the hips and lumbar spine. Alpha angle of the hips and Pfirrmann score of lumbar discs were measured.

Results

85% of rowers had a cam morphology in at least one hip. Alpha angle was greatest at the 1 o’clock position ((bone 70.9 (SD 16.9), cartilage 71.4 (16.3)). 95% of the group were noted to have labral tears, but only 50% of the group had history of groin pain. 85% of rowers had at least one disc with a Pfirrmann score of 3 or more and 95% had a history of back pain. A positive correlation was observed between the alpha angle and radiological degenerative disc disease (correlation coefficient=3.13, p=0.012). A negative correlation was observed between hip joint internal rotation and radiological degenerative disc disease (correlation coefficient=−2.60, p=0.018).

Conclusions

Rowers have a high prevalence of labral tears, cam morphology and lumbar disc disease. There is a possible association between cam morphology and radiological lumbar degenerative disc disease, however, further investigation is required.

Predictive factors of in-hospital mortality in patients with laboratory-confirmed Escherichia coli, Klebsiella species or Pseudomonas aeruginosa bloodstream infections

Gram-negative bloodstream infections (GNBSI) are confirmed by the presence of gram-negative bacteria in the bloodstream and pose a significant healthcare issue as they increase the risk of sepsis and mortality. In England, the aim is to reduce GNBSI cases and further deterioration through enhanced population surveillance of patients with a laboratory-confirmed GNBSI to inform on healthcare policies. The objective of this study was to evaluate the factors associated with in-hospital mortality in patients with a laboratory-confirmed Escherichia coli, Klebsiella or Pseudomonas aeruginosa GNBSIs, with data obtained from the enhanced data capture for the surveillance of GNBSIs. All patients with a laboratory-confirmed GNBSI at a single centre, admitted between April 2017 and March 2019, were included in this retrospective observational study. Demographic and recent exposure to healthcare risk factors were collected and assessed for the association with in-hospital mortality. In 1113 patients with laboratory-confirmed GNBSIs, the in-hospital mortality rate was 13%. Multivariable analysis confirmed that patients with respiratory (OR = 3.73, 95%CI = 2.05-6.76), gastrointestinal (2.61; 1.22-5.58) or skin (3.61; 1.24-10.54) infection primary focus had a greater risk of in-hospital mortality, compared to upper urinary tract infections. Increased risk of in-hospital mortality was also observed in patients with hospital-onset GNBSIs (OR = 1.87; 1.17-2.97) compared with community-onset healthcare acquired GNBSIs, or who were on dialysis at the time of the GNBSI (3.28; 1.01-10.14), as well as in patients who had recently been discharged from hospital (1.55; 1.01-2.38), or had a vascular device recently manipulated (2.41; 1.01-5.74). Results confirm that the data obtained from the enhanced data capture for GNBSIs in England can predict in-hospital mortality in patients with a GNBSI. Several factors associated with an increased risk of in-hospital mortality have been identified. Results should be reported back to clinicians in order to identify patients at a greater risk of dying in-hospital who may benefit from further monitoring.

Interspecific and intraspecific foraging differentiation of neighbouring tropical seabirds

BACKGROUND

Social interactions, reproductive demands and intrinsic constraints all influence foraging decisions in animals. Understanding the relative importance of these factors in shaping the way that coexisting species within communities use and partition resources is central to knowledge of ecological and evolutionary processes. However, in marine environments, our understanding of the mechanisms that lead to and allow coexistence is limited, particularly in the tropics.

METHODS

Using simultaneous data from a suite of animal-borne data loggers (GPS, depth recorders, immersion and video), dietary samples and stable isotopes, we investigated interspecific and intraspecific differences in foraging of two closely-related seabird species (the red-footed booby and brown booby) from neighbouring colonies on the Cayman Islands in the Caribbean.

RESULTS

The two species employed notably different foraging strategies, with marked spatial segregation, but limited evidence of interspecific dietary partitioning. The larger-bodied brown booby foraged within neritic waters, with the smaller-bodied red-footed booby travelling further offshore. Almost no sex differences were detected in foraging behaviour of red-footed boobies, while male and female brown boobies differed in their habitat use, foraging characteristics and dietary contributions. We suggest that these behavioural differences may relate to size dimorphism and competition: In the small brown booby population (n < 200 individuals), larger females showed a higher propensity to remain in coastal waters where they experienced kleptoparasitic attacks from magnificent frigatebirds, while smaller males that were never kleptoparasitised travelled further offshore, presumably into habitats with lower kleptoparasitic pressure. In weakly dimorphic red-footed boobies, these differences are less pronounced. Instead, density-dependent pressures on their large population (n > 2000 individuals) and avoidance of kleptoparasitism may be more prevalent in driving movements for both sexes.

CONCLUSIONS

Our results reveal how, in an environment where opportunities for prey diversification are limited, neighbouring seabird species segregate at-sea, while exhibiting differing degrees of sexual differentiation. While the mechanisms underlying observed patterns remain unclear, our data are consistent with the idea that multiple factors involving both conspecifics and heterospecifics, as well as reproductive pressures, may combine to influence foraging differences in these neighbouring tropical species.

Improving the identification of patients with a genetic diagnosis of familial hypercholesterolaemia in primary care: A strategy to achieve the NHS long term plan

BACKGROUND AND AIMS

We aimed to validate a nurse-led process using electronic health records to identify those at risk of familial hypercholesterolaemia (FH) for genetic diagnosis in primary care.

METHODS

Those at risk of FH were identified using searches developed and refined locally and implemented in primary care by a trained nurse; they were invited for further assessment and genetic testing if indicated. Family members at risk of FH were identified and invited for cascade testing.

RESULTS

In total 94,444 patient records were screened (expected prevalence of FH (1 in 250); 377). Of 176 records which already had a diagnostic for FH, 15 had been genetically confirmed and one was undergoing DNA testing. A further 572 (0.61%) were identified as high risk of FH. After desktop screening, 113 (15%) were invited for further assessment. Of these, 73 individuals attended the primary care clinic (64%) of whom 61 (54%) underwent proband genetic testing. Pathogenic variants were detected in 22 cases (36%) and variants of unknown significance in a further 4 cases; a total of 26 probands (43%) were therefore referred for family cascade testing.

CONCLUSIONS

An optimised FH identification pathway, based on the NICE CG71 recommendations for systematic searching of primary care electronic health records, can be deployed successfully in primary care settings.

New insights into the socio-economic aspects of multiple sclerosis in a cohort of Polish patients

INTRODUCTION AND OBJECTIVE

The diagnosis of multiple sclerosis (MS) affects the socio-economic aspects of patients' lives and poses new challenges. The objectives of the study were: 1) to determine selected socio-economic aspects of MS in Poland in relation to the disease type and patients' place of residence, and 2) to evaluate the profile of patients via the MS Society (MSS) and the occupational consequences of informing an employer about the diagnosis.

MATERIAL AND METHODS

A retrospective, observational study was undertaken to assess a cohort of 375 Polish MS patients. Socio-economic data was collected based on the patients' responses to questions on a questionnaire. Clinical data was obtained from available medical records.

RESULTS

Patients with relapsing-remitting MS had a significantly longer time of occupational activity, higher economic status, higher level of education, better relationships with life partner, less likely to benefit from disability benefits, and members of MSS, than patients with progressive types of the disease. The patients living in rural areas had a significantly shorter time of occupational activity, more often experienced a decrease in income, received disability pension, and were less educated than urban residents. Patients who informed their employer about an MS diagnosis significantly more often received support from the company, were professionally active for longer, and less likely to experience a decrease in income. Membership of the MSS were dominated by patients with progressive variants of the disease and advanced disability.

CONCLUSIONS

The disease variant and, to a lesser extent, the place of residence, affected the socio-economic aspects of MS. It might be advantageous for the patient to disclose information about MS diagnosis to the employer.

AS-amyloidosis. Dual pathology or novel disease? A multimodality, multi-centre assessment across health and disease

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

onbehalf

AS-Amyloidosis consortium

Background

The coexistence of severe aortic stenosis (lone AS) and transthyretin cardiac amyloidosis (lone amyloidosis) is common, but the resultant AS-amyloidosis phenotype is unclear.

Purpose

We characterised AS-amyloidosis, hypothesizing that the dual insult of AS-amyloidosis results is a severe phenotype.

Methods

We compared four cohorts with deep phenotyping: 81 older age controls, 359 lone AS, 36 AS-amyloidosis (Perugini grade 2 and 3) and 107 lone amyloidosis (Perugini grade 2 and 3).

Results

AS-amyloidosis was similar to lone AS with respect to left ventricular mass and LVEF (57 (45, 64)%). It was similar to lone amyloidosis with respect to lateral S" (0.04 (0.03, 0.06) m/s), NT-proBNP (4149 (1449, 6459) ng/L) and troponin T (56 (34, 100) ng/L). Whilst, prevalence of carpal tunnel syndrome (CTS) (17%) and diastolic function (E/A ratio 1.1 (0.8, 2.8)) were intermediate.

Conclusion

AS-amyloidosis is not a double insult from AS and amyloidosis, but a mixed phenotype with features similar to lone amyloidosis (cardiac biomarkers), lone AS (remodelling and LVEF) or intermediate (diastology and CTS).

Characteristics across all 4 groups Variable Older age controls (n = 81) Lone AS (n = 359) AS-amyloidosis (n = 36) Lone amyloidosis (n = 107) P value Age (years) 82 (80, 84)*†‡ 85 (80, 88)§∞ 88 (85, 92)# 80 (75, 84) &lt;0.005 Sex (% male) 69 *‡ 49 ∞ 61 # 94 &lt;0.005 Carpal tunnel syndrome (%) 0 2 § 17 # 38 &lt;0.005 Voltage/mass ratio 0.22 (0.14, 0.27)‡ 0.18 (0.13, 0.28)∞ 0.18 (0.09, 0.21)# 0.07 (0.05, 0.10) &lt;0.005 NT-ProBNP (ng/L) 131 (66, 221)*†‡ 1629 (639, 3941)§∞ 4149 (1449, 6459) 2888 (1755, 5483) &lt;0.005 hsTnT (ng/L) 12 (8, 17)*†‡ 24 (15, 40)§∞ 56 (34, 100) 62 (41, 82) &lt;0.005 Inferolateral wall thickness (cm) 0.9 (0.8, 1.0)*†‡ 1.1 (0.9, 1.3)∞ 1.3 (1.1, 1.5)# 1.7 (1.6, 1.9) &lt;0.005 Anteroseptal wall thickness (cm) 1.0 (0.9, 1.2)*†‡ 1.4 (1.2, 1.6)§∞ 1.5 (1.3, 1.8) 1.7 (1.6, 1.9) &lt;0.005 Indexed LV mass (g/m2) 79 (66, 102)*†‡ 128 (99, 152)∞ 126 (116, 140)# 174 (159, 200) &lt;0.005 LVEF (%) 59 (54, 63)‡ 59 (50, 65)∞ 57 (45, 64)# 39 (31, 48) &lt;0.005 Lateral S" (m/s) 0.08 (0.07, 0.09)*†‡ 0.07 (0.05, 0.08)§∞ 0.05 (0.04, 0.07) 0.05 (0.04, 0.06) &lt;0.005 Septal S" (m/s) 0.06 (0.06, 0.08)*†‡ 0.05 (0.04, 0.06)∞ 0.04 (0.03, 0.06) 0.04 (0.03, 0.05) &lt;0.005 E/A 0.7 (0.6, 0.8)*†‡ 0.8 (0.7, 1.3)§∞ 1.1 (0.8, 2.8)# 2.4 (1.8, 3.3) &lt;0.005 RV Wall thickness (cm) 0.4 (0.3, 0.4)*†‡ 0.4 (0.4, 0.6)∞ 0.6 (0.4, 0.7)# 0.8 (0.7, 1.0) &lt;0.005 TAPSE (cm) 2.4 (2.0, 2.7)*†‡ 2.1 (1.6, 2.5)∞ 1.9 (1.5, 2.1)# 1.4 (1.2, 1.9) &lt;0.005 Classical LFLG AS (%) 9 13 0.472 * p &lt; 0.05, Old age control vs Lone AS † p &lt; 0.05, Old age control vs AS-amyloidosis ‡ p &lt; 0.05, Old age control vs Lone amyloidosis § p &lt; 0.05, Lone AS vs AS-amyloidosis ∞ p &lt; 0.05, Lone AS vs Lone amyloidosis # p &lt; 0.05, AS-amyloidosis vs Lone amyloidosis Abstract Figure. AS-amyloidosis compared to other cohorts

Impact of a community-acquired pneumonia care bundle in North East England from 2014 to 2017-A quality improvement project

OBJECTIVES

To explore the impact of implementation of Community-Acquired Pneumonia (CAP) quality care bundle.

SETTING

Eight acute hospitals in the North East of England and North Cumbria.

PARTICIPANTS

ICD-10 coded CAP aged >18 were identified. A total of 16 201 CAP patients were discharged 2016/2017 (15 707; 2015/2016 and 10 733; 2014/2015).

OUTCOME MEASURES

Secondary User Service (SUS) data were collected monthly from April 2014 to 2017. Data were pseudonymised and data flows governed by Data Sharing Agreements. CAP measures were based on British Thoracic Society guidance and agreed following clinician consultation. CAP admissions and individual organisational compliance with and impact of, CAP quality bundle measures was explored.

RESULTS

Average length of stay (LOS) was 10.4 days (median 6) 25% >13 days. Crude in-hospital mortality rate was 17.6%, significantly lower (95% CI) than 19.1% in 2015/2016 and 19.3% in 2014/2015. Emergency readmissions within 28 days were 19.7% (19.2%; 2015/2016, 17.9%; 2014/2015). A total of 39.5% of patients received all appropriate care measures. Compliance has improved over time, although not for all hospitals. Most quality measures have higher mortality for those passing measures compared to those failing (P < .05 95% CI). Giving oxygen, had a significantly higher emergency readmission rate, 3.3% higher (95% CI 1.1% to 5.5%). Appropriate antibiotics and recording CURB-65 scores reduced the emergency readmission rates (-2.7% (95% CI -4.5% to -0.8%) -2.6% (95% CI -3.8% to -1.4%), respectively, (P = ns)).

CONCLUSION

CAP accounts for significant bed days, mortality and readmissions. Although mortality was lower, LOS and readmission rates were not, despite improvements in compliance after implementation of the care bundle. Care bundle use remained sub-optimal.

Knowledge transfer in Leadership, advocacy and analysis

Background

The UK Faculty recognises the importance of the effective use of evidence and data in the past, present and future practice of public health. In setting standards for education and training and in its advocacy and leadership roles the Faculty emphasises use of three types of knowledge quantitative information from statistics and surveillance, research evidence and evidence from experience. To equip the public health workforce of the future it is important to understand likely knowledge requirements across these areas.

Objectives

To describe areas of work in current public health advocacy and leadership where knowledge transfer is being used to improve health and reduce health inequalities. To illustrate how the Faculty works with partner organisation to influence policy based on the best knowledge and evidence.

Body of the session

The session will briefly consider the current policy context for public health in the UK and propose a set of areas in which the Faculty sees a role for the use of data and evidence to improve health. The talk will give examples of how the Faculty works with partners such as the Academy of Royal Colleges, Government agencies, and other professional groups representing public health professionals to support individual professionals, to develop its own advocacy positions and to influence policy. A recent example of the English Government's Green Paper on prevention will be used to illustrate the approach.

Conclusions

Effective public health practice can greatly improve the quality and value of public health policy. However, to be effective public health leaders need to be trained and equipped to deliver the best advice effectively and have good access to the relevant evidence. They also need to be supported by strong leadership organisations such as the Faculty that have earned the respect of policy makers.

Fracture prevention: a population-based intervention delivered in primary care

BACKGROUND

Osteoporosis is common, increasing as the population ages and has significant consequences including fracture. Effective treatments are available.

AIM

To support proactive fracture risk assessment (FRAX) and optimizing treatment for high-risk patients in primary care.

DESIGN

Clinical cohort.

SETTING

November 2017 to November 2018, support was provided to 71 practices comprising 69 of 90 practices within two National Health Service Clinical Commissioning Groups areas. Total population 579 508 (207 263 aged over 50 years).

PARTICIPANTS

FRAX (National Institute for Care and Clinical Excellence, NICE CG146) in (i) males aged 75 years and over, (ii) females aged 65 years and over, (iii) females aged under 65 years and males aged under 75 years with risk factors and (iv) under 50 years with major risk factors.

RESULTS

A total of 158 946 met NICE CG146, 11 961 were coded with an osteoporosis diagnosis (7.5%), of those, 42% were prescribed treatment with a bone sparing agent (BSA). In total, 6942 were assessed to initiate BSA. Thirty percent of untreated osteoporosis diagnosis patients had never been prescribed BSA. Even when prescribed, 1700 people (35%) were for less than minimum recommended duration. Of the total 9784 patients within the FRAX recommended to treat threshold, 3197 (33%) were currently treated with BSA and 3684 (37%) had no history of ever receiving BSA. From untreated patients, expected incidence of 875 fractures over a 3-year period (approximately £3.4 million). Treatment would prevent 274 fractures (cost reduction: £1 274 045, with prescribing costs: saving £805 145 after 3 years of treatment).

CONCLUSION

Underdiagnosis and suboptimal treatment of osteoporosis was identified. Results suggest that implementing NICE guidance and optimizing treatment options in practice is possible and could prevent significant fractures.

Bronchiectasis Information and Education: a randomised, controlled feasibility trial

Background

There has been comparatively little patient information about bronchiectasis, a chronic lung disease with rising prevalence. Patients want more information, which could improve their understanding and self-management. A novel information resource meeting identified needs has been co-developed in prior work. We sought to establish the feasibility of conducting a multi-centre randomised controlled trial to determine effect of the information resource on understanding, self-management and health outcomes.

Methods/design

We conducted an unblinded, single-centre, randomised controlled feasibility trial with two parallel groups (1:1 ratio), comparing a novel patient information resource with usual care in adults with bronchiectasis. Integrated qualitative methods allowed further evaluation of the intervention and trial process. The setting was two teaching hospitals in North East England. Participants randomised to the intervention group received the information resource (website and booklet) and instructions on its use. Feasibility outcome measures included willingness to enter the trial, in addition to recruitment and retention rates. Secondary outcome measures (resource use and satisfaction, quality of life, unscheduled healthcare presentations, exacerbation frequency, bronchiectasis knowledge and lung function) were recorded at baseline, 2 weeks and 12 weeks.

Results

Sixty-two participants were randomised (control group = 30; intervention group = 32). Thirty-eight (61%) were female, and the participants’ median age was 65 years (range 15–81). Median forced expiratory volume in 1 s percent predicted was 68% (range 10–120). Sixty-two of 124 (50%; 95% CI, 41–59%) of potentially eligible participants approached were recruited. Sixty (97%) of 62 participants completed the study (control group, 29 of 30 [97%]; 95% CI, 83–99%; 1 unrelated death; intervention group, 31 [97%] of 32; 95% CI, 84–99%; 1 withdrawal). In the intervention group, 27 (84%) of 32 reported using the information provided, and 25 (93%) of 27 of users found it useful, particularly the video content. Qualitative data analysis revealed acceptability of the trial and intervention. Web analytics recorded over 20,000 page views during the 16-month study period.

Conclusion

The successful recruitment process, high retention rate and study form completion rates indicate that it appears feasible to conduct a full trial based on this study design. Worldwide demand for online access to the information resource was high.

Trial registration

ISRCTN Registry, ISRCTN84229105. Registered on 25 July 2014.

Electron Capture Gas-Liquid Chromatographic Determination of Methyl Mercury in Fish and Shellfish: Collaborative Study

A method for determining methyl mercury in fish and shellfish was collaboratively studied in 8 laboratories. Methyl mercury is isolated from acetonewashed, homogenized tissue by adding hydrochloric acid and extracting into benzene the methyl mercuric chloride that is formed. The benzene extract is concentrated and analyzed for methyl mercuric chloride by electron capture gas-liquid chromatography on 5% DEGS-PS treated with inorganic mercuric chloride solution. The quantitation limit for the method is 0.05 μg Hg/g. Each collaborator determined methyl mercury at 2 levels in blind duplicate samples of swordfish, tuna, oyster, and shrimp tissues. Both fortified and unfortified samples were analyzed. Methyl-bound mercury in the samples ranged from 0.15 to 148 μg Hg/g. The reproducibility coefficients of variation for the 8 samples ranged from 3 to 13%. The accuracy, measured by comparison to reference values, ranged from 99 to 120%. Reference values were determined in the Associate Referee's laboratory by replicate analyses of the fortified and unfortified samples. The method has been adopted official first action.

P214 Clinical audit of in-patient echocardiography in acute heart failure: real world data from a tertiary hospital

Background

Over the last ten years, an increase in admission rates for acute heart failure (HF) has been noted in England and Wales, with one year mortality rates varying between 30% and 60%. Transthoracic echocardiography (TTE) is recommended within 48 hours of admission for suspected acute heart failure, so to guide treatment accordingly.

Our centre has a specialist team who assesses patients with suspected HF on admission, and refers them for urgent in-patient TTE, using two priority in-patient echo slots per day. Patients are initially referred for HF assessment by general medics and geriatricians, across non-specialist medical wards. We audited the referrals and results of those who received TTE in this context.

Methods and results

We screened the medical notes of 252 patients admitted with suspected HF between January and December 2017, and reviewed the echocardiography results of those who received it during their admission.

50% of these patients were female and 59% were elderly (over 80 years old). 245 of these patients (97.2%) had in-patient echocardiography performed during their hospital stay. The mean wait for echocardiography was 0.58 days, with 92% of the scans being performed within 24 hours. The mean admission duration was 8.6 days (SD 10.9). 17.9% of patients were readmitted with suspected heart failure within six months, 69% of which were elderly.

The majority of this cohort presented with heart failure with preserved ejection fraction (HFpEF), 50%), followed by heart failure with reduced ejection fraction (HFrEF, 29%) and heart failure with mid-range ejection fraction (HFmrEF, 16%). 41% of the patients who received an echocardiogram were in atrial fibrillation, 51% of which were diagnosed with HFpEF.

All patients had their HF medical treatment optimised post-echocardiography and only 18.4% were readmitted within 6 months of the first admission. The majority of these patients was elderly (68.9%). 38.8% of patients who received echocardiography were referred for specialist clinic follow-up, with HFrEF patients more likely to be seen in this setting (42%).

Six-month mortality occurred in 19.8% of patients; cause of death (COD) was undocumented in 25.8% of cases. In those where a post-mortem was conducted, the main COD was HF (16.7%), followed by sepsis (13.6%), cardiac (6.1%) and respiratory arrest (6.1%). 66% of the deceased patients were elderly and 48% presented with HFpEF.

Conclusion

Our cohort is an accurate representation of the current HF statistics seen nationwide. Appropriate treatment was offered to the large majority of patients who received in-patient echocardiography within the first 24 hours of their admission, with low six-month readmission rates. This approach also allowed for the inclusion of these patients on a systematic review plan, including specialist cardiology follow-up. Our numbers are consistent with the higher awareness about HFpEF currently seen in the medical community.

19 The Efficacy, Safety and Acceptability of Non-Pharmacologic Therapy for Orthostatic Hypotension in Older People: A Mixed Methods Study

Introduction

First-line treatment for OH is typically with non-pharmacologic therapy. However, the current evidence base is poor, particularly in older people.

Aim

Determine the safety, efficacy and acceptability of single and combination therapies for OH in older people.

Methods

A three-stage, mixed-methods study consisting of a phase 2 efficacy study with a nested qualitative study. Stage One calculated response rates to therapy (defined as an improvement in standing systolic blood pressure (SSBP) by ≥10 mmHg). Stage Two explored the tolerability of therapies in qualitative interviews. Stage Three evaluated response rates to combinations of the most efficacious and tolerable therapies. All participants were aged ≥60 years, had OH and were recruited from a UK Falls and Syncope Service.

Results

Stage One. Response rates to therapies were evaluated in 25 older people (74 years, 60-92): Bolus-water drinking 56% (95%CI 35, 76); abdominal compression 52% (95%CI 31, 72), physical counter-maneuvers 44% (PCM, 95%CI 24, 65), full-leg length compression 32% (95%CI 15, 54).

Stage Two. PCM was considered an acceptable therapy as no equipment is required, is only needed during postural change and can be performed conspicuously. Water was largely acceptable but there were concerns around urinary frequency. Compression stockings were considered unacceptable due to cosmesis, practicalities and discomfort. There were mixed views on the tolerability of abdominal compression. There were no adverse events.

Stage Three. Response rates to combination therapy were evaluated in 37 older people (71 years, 60-94). Bolus water drinking + PCM 38% (95%CI 22, 55); water + PCM + abdominal compression 46% (95%CI 29, 63).

Conclusions

Due to its superior efficacy, safety and acceptability, bolus water drinking should become standard first-line therapy. Conversely, compression stockings should be disregarded in this population, as they are the least efficacious and most unacceptable treatment. Surprisingly, there is no additional benefit of combining therapies.

151 Falls in the United Kingdom: Magnitude, Risk, Disparities, and Solutions

In the UK each year there are over 250,000 emergency hospital admissions due to falls, costing £4.4 billion for falls-related fractures alone. To help reduce pressure on the NHS, the UK Fire Service are now providing home safety checks which include a review of falls hazards, provision of falls and loneliness advice and in some cases, immediate provision of aids such as grab rails. It is yet to be seen whether this will translate into a reduction in falls but it appears that the trust people place in the Fire Service is resulting in an uptake of falls prevention advice.

Although we have reasonably good evidence that multifactorial falls interventions reduce the rate of falls, they are resource intensive and do not reduce the risk of falls. In contrast, exercise interventions reduce both the rate and the risk of falls and can be delivered in a group setting; however uptake and adherence is low. In an attempt to encourage local care providers to invest in falls prevention exercise, Public Health England created a Return-of-Investment tool (available online) for local commissioners to calculate the anticipated cost savings by investing in falls prevention exercise programmes.

A recent, novel approach to falls prevention developed in the UK is a Massive Open Online Course (MOOC). This is a free, open-access, online course open to anyone with access to the Internet. The purpose of the ‘Ageing Well: Falls’ MOOC is to educate people about falls prevention and empower them to take action. In five years, the course has educated over 10,000 people from over 100 countries worldwide. One survey revealed that 95% of learners felt more empowered to manage their falls risk, with an increase in confidence to engage in falls prevention behaviours but also an increase in confidence to seek help for falls.

Slowing improvements in life expectancy across European Economic Area countries

Background

Life expectancy improvements have slowed down in several European countries since around 2011. The relative contributions from changes in specific conditions (e.g. cancers) and broader risk factors (e.g. smoking or austerity) remain unclear. We aimed to explore the different potential causes in 17 European Economic Area (EEA) countries.

Methods

We compared Global Burden of Disease (GBD) study estimates for life expectancy, years of life lost (YLLs) and population attributable fractions (PAFs) for risk factors, for 2005-2011 and 2011-2017 for 17 EEA countries. Three countries with the largest absolute improvements and three with the smallest were selected for analysis by gender, age, condition and risk factors.

Results

Norway, France and Belgium had the largest improvement in life expectancy (+1.5, +1.2 and +1.2 years respectively) from 2011 to 2017, and Germany, Iceland and the UK the smallest (+0.1, +0.2 and +0.2 years). Life expectancy reduced slightly for women aged over 80 in Germany and UK, men aged over 50 in Germany, and for men in all age groups up to 90 years in Iceland. Norway, France and Belgium saw faster improvements in YLLs from lung cancer and Norway and France for COPD in both men and women, and from self-harm in men, after 2011 than before. PAF for tobacco declined faster after 2011. Germany, Iceland and the UK saw slower improvements in cardiovascular disease and in Germany and the UK lung cancer. In Iceland, YLLs for cancers, self harm, respiratory disease, cirrhosis and dementia all worsened after 2011. PAF for tobacco remained high or declined less after 2011 in all 3 countries. PAFs for alcohol and drug use remained high in Iceland and UK.

Conclusions

Differential changes in major fatal diseases and risk factors help explain national changes in life expectancies, but national differences in data availability may affect results. Further research is needed into the ‘causes of the causes’, such as the 2008 economic crash in Iceland.

Key messages

Differential changes in major fatal diseases and risk factors help explain national changes in life expectancies. Norway, France and Belgium had the largest improvement in life expectancy from 2011 to 2017, and Germany, Iceland and the UK the smallest.

Development of composite indicators to monitor burden of disease across Member States

Background

The burden of disease (BoD) methods are not part of routine public health activities and policy development process across all Member States (MSs). The main reasons for this are varying levels of knowledge, experience, and capability to apply and use BoD methods. Therefore, MSs need support, guidance and training to adopt and integrate BoD approaches in their public health systems. In this context, two workshops have been organised by InfAct. The main objectives of the workshops are to raise awareness, share knowledge and experience, and to provide mutual support to to integrate BoD indicators in the public health policies across Europe.

Methods

The workshops were about the BoD concept and methodologies, and the use of BoD data in public health policy. These workshops were supported by technical presentations describing methods and the use of BoD data in health policy with various case studies, followed by expert exchange with facilitated discussions and group work. The case studies included national BoD studies from Belgium, Germany, Netherland, and Scotland.

Results

Two workshops were held at Santé Publique France, and attended by 16 BoD experts and 40 participants from 25 MSs. The workshops were well received by the participants particularly with regards to the diversity of the group and the possibility to share knowledge and experience from various perspectives. Three areas of action were highlighted: 1. the need for methodological trainings to strengthen skills in interpreting and calculating BoD estimates; 2. the encouragement of more collaborations across MSs to share or exchange good practices on BoD; and 3. the importance of the implications of BoD data to guide policies across MSs.

Conclusions

The workshops highlighted the need for capacity building activities to implement BoD approaches across MSs in routine public health activities and to use BoD data to guide health policy. More collaborations among MSs on BoD activities are needed in the future.

Global Burden of Disease Study: overview and experience from England

Changes in health in the countries of the UK and 150 English Local Authority areas 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.

Lymphoedema management by independent hospices: a cohort study

Objectives

To consider the type and cost of clinical services delivered for patients with lymphoedema.

Design

Clinical cohort.

Setting

Independent hospices in the North East of England.

Participants

All those attending lymphoedema services delivered by the independent hospice sector 2017/2018.

Results

13 914 lymphoedema appointments were recorded across four independent hospices. Twelve thousand nine hundred and sixty-five were attended, which equates to an approximate cost of £1.56 million. Those with lymphoedema were predominately aged over 65 (54.5%) years with females across all age groups being more predominant (3.3:1). Where the cause was recorded, 66% of activity related to lymphoedema was not secondary to cancer.

Conclusion

Independent hospices are providing a specialist lymphoedema service, which is high in volume and largely invisible. This service is delivered at not insignificant cost. In contrast to previous work, in the North East of England, lymphoedema sufferers are more likely to be female and not have the condition in association with cancer. The availability of rigorous data collection will allow the independent hospices to understand better the delivery and associated costs of lymphoedema services.

Host identification in unfed ticks from stable isotope compositions (δ13 C and δ15 N)

Determination of the ratios of natural stable isotopes (¹³ C/¹² C and ¹⁵ N/¹⁴ N) in unfed Ixodes ricinus nymphs and adults, which, in their previous stage, fed on captive wild rodents (Apodemus sylvaticus and Myodes glareolus), wild birds (Parus major and Cyanistes caeruleus) or domestic ruminants (Ovis aries and Bos taurus), demonstrated that it is possible to identify each host category with confidence. First, the tick-blood spacing, which is the difference between values obtained from ticks and the blood of hosts that they had fed on in the previous stage, was consistent (152 spacings investigated from 15 host individuals in total). Second, potential confounding factors (tick age and sex) did not affect the discriminatory power of the isotope patterns, nor did different rearing conditions (room temperature vs. 4 °C) or the duration of development (maximum of 430 days). The findings that the tick-blood isotope spacings, across a diverse range of hosts, were similar and predictable, and that confounders had little or no effect on this, strongly support the usage of the isotope approach. Because each of the host categories has a different role in the population dynamics of I. ricinus and in tick-borne pathogen ecology, the method described here has great potential for the clarification of tick and tick-borne pathogen ecology in the field.

Brain Responses in CFS and TMD to Autonomic Challenges: An Exploratory fMRI Study

INTRODUCTION

Dysfunction of the autonomic nervous system (ANS) is seen in chronic fatigue syndrome (CFS) and temporomandibular disorders (TMDs). Both conditions have poorly understood pathophysiology. Several brain structures that play a role in pain and fatigue, such as the insular cortex and basal ganglia, are also implicated in autonomic function.

OBJECTIVES

ANS dysfunction may point to common neurophysiologic mechanisms underlying the predominant symptoms for CFS and TMD. No studies to date have investigated the combination of both conditions. Thus, our aim was to test whether patients with CFS with or without TMD show differences in brain responses to autonomic challenges.

METHODS

In this exploratory functional imaging study, patients with CFS who screened positive for TMD (n = 26), patients who screened negative for TMD (n = 16), and age-matched control participants (n = 10) performed the Valsalva maneuver while in a 3-T magnetic resonance imaging scanner. This maneuver is known to activate the ANS.

RESULTS

For all 3 groups, whole-brain F test showed increased brain activation during the maneuver in the superior and inferior frontal gyri, the left and right putamen and thalamus, and the insular cortex. Furthermore, group contrasts with small-volume correction showed that patients with CFS who screened positive for TMD showed greater activity in the left insular cortex as compared with patients who screened negative and in the left caudate nucleus as compared with controls.

CONCLUSION

Our results suggest that increased activity in the cortical and subcortical regions observed during autonomic challenges may be modulated by fatigue and pain. ANS dysfunction may be a contributing factor to these findings, and further work is required to tease apart the complex relationship among CFS, TMD, and autonomic functions.

KNOWLEDGE TRANSFER STATEMENT

Brain activity related to activation of the autonomic nervous system in patients with chronic fatigue syndrome who screened positive for painful temporomandibular disorder was greater than in patients who screened negative; activity was seen in brain regions associated with autonomic functions and pain. These findings suggest that autonomic dysfunction may play a role in the pathophysiology of both conditions, explain some of the apparent comorbidity between them, and offer avenues to help with treatment.

Increased Risk of Musculoskeletal Disorders and Mental Health Problems in Retired Professional Jockeys: A Cross-Sectional Study

To examine the prevalence of chronic disease and mental health problems in retired professional, male jockeys compared to an age-matched reference population. A cross-sectional study comparing data from a cohort of retired professional jockeys with an age-matched general population sample. Male participants (age range: 50-89 years old) were used to compare health outcomes of self-reported physician-diagnosed conditions: heart disease, stroke, diabetes, hypertension, osteoporosis, osteoarthritis, depression and anxiety between study populations. Conditional logistic regression models were used to estimate associations between study groups and health outcome. In total, 810 participants (135 retired professional male jockeys and 675 participants from the reference population) were included, with an average age of 64.7±9.9 years old. Increased odds of having osteoporosis (OR=6.5, 95%CI 2.1-20.5), osteoarthritis (OR=7.5, 95%CI 4.6-12.2), anxiety (OR=2.8, 95%CI 1.3-5.9) and depression (OR=2.6, 95%CI 1.3-5.7) were seen in the retired professional jockeys. No differences were found for the remaining health outcomes. Retired professional jockeys had increased odds of musculoskeletal disease and mental health problems compared to the general population. Understanding the prevalence of chronic disease and mental health problems in retired professional jockeys will help inform screening and intervention strategies for jockeys.

2 The incidence of undiagnosed coeliac disease in patients presenting with stress fracture to a tertiary referral centre

Aim

Stress fracture aetiology is often multifactorial and laboratory blood tests (LBT) can unmask underlying metabolic bone risk factors and disorders. Coeliac disease (CD) is associated with low bone mineral density and an increased risk of fractures.1 In addition, there are rare reports of occult CD presenting with stress fractures.2 Anti-tissue transglutaminase antibody (TTG) testing has a high sensitivity and specificity for CD and is used as a screening test.3 This report examines the incidence of undiagnosed CD in patients presenting with stress fractures to a Sport and Exercise Medicine (SEM) clinic.

Methods

A retrospective analysis of 100 consecutive patients with radiologically proven stress fractures presenting to a single tertiary NHS SEM clinic was performed. Age, gender, fracture site, co-morbidities, TTG result and subsequent investigations were examined. Records were reviewed to confirm LBT, including TTG, had been performed at the time of diagnosis.

Results

Seventy patients (70%) were female and mean age was 37 years (range 18–69). Metatarsal (35%) and tibial (21%) fractures were most common. TTG was performed in 85 patients. Two patients were excluded due to pre-existing CD. Five patients (5/83 (6%), mean age 38 years (28–57), 80% female) had a positive TTG; three of whom had CD confirmed by endoscopic biopsy and two are awaiting investigation. Four patients with a positive TTG underwent dual energy X-ray absorptiometry, with osteopenia (T-Score between −1.0 and −2.5) found in 75% of cases, although only one had a Z-score less than -2.0.

Conclusion

In this cohort, the incidence of undiagnosed CD was between 3.6% to 6%, with a prevalence between 5% to 7%, approximately 5-fold higher than UK population estimates. We recommend that TTG screening should be performed in all patients presenting with stress fractures to identify underlying CD. Further work is required to confirm this association and elucidate potential underlying mechanisms.

References

Heikkilä K, Pearce J, Mäki M, et al. Celiac disease and bone fractures: a systematic review and meta-analysis. J Clin Endocrinol Metab 2015;100(1):25–34.

Gilbody J, Trevett M. Coeliac disease presenting with bilateral fibular stress fractures. Foot Ankle Surg 2009;15:96–100.

3. Downey L, Houten R, Murch S, Longson D, Group GD. Recognition, assessment, and management of coeliac disease: summary of updated NICE guidance. BMJ 2015;351:h4513.

Gravity-induced exercise intervention in an individual with chronic fatigue syndrome/myalgic encephalomyeltis and postural tachycardia syndrome: a case report

Background/Aims

Chronic fatigue syndrome/myalgic encephalomyeltis is a condition of complex nature, characterised by unexplained disabling fatigue and a combination of non-specific accompanying symptoms. Individuals with chronic fatigue syndrome/myalgic encephalomyeltis frequently present with debilitating orthostatic symptoms, which may fall under the umbrella of postural tachycardia syndrome. Postural tachycardia syndrome is underpinned by autonomic nervous system dysfunction. The gravitational deconditioning that occurs in those severely affected by chronic fatigue syndrome/myalgic encephalomyeltis alongside postural tachycardia syndrome has been suggested as a key focus for interventions in this group. This case report documents the evaluation and rationale behind a novel gravity-induced exercise intervention to improve the symptoms of a 44-year-old female severely affected by chronic fatigue syndrome/myalgic encephalomyeltis and postural tachycardia syndrome, who had been bedbound for 10–15 years.

Methods

An exercise intervention was designed to challenge and therefore improve key areas of autonomic nervous system regulation in the presence of gravity. It contained seven different exercises conducted once a month in a class over a 6-month period.

Results

Fatigue impact score, activity levels and heart rate upon standing, as detected by an active stand test, improved during the exercise intervention and at follow up.

Conclusions

Gravity-induced exercise intervention can have a positive effect on an individual severely affected by Chronic fatigue syndrome/myalgic encephalomyeltis alongside postural tachycardia syndrome.

Fatigue and cognitive impairment in immune thrombocytopenic purpura remain stable over time: short report from a longitudinal study

Immune thrombocytopenic purpura (ITP) is an autoimmune disorder characterised by low platelet counts and increased bleeding risk. In 2009, two cross-sectional studies determined that fatigue and cognitive impairment (CI) were common in ITP. Here, we report the results from a longitudinal study of 34 people with ITP. Fatigue severity remained unchanged over 7 years, and CI significantly improved. Future fatigue and CI severity could be predicted using baseline severity scores. These findings may be reassuring for ITP patients, as symptoms remain stable over time. Furthermore, using baseline scores to predict future severity could aid the clinical management of ITP.

Empowering podiatrists to perform pulse checks for opportunistic atrial fibrillation detection during annual diabetes foot checks

Objective

To determine whether training podiatrists to provide opportunistic screening for atrial fibrillation (AF) during the local diabetes foot check was feasible and whether it detects previously unknown AF.

Method

During the initiative, 45 podiatrists from across North Durham, Darlington and Durham Dales Easington and Sedgefield Clinical Commissioning Groups were trained to recognise heart irregularities when taking pulse readings of feet of patients with diabetes during their annual foot screening reviews.

Results

Over the course of the 3-month pilot, 5000 patients with diabetes had their feet pulse-tested. The project uncovered that for every 500 patients who had their feet checked, one new case of AF could be identified.

Conclusion

A report following the Podiatry and Atrial Fibrillation Case Finding scheme revealed that the National Health Service in the United Kingdom North East and North Cumbria area could benefit from potential cost savings in excess of £500 000. In 2013, the National Diabetes Information Service, Yorkshire and Humber Public Health Observatory estimated 231 777 people in the North East, North Cumbria, Hambleton and Richmondshire area with diabetes. Therefore 463 patients could be found with AF, preventing 23 strokes and saving £539 742 or in excess of £0.5 M.

15-Epi-LXA4 and MaR1 counter inflammation in stromal cells from patients with Achilles tendinopathy and rupture

Resolution of inflammation is poorly understood in Achilles tendon disorders. Herein, we investigated the bioactive lipid mediator profiles of tendon-derived stromal cells isolated from patients with Achilles tendinopathy (AT) or Achilles rupture (AR) under baseline and IL-1β–stimulated conditions. We also determined whether incubating these cells with 2 of the mediators produced by tendon-derived stromal cells, 15-epi-Lipoxin A₄ (15-epi-LXA₄) or maresin (MaR)-1, moderated their proinflammatory phenotype. Under baseline conditions, AT cells showed concurrent increased levels of proinflammatory eicosanoids and proresolving mediators compared with AR cells. IL-1β treatment induced profound prostaglandin E₂ release in AR compared with AT cells. Incubation of IL-1β treated AT and AR tendon-derived stromal cells in 15-epi-LXA₄ or MaR1 reduced proinflammatory eicosanoids and potentiated the release of proresolving mediators. These mediators also induced specialized proresolving mediator (SPM) biosynthetic enzymes arachidonate lipoxygenase (ALOX) 12 and ALOX15 and up-regulated the proresolving receptor ALX compared with vehicle-treated cells. Incubation in 15-epi-LXA₄ or MaR1 also moderated the proinflammatory phenotype of AT and AR cells, regulating podoplanin, CD90, signal transducer and activator of transcription (STAT)-1, IL-6, IFN regulatory factor (IRF) 5, and TLR4 and suppressed c-Jun N-terminal kinase 1/2/3, Lyn, STAT-3, and STAT-6 phosphokinase signaling. In summary, we identify proresolving mediators that are active in AT and AR and propose SPMs, including 15-epi-LXA₄ or MaR1, as a potential strategy to counterregulate inflammatory processes in these cells.—Dakin, S. G., Colas, R. A., Newton, J., Gwilym, S., Jones, N., Reid, H. A. B., Wood, S., Appleton, L., Wheway, K., Watkins, B., Dalli, J., Carr, A. J. 15-Epi-LXA₄ and MaR1 counter inflammation in stromal cells from patients with Achilles tendinopathy and rupture.

Cardiovascular regulation and body temperature: evidence from a nap vs. sleep deprivation randomized controlled trial

In this study we set out to understand is sleep fragmentation affects the cardiovascular regulation and circadian variability of core body temperature more or less than sleep deprivation. 50 healthy men (age 29.0+/-3.1 years; BMI 24.3+/-2.1 kg/m(2)) participated in a 3-day study that included one adaptative night and one experimental night involving randomization to: sleep deprivation (SD) and sleep fragmentation (SF). The evaluation included hemodynamic parameters, measures of the spectral analysis of heart rate and blood pressure variability, and the sensitivity of arterial baroreflex function. Core body temperature (CBT) was measured with a telemetric system. SF affects heart rate (61.9+/-5.6 vs. 56.2+/-7.6, p<0.01) and stroke index (52.7+/-11.1 vs. 59.8+/-12.2, p<0.05) with significant changes in the activity of the ANS (LF-sBP: 6.0+/-5.3 vs. 3.4+/-3.7, p<0.05; HF-sBP: 1.8+/-1.8 vs. 1.0+/-0.7, p<0.05; LF-dBP: 5.9+/-4.7 vs. 3.5+/-3.2, p<0.05) more than SD. Post hoc analysis revealed that after SD mean value of CBT from 21:30 to 06:30 was significantly higher compared to normal night's sleep and SF. In healthy men SF affects the hemodynamic and autonomic changes more than SD. Sympathetic overactivity is the proposed underlying mechanism.

Trial of exercise to prevent HypeRtension in young adults (TEPHRA) a randomized controlled trial: study protocol

Background

Hypertension prevalence in young adults has increased and is associated with increased incidence of cerebrovascular and cardiovascular events in middle age. However, there is significant debate regards how to effectively manage young adult hypertension with recommendation to target lifestyle intervention. Surprisingly, no trials have investigated whether lifestyle advice developed for blood pressure control in older adults is effective in these younger populations.

Methods/Design

TEPHRA is an open label, parallel arm, randomised controlled trial in young adults with high normal and elevated blood pressure. The study will compare a supervised physical activity intervention consisting of 16 weeks structured exercise, physical activity self-monitoring and motivational coaching with a control group receiving usual care/minimal intervention. Two hundred young adults aged 18–35 years, including a subgroup of preterm born participants will be recruited through open recruitment and direct invitation. Participants will be randomised in a ratio of 1:1 to either the exercise intervention group or control group. Primary outcome will be ambulatory blood pressure monitoring at 16 weeks with measure of sustained effect at 12 months. Study measures include multimodal cardiovascular assessments; peripheral vascular measures, blood sampling, microvascular assessment, echocardiography, objective physical activity monitoring and a subgroup will complete multi-organ magnetic resonance imaging.

Discussion

The results of this trial will deliver a novel, randomised control trial that reports the effect of physical activity intervention on blood pressure integrated with detailed cardiovascular phenotyping in young adults. The results will support the development of future research and expand the evidence-based management of blood pressure in young adult populations.

Trial Registration

Clinicaltrials.gov registration number NCT02723552, registered on 30 March, 2016.

Randomised controlled trial of cognitive behavioural therapy in COPD

Anxiety is an important comorbidity in chronic obstructive pulmonary disease (COPD). We investigated if cognitive behavioural therapy (CBT), delivered by respiratory nurses, reduced symptoms of anxiety and was cost-effective. Patients with COPD and anxiety were randomised to CBT or self-help leaflets. Anxiety, depression and quality of life were measured at baseline, 3, 6 and 12 months. A cost-effectiveness analysis was conducted from a National Health Service hospital perspective and quality-adjusted life-years estimated using the EuroQol-5D questionnaire. In total, 279 patients were recruited. Group mean change from baseline to 3 months in the Hospital Anxiety and Depression Anxiety Subscale was 3.4 (95% CI 2.62-4.17, p<0.001) for the CBT group and 1.88 (95% CI 1.19-2.55, p<0.001) in the leaflet group. The CBT group was superior to leaflets at 3 months (mean difference in the Hospital Anxiety and Depression Anxiety Subscale was 1.52, 95% CI 0.49-2.54, p=0.003). Importantly, the CBT intervention was more cost-effective than leaflets at 12 months, significantly lowering hospital admissions and attendance at emergency departments. CBT delivered by respiratory nurses is a clinically and cost-effective treatment for anxiety in patients with COPD relative to self-help leaflets.

Cardiovascular regulation and body temperature: evidence from a nap vs. sleep deprivation randomized controlled trial

In this study we set out to understand is sleep fragmentation affects the cardiovascular regulation and circadian variability of core body temperature more or less than sleep deprivation. 50 healthy men (age 29.0+/-3.1 years; BMI 24.3+/-2.1 kg/m(2)) participated in a 3-day study that included one adaptative night and one experimental night involving randomization to: sleep deprivation (SD) and sleep fragmentation (SF). The evaluation included hemodynamic parameters, measures of the spectral analysis of heart rate and blood pressure variability, and the sensitivity of arterial baroreflex function. Core body temperature (CBT) was measured with a telemetric system. SF affects heart rate (61.9+/-5.6 vs 56.2+/-7.6, p<0.01) and stroke index (52.7+/-11.1 vs. 59.8+/-12.2, p<0.05) with significant changes in the activity of the ANS (LF-sBP: 6.0+/-5.3 vs. 3.4+/-3.7, p<0.05; HF-sBP: 1.8+/-1.8 vs 1.0+/-0.7, p<0.05; LF-dBP: 5.9+/-4.7 vs. 3.5+/-3.2, p<0.05) more than SD. Post-hoc analysis revealed that after SD mean value of CBT from 21:30 to 06:30 was significantly higher compared to normal night's sleep and SF. In healthy men SF affects the hemodynamic and autonomic changes more than SD. Sympathetic overactivity is the proposed underlying mechanism.

Harmonising measures of knee and hip osteoarthritis in population-based cohort studies: an international study

OBJECTIVE

Population-based osteoarthritis (OA) cohorts provide vital data on risk factors and outcomes of OA, however the methods to define OA vary between cohorts. We aimed to provide recommendations for combining knee and hip OA data in extant and future population cohort studies, in order to facilitate informative individual participant level analyses.

METHOD

International OA experts met to make recommendations on: 1) defining OA by X-ray and/or pain; 2) compare The National Health and Nutrition Examination Survey (NHANES)-type OA pain questions; 3) the comparability of the Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC) scale to NHANES-type OA pain questions; 4) the best radiographic scoring method; 5) the usefulness of other OA outcome measures. Key issues were explored using new analyses in two population-based OA cohorts (Multicenter Osteoarthritis Study; MOST and Osteoarthritis Initiative OAI).

RESULTS

OA should be defined by both symptoms and radiographs, with symptoms alone as a secondary definition. Kellgren and Lawrence (K/L) grade ≥2 should be used to define radiographic OA (ROA). The variable wording of pain questions can result in varying prevalence between 41.0% and 75.4%, however questions where the time anchor is similar have high sensitivity and specificity (91.2% and 89.9% respectively). A threshold of 3 on a 0-20 scale (95% CI 2.1, 3.9) in the WOMAC pain subscale demonstrated equivalence with the preferred NHANES-type question.

CONCLUSION

This research provides recommendations, based on expert agreement, for harmonising and combining OA data in existing and future population-based cohorts.