Fatty acid binding protein 5 suppression attenuates obesity-induced hepatocellular carcinoma by promoting ferroptosis and intratumoral immune rewiring

Due to the rise in overnutrition, the incidence of obesity-induced hepatocellular carcinoma (HCC) will continue to escalate; however, our understanding of the obesity to HCC developmental axis is limited. We constructed a single-cell atlas to interrogate the dynamic transcriptomic changes during hepatocarcinogenesis in mice. Here we identify fatty acid binding protein 5 (FABP5) as a driver of obesity-induced HCC. Analysis of transformed cells reveals that FABP5 inhibition and silencing predispose cancer cells to lipid peroxidation and ferroptosis-induced cell death. Pharmacological inhibition and genetic ablation of FABP5 ameliorates the HCC burden in male mice, corresponding to enhanced ferroptosis in the tumour. Moreover, FABP5 inhibition induces a pro-inflammatory tumour microenvironment characterized by tumour-associated macrophages with increased expression of the co-stimulatory molecules CD80 and CD86 and increased CD8+ T cell activation. Our work unravels the dual functional role of FABP5 in diet-induced HCC, inducing the transformation of hepatocytes and an immunosuppressive phenotype of tumour-associated macrophages and illustrates FABP5 inhibition as a potential therapeutic approach.

Novel muscle-derived extracellular matrix hydrogel promotes angiogenesis and neurogenesis in volumetric muscle loss

Volumetric muscle loss (VML) represents a clinical challenge due to the limited regenerative capacity of skeletal muscle. Most often, it results in scar tissue formation and loss of function, which cannot be prevented by current therapies. Decellularized extracellular matrix (DEM) has emerged as a native biomaterial for the enhancement of tissue repair. Here, we report the generation and characterization of hydrogels derived from DEM prepared from WT or thrombospondin (TSP)-2 null muscle tissue. TSP2-null hydrogels, when compared to WT, displayed altered architecture, protein composition, and biomechanical properties and allowed enhanced invasion of C2C12 myocytes and chord formation by endothelial cells. They also displayed enhanced cell invasion, innervation, and angiogenesis following subcutaneous implantation. To evaluate their regenerative capacity, WT or TSP2 null hydrogels were used to treat VML injury to tibialis anterior muscles and the latter induced greater recruitment of repair cells, innervation, and blood vessel formation and reduced inflammation. Taken together, these observations indicate that TSP2-null hydrogels enhance angiogenesis and promote muscle repair in a VML model.

Pharmacological and non-pharmacological interventions to prevent delirium after cardiac surgery: a protocol for a systematic review and meta-analysis

INTRODUCTION

Delirium is a syndrome characterised by a disturbance in attention, awareness and cognition as a result of another physical condition. It occurs in up to 50% of patients after cardiac surgery and is associated with increased mortality, prolonged intensive care and hospital stay and long-term cognitive dysfunction. Identifying effective preventive interventions is important. We will therefore conduct a systematic review to identify all randomised controlled studies that have tested a pharmacological or non-pharmacological intervention to prevent delirium.

METHODS AND ANALYSIS

We will search electronic databases (CDSR (Reviews), CENTRAL (Trials), MEDLINE Ovid, Embase Ovid, PsycINFO Ovid) as well as trial registers (clinicaltrials.gov and ISCRTN) for randomised controlled trials of both pharmacological and non-pharmacological interventions designed to prevent delirium after cardiac surgery in adults. Screening of search results and data extraction from included articles will be performed by two independent reviewers using Rayyan. The primary outcome will be the incidence of delirium. Secondary outcomes include: duration of postoperative delirium, all-cause mortality, length of postoperative hospital and intensive care stay, postoperative neurological complications other than delirium, health-related quality of life and intervention-specific adverse events. Studies will be assessed for risk of bias using the Cochrane RoB2 tool. A narrative synthesis of all included studies will be presented and meta-analysis (if appropriate network meta-analysis) will be undertaken where there are sufficient studies (three or more) for pooling results. Results will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

ETHICS AND DISSEMINATION

No ethical approval is required. This review will be disseminated via peer-reviewed manuscript and conferences.

PROSPERO REGISTRATION NUMBER

CRD42022369068.

A survey in the West Midlands of the United Kingdom of current practice in managing hypotension in lower segment caesarean section under spinal anaesthesia

BACKGROUND

Spinal anaesthesia, the most common form of anaesthesia for caesarean section, leads to sympathetic blockade and profound maternal hypotension resulting in adverse maternal and neonatal outcomes. Hypotension, nausea and vomiting remain common but until the publication of the National Institute of Health and Care Excellence (NICE) 2021 guidance, no national guideline existed on how best to manage maternal hypotension following spinal anaesthesia for caesarean section. A 2017 international consensus statement recommended prophylactic vasopressor administration to maintain a systolic blood pressure of >90% of an accurate pre-spinal value, and to avoid a drop to <80% of this value. This survey aimed to assess regional adherence to these recommendations, the presence of local guidelines for management of hypotension during caesarean section under spinal anaesthesia, and the individual clinician's treatment thresholds for maternal hypotension and tachycardia.

METHODS

The West Midlands Trainee-led Research in Anaesthesia and Intensive Care Network co-ordinated surveys of obstetric anaesthetic departments and consultant obstetric anaesthetists across 11 National Health Service Trusts in the Midlands, England.

RESULTS

One-hundred-and-two consultant obstetric anaesthetists returned the survey and 73% of sites had a policy for vasopressor use; 91% used phenylephrine as the first-line drug but a wide range of recommended delivery methods was noted and target blood pressure was only listed in 50% of policies. Significant variation existed in both vasopressor delivery methods and target blood pressures.

CONCLUSIONS

Although NICE has since recommended prophylactic phenylephrine infusion and a target blood pressure, the previous international consensus statement was not adhered to routinely.

The Effect of Intermittent Fasting on Appetite: A Systematic Review and Meta-Analysis

Previously, narrative reviews have considered the effects of intermittent fasting on appetite. One suggestion is that intermittent fasting attenuates an increase in appetite that typically accompanies weight loss. Here, we conducted the first systematic review and meta-analysis to quantify the effects of intermittent fasting on appetite, when compared to a continuous energy restriction intervention. Five electronic databases and trial registers were searched in February 2021 and February 2022. Abstracts (N = 2800) were screened and 17 randomized controlled trials (RCTs), consisting of a variety of intermittent fasting regimes, met our inclusion criteria. The total number of participants allocated to interventions was 1111 and all RCTs were judged as having either some concerns or a high risk of bias (Cochrane RoB 2.0 tool). Random effects meta-analyses were conducted on change-from-baseline appetite ratings. There was no clear evidence that intermittent fasting affected hunger (WMD = -3.03; 95% CI [-8.13, 2.08]; p = 0.25; N = 13), fullness (WMD = 3.11; 95% CI [-1.46, 7.69]; p = 0.18; N = 10), desire to eat (WMD = -3.89; 95% CI [-12.62, 4.83]; p = 0.38; N = 6), or prospective food consumption (WMD = -2.82; 95% CI [-3.87, 9.03]; p = 0.43; N = 5), differently to continuous energy restriction interventions. Our results suggest that intermittent fasting does not mitigate an increase in our drive to eat that is often associated with continuous energy restriction.

A Case of Asymptomatic Uterine Incarceration in a Patient Undergoing Dilation and Evacuation

Uterine incarceration is a rare pregnancy complication that occurs when the uterine fundus becomes trapped beneath the sacral promontory. We present a case of incarceration in a patient seeking dilation and evacuation (D&E) and a discussion of strategies for uterine reduction and cervical preparation.

Behavioral and Transcriptome Profiling of Heterozygous Rab10 Knock-Out Mice

A central question in the field of aging research is to identify the cellular and molecular basis of neuroresilience. One potential candidate is the small GTPase, Rab10. Here, we used Rab10+/- mice to investigate the molecular mechanisms underlying Rab10-mediated neuroresilience. Brain expression analysis of 880 genes involved in neurodegeneration showed that Rab10+/- mice have increased activation of pathways associated with neuronal metabolism, structural integrity, neurotransmission, and neuroplasticity compared with their Rab10+/+ littermates. Lower activation was observed for pathways involved in neuroinflammation and aging. We identified and validated several differentially expressed genes (DEGs), including Stx2, Stx1b, Vegfa, and Lrrc25 (downregulated) and Prkaa2, Syt4, and Grin2d (upregulated). Behavioral testing showed that Rab10+/- mice perform better in a hippocampal-dependent spatial task (object in place test), while their performance in a classical conditioning task (trace eyeblink classical conditioning, TECC) was significantly impaired. Therefore, our findings indicate that Rab10 differentially controls the brain circuitry of hippocampal-dependent spatial memory and higher-order behavior that requires intact cortex-hippocampal circuitry. Transcriptome and biochemical characterization of these mice suggest that glutamate ionotropic receptor NMDA type subunit 2D (GRIN2D or GluN2D) is affected by Rab10 signaling. Further work is needed to evaluate whether GRIN2D mediates the behavioral phenotypes of the Rab10+/- mice. We conclude that Rab10+/- mice described here can be a valuable tool to study the mechanisms of resilience in Alzheimer's disease (AD) model mice and to identify novel therapeutical targets to prevent cognitive decline associated with normal and pathologic aging.

The Role of the Mediterranean Diet in Breast Cancer Survivorship: A Systematic Review and Meta-Analysis of Observational Studies and Randomised Controlled Trials

Female breast cancer is the most frequently diagnosed cancer. The long-term survival rates for this disease have increased; however, the unique demand for high-quality healthcare to improve breast-cancer survivorship are commonly unmet. The Mediterranean diet (MD) is associated with reduced breast-cancer risk and various health-related benefits in the general population, but its effect on breast-cancer survivors remains uncertain. The objective of this systematic review and meta-analysis was to assess current evidence from randomised controlled trials (RCTs) and observational studies (cohort, cross-sectional and case-control) regarding the effect of the MD on survival, quality of life (QoL) and health-related outcomes in female breast-cancer survivors. MEDLINE, EMBASE, Web of Science and the Cochrane library were searched for studies published before and including April 2022. Two reviewers independently screened the literature and completed the data extraction and risk-of-bias assessment. Eleven studies (fifteen reports) were included, including two RCTs, four cohort and five cross-sectional studies. The meta-analysis of the cohort studies showed strong evidence of an inverse association between high adherence to the MD and all-cause mortality (hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.66-0.93, I²: 0%, Grading of Recommendations Assessment, Development and Evaluation (GRADE) = low certainty of evidence) and non-breast-cancer mortality (HR 0.67, 95% CI 0.50-0.90, I²: 0%, GRADE = very low certainty of evidence). The associations between high adherence to the MD and QoL and health-related parameters were not consistent. These findings highlight the potential of adherence to the MD to reduce the risk of mortality. Future research with better study designs, as well as more consistent measurements of QoL and MD adherence, taking into account changes in MD adherence over time and population subgroups, is needed to provide more robust evidence on the survival, QoL and health-related outcomes in BC survivors.

Geography, environment, and colonization history interact with morph type to shape genomic variation in an Arctic fish

Polymorphic species are useful models for investigating the evolutionary processes driving diversification. Such processes include colonization history as well as contemporary selection, gene flow, and genetic drift, which can vary between intraspecific morphs as a function of their distinct life histories. The interactive and relative influence of such evolutionary processes on morph differentiation critically informs morph-specific management decisions and our understanding of incipient speciation. We therefore investigated how geographic distance, environmental conditions, and colonization history interacted with morph migratory capacity in the highly polymorphic fish species, Arctic Charr (Salvelinus alpinus). Using an 87k SNP chip we genetically characterized recently evolved anadromous, resident, and landlocked charr collected from 45 locations across a secondary contact zone of three charr glacial lineages in eastern Canada. A strong pattern of isolation by distance across all populations suggested geographic distance principally shaped genetic structure. Landlocked populations had lower genetic diversities and higher genetic differentiation than anadromous populations. However, effective population size was generally temporally stable in landlocked populations in comparison to anadromous populations. Genetic diversity positively correlated with latitude, potentially indicating southern anadromous populations' vulnerability to climate change and greater introgression between the Arctic and Atlantic glacial lineages in northern Labrador. Local adaptation was suggested by the observation of several environmental variables strongly associating with functionally relevant outlier genes including a region on chromosome AC21 potentially associated with anadromy. Our results demonstrate that gene flow, colonization history, and local adaptation uniquely interact to influence the genetic variation and evolutionary trajectory of populations.

168. Closing Time: A Quasi-experiment Comparing Time to Optimal Therapy using Traditional Identification and Susceptibility Methods, Rapid Identification, or Rapid Identification with Phenotype for Gram-negative Bloodstream Infections

Background

Bloodstream infections (BSI) are a major cause of morbidity and mortality. Compared to traditional microbiology methods, rapid diagnostic testing (RDT) provides prompt organism identification and antibiotic susceptibility results. This leads to earlier opportunities to optimize therapy, which may improve patient outcomes.

Methods

This was a single center quasi-experimental study of hospitalized adults with Gram-negative (GN) BSI, comparing the management and outcomes across three periods: pre-RDT (traditional identification and susceptibilities with BD Phoenix®, December 2014 to September 2016), RDT1 (Nanosphere Verigene®, December 2016 to December 2019), and RDT2 (Accelerate Pheno™, February 2020 to September 2021). The primary outcome was time to optimal therapy (TTOT). Secondary outcomes included time to oral antibiotic step-down, hospital length of stay (LOS), incidence of Clostridioides difficile infection, and 30-day inpatient mortality. Chi-squared and Kruskal-Wallis tests were used to compare categorical and continuous variables. Significance values for the primary endpoint were adjusted with Bonferroni correction to account for multiple pairwise comparisons.

Results

Of 296 included patients, 100 were in the pre-RDT, 98 in the RDT1, and 98 in the RDT2 arms. The most common organisms were Escherichia coli (64.5%) and Klebsiella species (20.3%). The TTOT (median, interquartile range) in the pre-RDT, RDT1, and RDT2 groups were 46 (7-61), 30 (0-53), and 12 (0-28) hours (P< 0.001), respectively. The time to oral antibiotic step-down and hospital LOS was similar between groups. There was no difference in C. difficile infection or 30-day inpatient mortality (Table 1). Table 1.

Diabetes medications and risk of HCC

Type 2 diabetes mellitus is a recognized risk factor for HCC in patients with liver disease, independent from the etiology of their liver disease. Hence, prevention and treatment of type 2 diabetes mellitus and its underlying cause, insulin resistance, should be considered a treatment target for patients with liver disease. The drug armamentarium for diabetes is wide and consists of agents with insulin-sensitizing activity, agents that stimulate insulin secretion, insulin itself, and agents that reduce gastrointestinal and urinary glucose absorption. From an endocrinology perspective, the main goal of treatment is the achievement of euglycemia; however, in patients at risk of, or with known underlying liver disease, the choice of diabetic medication as it relates to potential hepatic carcinogenesis remains complex and should be carefully considered. In the last decade, increasing evidence has suggested that metformin may reduce the risk of HCC, whereas evidence for other classes of diabetic medications, particularly some of the newer agents including the sodium glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, is fewer and often inconsistent. In this review, we aim to summarize the current evidence on the potential effects of the most widely used diabetic agents on liver cancer tumorigenesis.

Impact of low iodine diets on ablation success in differentiated thyroid cancer: A mixed-methods systematic review and meta-analysis

BACKGROUND

Debate remains regarding whether to recommend a low iodine diet (LID) before radioactive-iodine treatment and its duration and stringency. This mixed-methods review aimed to determine if iodine status affects treatment success, the most effective diet to reduce iodine status, and how LID impacts wellbeing.

METHODS

Five electronic databases were searched until February 2021. An effectiveness synthesis (quantitative studies) and views synthesis (qualitative, survey, and experience-based evidence) were conducted individually and then integrated. Quality assessment was undertaken.

RESULTS

Fifty-six quantitative and three qualitative studies were identified. There was greater ablation success for those with an iodine status of &lt;50 mcg/L (or mcg/gCr) compared with ≥250 (odds ratio [OR] = 2.63, 95% confidence interval [CI], 1.18-5.86, n = 283, GRADE certainty of evidence very low). One study compared &lt;50 mcg/L (or mcg/gCr) to 100-199 and showed similar rates of ablation success (OR = 1.59, 95% CI, 0.48-6.15, n = 113; moderate risk of bias). People following a stricter LID before ablation had similar rates of success to a less-strict diet (OR = 0.67, 95% CI, 0.26-1.73, n = 256, GRADE certainty of evidence very low). A stricter LID reduced iodine status more than a less strict (SMD = -0.40, 95% CI, -0.56 to -0.24, n = 816), and reduction was seen after 1 and 2 weeks. The main challenges were a negative impact on psychological health, over restriction, confusion, and difficulty for sub-groups.

CONCLUSIONS

Although a LID of 1-2 weeks reduces iodine status, it remains unclear whether iodine status affects treatment success as only a few low-quality studies have examined this. LIDs are challenging for patients. Higher-quality studies are needed to confirm whether a LID is necessary.

Effective practices during emergency school lockdowns: shared experiences of four Australian schools

This study investigates common features of a set of diverse schools' responses to the initial school lockdown period during the pandemic in 2020, with a focus on practices supporting learning, inclusion and wellbeing. It comprises a collective case study of four Australian schools that were selected based on their reputation for impactful support of students and teachers during the emergency remote teaching period. Methods included interviews and focus groups with school leaders, teachers and students. The schools had widely differing contexts, technology access and student needs. Despite these varied contexts, the findings provided important insights into common practices supporting effective remote teaching. Emerging principles of effective practice illuminate ways forward to mitigate the significant risks accompanying emergency remote teaching, and guide practices in a variety of school contexts.

Communication of palliative care needs in discharge letters from hospice providers to primary care: a multisite sequential explanatory mixed methods study

Background

The provision of palliative care is increasing, with many people dying in community-based settings. It is essential that communication is effective if and when patients transition from hospice to community palliative care. Past research has indicated that communication issues are prevalent during hospital discharges, but little is known about hospice discharges.

Methods

An explanatory sequential mixed methods study consisting of a retrospective review of hospice discharge letters, followed by hospice focus groups, to explore patterns in communication of palliative care needs of discharged patients and describe why these patients were being discharged. Discharge letters were extracted for key content information using a standardised form. Letters were then examined for language patterns using a linguistic methodology termed corpus linguistics. Thematic analysis was used to analyse the focus group transcripts. Findings were triangulated to develop an explanatory understanding of discharge communication from hospice care.

Results

We sampled 250 discharge letters from five UK hospices whereby patients had been discharged to primary care. Twenty-five staff took part in focus groups. The main reasons for discharge extracted from the letters were symptoms “managed/resolved” (75.2%), and/or the “patient wishes to die/for care at home” (37.2%). Most patients had some form of physical needs documented on the letters (98.4%) but spiritual needs were rarely documented (2.4%). Psychological/emotional needs and social needs were documented in 46.4 and 35.6% of letters respectively. There was sometimes ambiguity in “who” will be following up “what” in the discharge letters, and whether described patients’ needs were resolved or ongoing for managing in the community setting. The extent to which patients received a copy of their discharge letter varied. Focus groups conveyed a lack of consensus on what constitutes “complexity” and “complex pain”.

Conclusions

The content and structure of discharge letters varied between hospices, although generally focused on physical needs. Our study provides insights into patterns associated with those discharged from hospice, and how policy and guidance in this area may be improved, such as greater consistency of sharing letters with patients. A patient-centred set of hospice-specific discharge letter principles could help improve future practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01038-8.

Clinical consensus regarding the importance of rapid reduction in depressive symptoms in major depressive disorder with acute suicidal ideation or behavior (MDSI)

Introduction

Patients with major depressive disorder (MDD) with acute suicidal ideation or behavior (MDSI) require immediate intervention. Though oral antidepressants can be effective at reducing depressive symptoms, they can take 4–6 weeks to reach full effect.

Objectives

This study aimed to identify unmet needs in the treatment of patients with MDSI, specifically exploring the potential clinical benefits of rapid reduction of depressive symptoms.

Methods

A Delphi panel consisting of practicing psychiatrists (n=12) from the US, Canada and EU was conducted between December 2020–June 2021. Panelists were screened to ensure they had sufficient experience with managing patients with MDD and MDSI. Panelists completed two survey rounds, and a virtual consensus meeting.

Results

This research confirmed current unmet needs in the treatment of patients with MDSI.

Hopelessness, functional impairment, worsening of MDD symptoms, recurrent hospitalization and higher risk of suicide attempt were considered as key consequences of the slow onset of action of oral antidepressants.

Treatment with rapid acting antidepressant was anticipated by panelists to provide short-term benefit such as rapid reduction of core MDD symptoms which may contribute to shorter hospital stays and improved patient engagement/compliance, allowing for earlier interventions and improved patient outcomes. For long-term benefits, panelists agreed that improved daily functioning and increased trust/confidence in treatment options, constitute key benefits of rapid-acting treatments

Conclusions

There is need for rapid-acting treatments which may help address key unmet needs and provide clinically meaningful benefits driven by the rapid relief of depressive symptoms particularly in patients with MDSI.

Disclosure

SB, ED, KJ, MO’H, QZ, MM, MH, SR, JA and DZ are employees of Janssen and hold stock in Johnson & Johnson Inc. AN is currently employed by Neurocrine Biosciences Inc. RP is an employee of Adelphi Values PROVE hired by Janssen.

Short-term effectiveness of nutrition therapy to treat type 2 diabetes in low-income and middle-income countries: systematic review and meta-analysis of randomised controlled trials

OBJECTIVES

This review examined the evidence arising from randomised controlled trials regarding the impact of nutrition therapy on glycaemic control in people living with type 2 diabetes mellitus (T2DM) in low/middle-income countries (LMICs).

DESIGN

Systematic review and meta-analysis using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Approach.

DATA SOURCES

MEDLINE, EMBASE, Web of Science, OpenGrey and the International Clinical Trials Registry were searched (up to July 3 2020).

ELIGIBILITY CRITERIA

Trials were included if they evaluated nutrition therapy in adults diagnosed with T2DM, were conducted in LMICs, measured glycaemic control and the trial included a 3-month post-intervention assessment. Nutrition therapy was defined according to American Diabetes Association recommendations.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened the database. Study characteristics and outcome data were extracted using a data collection form. Meta-analyses were conducted for glycated haemoglobin (HbA1c) and fasting blood glucose. Trials were assessed for risk of bias (Cochrane Risk-of-Bias, Version 2.0) and overall certainty of evidence (GRADE).

RESULTS

Four trials met inclusion criteria (total n=463), conducted in Malaysia, Iran and South Africa. All trials focused on nutrition education with no direct prescription or manipulation of diet. Mean differences between intervention and standard care were -0.63% (95% CI -1.47% to 0.21%) for HbA1c and -13.63 mg/dL (95% CI -37.61 to 10.34) for fasting blood glucose in favour of the intervention. Given the small number of eligible trials, moderate to high risk of publication bias and serious concerns regarding consistency and precision of the evidence, certainty of evidence was deemed to be very low.

CONCLUSIONS

There is a lack of well-conducted randomised controlled trials that examine the long-term impact of nutrition therapy in LMICs, preventing firm conclusions to be made on their effectiveness. Further research is essential to discover realistic, evidence-based solutions.

PROSPERO REGISTRATION NUMBER

CRD42020188435.

Patient preferences using telehealth during COVID-19 pandemic in four Victorian tertiary hospital services

INTRODUCTION

To measure patients' evaluation of telehealth, preferences for telehealth versus in-person appointments, and potential cost savings by patient characteristics.

METHODS

A cross-sectional online survey (including patient and appointment characteristics, telehealth evaluation, preferences for care and costs) of adult patients using video telehealth in four metropolitan tertiary hospital services in Melbourne, Victoria.

RESULTS AND DISCUSSIONS

A total of 1045 patients (44 years - IQR 29-59) participated with an overall response rate of 9.2%. For 98.7% patients telehealth was convenient, 96.4% stated that it saved time, 95.9% found telehealth acceptable to receive care and 97.0% found that telehealth improved their access to care. Most (62.6%) preferred in-person consultations, although 86.9% agreed that telehealth was equivalent to an in-person consultation. Those in regional and rural areas were less likely to prefer in-person consultations. Patients attending for medical reasons were less likely to prefer in-person consultation compared to patients with surgical reasons. Patient preference to telehealth were independent of level of education, appointment type, self-rated health status and socio-economic status. Patients saved an average of $120.9 (SD $93.0) per appointment, with greater cost savings for patients from low and middle socioeconomic areas and regional or rural areas. Telehealth video consultations were largely evaluated positively with most patients considering the service to be as good as in-person. Understanding patient preference is critical to consider when implementing telehealth as mainstream across hospital health services. This article is protected by copyright. All rights reserved.

The effect of exercise on left ventricular global longitudinal strain: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Cancer Research Institute, Allied Health and Human Performance, University of South Australia

Background/Introduction

Left ventricular global longitudinal strain (LVGLS) can detect early myocardial changes prior to clinical abnormalities arising, and is a strong prognostic indicator of future cardiovascular (CV) dysfunction and mortality. It is well established that exercise improves CV function and reduces risk of CV disease. However, the impact of exercise on LVGLS is currently unclear. If LVGLS increases in response to habitual exercise, it could offer a sensitive measure that can determine the effectiveness of an exercise regime on CV health.

Purpose

The aim of this systematic review and meta-analysis was to determine whether exercise impacts LVGLS across a range of healthy and diseased populations.

Methods

Four databases (Medline, Scopus, eMbase, SPORTDiscus) were searched in November 2020. Included studies assessed LVGLS before and after an exercise intervention (minimum 2 weeks) in adults aged 18 years and over, and were published in English from 2000 onwards. Random-effects meta-analyses were performed at a study level using Stata (v16.1) to calculate summary standardized mean differences (SMD) and 95% confidence intervals (CI). 39 studies met selection criteria, with 35 included in meta-analyses (1765 participants).

Primary meta-analyses included only studies that compared outcomes between one or more intervention arms to a standard (non-exercising) control arm (RCT’s, N-RCT’s, randomised crossover). Secondary analyses included data from studies with intervention arms only (single group pre-post studies, intervention group from RCT’s, N-RCT’s, randomised crossover).

Results

Primary:

In populations with CV disease, a moderate effect of exercise was observed compared to non-exercising controls (SMD = 0.59; 95% CI, 0.16-1.02; p = 0.01 – figure 1a). No significant effect of exercise was observed for CV risk (SMD = 0.07; 95% CI, -0.15-0.29; p = 0.56 – figure 1b) and healthy (SMD = -0.20; 95% CI, -0.73-0.33; p = 0.45) populations compared to non-exercising controls.

Secondary

In secondary meta-analyses, significant effects of exercise were observed in CV disease (SMD = 0.26; 95% CI, 0.07-0.46; p = 0.01), CV risk (SMD = 0.54; 95% CI, 0.15-0.93; p = 0.01), chronic kidney disease (SMD = 0.65; 95% CI, 0.03-1.28; p = 0.04) and athletic (SMD = 0.30; 95% CI, 0.20-0.41; p= &lt;0.001) populations.

Conclusion(s)

Increases in LVGLS observed in populations with CV disease may assist the prevention of secondary CV events. Secondary findings may support the use of exercise across a range of populations to increase LVGLS and enhance CV function. Future research must address the methodological limitations that currently exist, including improving upon study designs and reporting of individual data. Abstract Figure.

Social relationships and the risk of incident heart failure: results from a prospective population-based study of older men

Aims

Limited social relationships, particularly in older adults, have been implicated as a risk factor for cardiovascular disease. However, little is known about the associations between poor social relationships and heart failure incidence.

Methods and results

Prospective study of socially representative men aged 60–79 years drawn from general practices in 24 British towns and followed up for a maximum of 18 years. A total of 3698 participants with no previous diagnosis of heart failure were included. Information on social relationships was based on a combination of marital status, living circumstances, and social contacts with friends and family. These provided information on contact frequency, contact satisfaction, and a social relationship score (low to high) combining frequency and satisfaction with contact. Heart failure included both incidents non-fatal heart failure and death from heart failure. Among 3698 participants, 330 developed heart failure. Men with low compared to high frequency of contact with family and friends had an increased risk of incident heart failure [hazard ratio (HR) 1.59, 95% confidence interval (CI) 1.15–2.18]; this remained statistically significant after adjustment for social class, behavioural, and biological risk factors. Low compared to high scores for satisfaction with contacts was associated with increased risk of heart failure (adjusted HR = 1.54; 95% CI 1.14–2.07). Lower social relationship scores (combining frequency and satisfaction with contact) were associated with greater risk of incident heart failure (adjusted HR = 1.38, 95% CI 1.02–1.87). Marital status and living alone were not significantly associated with heart failure.

Conclusion

Weaker social relationships appear to increase the risk of developing heart failure in older age. Further research is needed to investigate pathways underlying these associations and to test whether interventions to strengthen social relationships can reduce the risk of heart failure.

Omega-3 fatty acids for depression in adults

BACKGROUND

Major depressive disorder (MDD) is highly debilitating, difficult to treat, has a high rate of recurrence, and negatively impacts the individual and society as a whole. One potential treatment for MDD is n-3 polyunsaturated fatty acids (n-3PUFAs), also known as omega-3 oils, naturally found in fatty fish, some other seafood, and some nuts and seeds. Various lines of evidence suggest a role for n-3PUFAs in MDD, but the evidence is far from conclusive. Reviews and meta-analyses clearly demonstrate heterogeneity between studies. Investigations of heterogeneity suggest different effects of n-3PUFAs, depending on the severity of depressive symptoms, where no effects of n-3PUFAs are found in studies of individuals with mild depressive symptomology, but possible benefit may be suggested in studies of individuals with more severe depressive symptomology. Hence it is important to establish their effectiveness in treating MDD. This review updates and incorporates an earlier review with the same research objective (Appleton 2015).

OBJECTIVES

To assess the effects of n-3 polyunsaturated fatty acids (also known as omega-3 fatty acids) versus a comparator (e.g. placebo, antidepressant treatment, standard care, no treatment, wait-list control) for major depressive disorder (MDD) in adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO together with trial registries and grey literature sources (to 9 January 2021). We checked reference lists and contacted authors of included studies for additional information when necessary.

SELECTION CRITERIA

We included studies in the review if they: used a randomised controlled trial design; provided n-3PUFAs as an intervention; used a comparator; measured depressive symptomology as an outcome; and were conducted in adults with MDD. Primary outcomes were depressive symptomology (continuous data collected using a validated rating scale) and adverse events. Secondary outcomes were depressive symptomology (dichotomous data on remission and response), quality of life, and non-completion of studies.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane. We assessed the certainty of the evidence using GRADE criteria.

MAIN RESULTS

The review includes 35 relevant studies: 34 studies involving a total of 1924 participants investigated the impact of n-3PUFA supplementation compared to placebo, and one study involving 40 participants investigated the impact of n-3PUFA supplementation compared to antidepressant treatment. For the placebo comparison, n-3PUFA supplementation resulted in a small to modest benefit for depressive symptomology, compared to placebo: standardised mean difference (SMD) (random-effects model) -0.40 (95% confidence interval (CI) -0.64 to -0.16; 33 studies, 1848 participants; very low-certainty evidence), but this effect is unlikely to be clinically meaningful. An SMD of 0.40 represents a difference between groups in scores on the HDRS (17-item) of approximately 2.5 points (95% CI 1.0 to 4.0), where the minimal clinically important change score on this scale is 3.0 points. The confidence intervals include both a possible clinically important effect and a possible negligible effect, and there is considerable heterogeneity between studies. Sensitivity analyses, funnel plot inspection and comparison of our results with those of large well-conducted trials also suggest that this effect estimate may be biased towards a positive finding for n-3PUFAs. Although the numbers of individuals experiencing adverse events were similar in intervention and placebo groups (odds ratio (OR) 1.27, 95% CI 0.99 to 1.64; 24 studies, 1503 participants; very low-certainty evidence), the confidence intervals include a small decrease to a modest increase in adverse events with n-3PUFAs. There was no evidence for a difference between n-3PUFA and placebo groups in remission rates (OR 1.13, 95% CI 0.74 to 1.72; 8 studies, 609 participants, low-certainty evidence), response rates (OR 1.20, 95% CI 0.80 to 1.79; 17 studies, 794 participants; low-certainty evidence), quality of life (SMD -0.38 (95% CI -0.82 to 0.06), 12 studies, 476 participants, very low-certainty evidence), or trial non-completion (OR 0.92, 95% CI 0.70 to 1.22; 29 studies, 1777 participants, very low-certainty evidence). The evidence on which these results are based was also very limited, highly heterogeneous, and potentially biased. Only one study, involving 40 participants, was available for the antidepressant comparison. This study found no differences between treatment with n-3PUFAs and treatment with antidepressants in depressive symptomology (mean difference (MD) -0.70, 95% CI -5.88 to 4.48), rates of response to treatment (OR 1.23, 95% CI 0.35 to 4.31), or trial non-completion (OR 1.00, 95% CI 0.21 to 4.71). Confidence intervals are however very wide in all analyses, and do not rule out important beneficial or detrimental effects of n-3PUFAs compared to antidepressants. Adverse events were not reported in a manner suitable for analysis, and rates of depression remission and quality of life were not reported.

AUTHORS' CONCLUSIONS

At present, we do not have sufficient high-certainty evidence to determine the effects of n-3PUFAs as a treatment for MDD. Our primary analyses may suggest a small-to-modest, non-clinically beneficial effect of n-3PUFAs on depressive symptomology compared to placebo; however the estimate is imprecise, and we judged the certainty of the evidence on which this result is based to be low to very low. Our data may also suggest similar rates of adverse events and trial non-completion in n-3PUFA and placebo groups, but again our estimates are very imprecise. Effects of n-3PUFAs compared to antidepressants are very imprecise and uncertain. More complete evidence is required for both the potential positive and negative effects of n-3PUFAs for MDD.

The feasibility, acceptability, and benefit of interventions that target eating speed in the clinical treatment of children and adolescents with overweight or obesity: A systematic review and meta-analysis

Eating at a faster speed is positively correlated with having a higher BMI. Modifying eating speed may offer a treatment opportunity for those with overweight and obesity. This review sought to understand the feasibility, acceptability, and benefit to using eating speed interventions in paediatric clinical weight-management settings. The PICO Framework was used. Clinical studies of eating speed interventions as a treatment for paediatric patients with overweight or obesity were included. No limits to search date were implemented. A systematic search of MEDLINE, PsychINFO and EMBASE via OVID, Web of Science and JBI, Database of systematic reviews and Implementation reports, along with trial registers NICE, ClinicalTrials.gov and Cochrane Central Register of Controlled Trials was conducted. Two authors were responsible for screening, extraction, and evaluation of the risk of bias. Fifteen papers reporting twelve interventions addressing eating-speed were identified, involving a total of 486 active participants (range 7-297). Study design was weak with only one full RCT and there were some concerns over quality and risk of bias (Cochrane RoB 2.0). Limited sample sizes and different measured outcomes did not allow powered evaluations of effect for all outcomes. There is some indication, overall, that addressing eating speed has the potential to be a beneficial adjunct to clinical obesity treatment, although the pooled effect estimate did not demonstrate a difference in BMISDS status following eating speed interventions compared to control [pooled mean difference (0.04, 95% CI -0.39 to 0.46, N = 3)]. Developments to improve the engagement to, and acceptability of, interventions are required, alongside rigorous high-quality trials to evaluate effectiveness.

A comparison of two assessment tools used in overviews of systematic reviews: ROBIS versus AMSTAR-2

BACKGROUND

AMSTAR-2 is a 16-item assessment tool to check the quality of a systematic review and establish whether the most important elements are reported. ROBIS is another assessment tool which was designed to evaluate the level of bias present within a systematic review. Our objective was to compare, contrast and establish both inter-rater reliability and usability of both tools as part of two overviews of systematic reviews. Strictly speaking, one tool assesses methodological quality (AMSTAR-2) and the other assesses risk of bias (ROBIS), but there is considerable overlap between the tools in terms of the signalling questions.

METHODS

Three reviewers independently assessed 31 systematic reviews using both tools. The inter-rater reliability of all sub-sections using each instrument (AMSTAR-2 and ROBIS) was calculated using Gwet's agreement coefficient (AC1 for unweighted analysis and AC2 for weighted analysis).

RESULTS

Thirty-one systematic reviews were included. For AMSTAR-2, the median agreement for all questions was 0.61. Eight of the 16 AMSTAR-2 questions had substantial agreement or higher (> 0.61). For ROBIS, the median agreement for all questions was also 0.61. Eleven of the 24 ROBIS questions had substantial agreement or higher.

CONCLUSION

ROBIS is an effective tool for assessing risk of bias in systematic reviews and AMSTAR-2 is an effective tool at assessing quality. The median agreement between raters for both tools was identical (0.61). Reviews that included a meta-analysis were easier to rate with ROBIS; however, further developmental work could improve its use in reviews without a formal synthesis. AMSTAR-2 was more straightforward to use; however, more response options would be beneficial.

The association between later eating rhythm and adiposity in children and adolescents: a systematic review and meta-analysis

CONTEXT

Childhood adiposity, an important predictor of adult chronic disease, has been rising dramatically. Later eating rhythm, termed night eating, is increasing in adults but rarely studied in younger ages.

OBJECTIVE

The objective of this study was to review the association between later eating rhythm and adiposity in children and adolescents. The aspects of later eating being considered included: energy intake (for evening main meal, evening snack, whole evening period, and around bedtime); timing (any food eaten at later timing); and meal frequency in the evening/night (evening main meal skipping, evening snack consumption).

DATA SOURCES

Five databases (the Cochrane Library, CINAHL, Embase, MEDLINE (via OVID), and Web of Science) were searched for eligible articles published prior to and including August 2020.

DATA EXTRACTION

Data extraction and quality assessment were conducted by 2 reviewers independently.

DATA ANALYSIS

Forty-seven studies were included, all of which were observational. Meta-analysis showed positive associations between both higher energy intake around bedtime (odds ratio [OR] 1.19, 95% CI 1.06, 1.33) and evening main meal skipping (OR 1.30, 95% CI 1.14, 1.48), and adiposity. There was evidence to suggest that consuming evening snacks reduced adiposity, but it was very weak (OR 0.80, 95% CI 0.62, 1.05). No association was seen between eating later and adiposity (OR 1.04, 95% CI 0.68, 1.61). In the narrative analysis, approximately half of the studies suggested that there was no association between later eating rhythm and adiposity, either as a whole or within exposure subsets.

CONCLUSION

The magnitude of the relationship between later eating rhythm and adiposity is very small, and may vary depending on which aspects of later eating rhythm are under consideration; however, the evidence for this conclusion is of very low certainty. Further research with a more consistent definition of "later timing", and longitudinal studies in different populations, may lead to different conclusions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42019134187.

Pre-admission interventions (prehabilitation) to improve outcome after major elective surgery: a systematic review and meta-analysis

OBJECTIVE

To determine the benefits and harms of pre-admission interventions (prehabilitation) on postoperative outcomes in patients undergoing major elective surgery.

DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs) (published or unpublished). We searched Medline, Embase, CENTRAL, DARE, HTA and NHS EED, The Cochrane Library, CINAHL, PsychINFO and ISI Web of Science (June 2020).

SETTING

Secondary care.

PARTICIPANTS

Patients (≥18 years) undergoing major elective surgery (curative or palliative).

INTERVENTIONS

Any intervention administered in the preoperative period with the aim of improving postoperative outcomes.

OUTCOMES AND MEASURES

Primary outcomes were 30-day mortality, hospital length of stay (LoS) and postoperative complications. Secondary outcomes included LoS in intensive care unit or high dependency unit, perioperative morbidity, hospital readmission, postoperative pain, heath-related quality of life, outcomes specific to the intervention, intervention-specific adverse events and resource use.

REVIEW METHODS

Two authors independently extracted data from eligible RCTs and assessed risk of bias and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation. Random-effects meta-analyses were used to pool data across trials.

RESULTS

178 RCTs including eight types of intervention were included. Inspiratory muscle training (IMT), immunonutrition and multimodal interventions reduced hospital LoS (mean difference vs usual care: -1.81 days, 95% CI -2.31 to -1.31; -2.11 days, 95% CI -3.07 to -1.15; -1.67 days, 95% CI -2.31 to -1.03, respectively). Immunonutrition reduced infective complications (risk ratio (RR) 0.64 95% CI 0.40 to 1.01) and IMT, and exercise reduced postoperative pulmonary complications (RR 0.55, 95% CI 0.38 to 0.80, and RR 0.54, 95% CI 0.39 to 0.75, respectively). Smoking cessation interventions reduced wound infections (RR 0.28, 95% CI 0.12 to 0.64).

CONCLUSIONS

Some prehabilitation interventions may reduce postoperative LoS and complications but the quality of the evidence was low.

PROSPERO REGISTRATION NUMBER

CRD42015019191.

Dietary management for people with an ileostomy: a scoping review

OBJECTIVE

The objective of this review was to identify and map the evidence for oral dietary management of ileostomies.

INTRODUCTION

Dietary advice is commonly provided for ileostomy management but can be inconsistent, conflicting, and inadequate. There is a lack of high-quality research investigating dietary management of ileostomies. This scoping review highlights gaps in the literature that need addressing to inform practice, and identifies dietary strategies and outcomes to be investigated in future studies.

INCLUSION CRITERIA

Evidence relating to the use of oral dietary strategies to manage complications and nutritional consequences associated with having an ileostomy was included. Evidence included all types of original research (ie, quantitative and qualitative methodologies, expert opinion articles, and consensus guidelines).

METHODS

This review followed JBI methodology for scoping reviews. A pre-determined search of 13 databases, including MEDLINE, Embase, and Web of Science, was conducted in August 2019. The search was not limited by date, but during screening, expert opinion evidence was limited to 2008 onward. Data extraction was carried out by two reviewers for each study/article using a database tool designed specifically for this review. Results are presented using a combination of tabular summaries and narrative reports.

RESULTS

Thirty-one research studies were included: 11 experimental (including four crossover randomized controlled trials), three pre-post design, 13 observational (12 cross-sectional, one longitudinal), and four qualitative. Forty-four expert opinion articles/guidelines were also included. In experimental studies, nine nutrient modifications and 34 individual foods/drinks were investigated. In pre-post studies, 10 nutrient modifications, 80 foods/drinks, and 11 eating-related behaviors were investigated. In observational studies, eight nutrient modifications, 94 foods/drinks, and five eating-related behaviors were reported. In qualitative studies, two nutrient modifications, 17 foods/drinks, and one eating-related behavior were reported. In expert opinion articles/guidelines, recommendations relating to 51 nutrient modifications, 339 foods/drinks, and 23 eating-related behaviors were reported. Although large numbers of individual foods and drinks were suggested to be associated with outcomes relating to ileostomy management, findings from observational studies showed these were generally reported by <50% of people with an ileostomy. The most common nutrients reported in association with outcomes related to ileostomy management were fiber, fat, and alcohol. Across most outcomes and studies/expert opinion, low fiber and low fat were suggested to be beneficial, while alcohol was detrimental. Other nutrient associations frequently reported in expert opinion (but with minimal attention in research studies) included negative consequences of caffeinated drinks and positive effects of white starchy carbohydrates on stoma output. Output volume and consistency were the most commonly reported outcomes relating to ileostomy management across all study types. Flatulence and odor were also common outcomes in observational studies.

CONCLUSIONS

This review found an abundance of literature, particularly expert opinion, reporting on dietary management for people with an ileostomy. However, this literature was highly heterogeneous in terms of dietary strategies and outcomes reported. It is likely that most dietary advice provided in practice is based on expert opinion with some supported by limited research. High-quality research investigating the effect of the dietary strategies identified in this review on commonly associated outcomes relating to ileostomy management is needed to improve evidence-based advice.

Exploring eating behavior and psychological mechanisms associated with obesity in patients with craniopharyngioma: a scoping review protocol

OBJECTIVE

The objective of the review is to explore the evidence that investigates behavioral and psychological mechanisms underlying the development of obesity in patients with craniopharyngioma, in order to map that evidence, identify gaps in the literature, and find avenues of future intervention.

INTRODUCTION

Craniopharyngiomas are low-grade intracranial tumors of the supersellar region. Obesity is associated with the tumor or surgery or radiotherapy to treat the tumor, however, the behavioral and psychological processes contributing to that association are not clear. This review will provide a synthesized evidence base of the relevant research.

INCLUSION CRITERIA

The scoping review will consider published studies with all types of study designs, including patients with childhood- or adult-onset craniopharyngioma. Articles assessing factors that may impact eating behavior will be included based on the following categories: eating behavior, obesity, neuroimaging, endocrine response, energy expenditure, sleep, and neuropsychology.

METHODS

MEDLINE, Embase, and PsycINFO will be searched, in addition to Cochrane Library, Web of Science, Scopus, Clinical trials.gov, NICE evidence search, and International Standard Randomised Controlled Trial Number (ISRCTN). No limits will be placed on the scope of the search. Methodology will follow the proposed three-stage process with two independent reviewers at each stage, including an initial database search, screening of titles and abstracts of retrieved studies, full-text assessment for inclusion criteria, and hand searching of reference lists. Data will be extracted using a standardized charting form and summarized in tables. The data will be synthesized using a narrative summary and diagrammatic map and will be based on the evidence for each of the proposed research categories.

Exploring high mortality rates among people with multiple and complex needs: a qualitative study using peer research methods

OBJECTIVE

To explore the perceived reasons underlying high mortality rates among people with multiple and complex needs.

DESIGN

Qualitative study using peer research.

SETTING

North East of England.

PARTICIPANTS

Three focus group discussions were held involving (1) people with lived experience of multiple and complex needs (n=5); (2) front-line staff from health, social care and voluntary organisations that support multiple and complex needs groups (n=7); and (3) managers and commissioners of these organisations (n=9).

RESULTS

Findings from this study provide valuable perspectives of people with multiple complex needs and those that provide them with support on what may be perceived factors underlying premature mortality. Mental ill health and substance misuse (often co-occurring dual diagnosis) were perceived as influencing premature mortality among multiple and complex needs groups. Perceptions of opportunities to identify people at risk included critical life events (eg, bereavement, relationship breakdown) and transitions (eg, release from prison, completion of drug treatment). Early prevention, particularly supporting young people experiencing adverse childhood experiences, was also highlighted as a priority.

CONCLUSION

High mortality in multiple and complex needs groups may be reduced by addressing dual diagnosis, providing more support at critical life events and investing in early prevention efforts. Future interventions could take into consideration the intricate nature of multiple and complex needs and improve service access and navigation.

What change in BMI is required to improve cardiovascular outcomes in childhood and adolescent obesity lifestyle interventions: a meta-regression

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): This study was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol

Background

There is minimal evidence regarding the change of body mass index (BMI) needed to improve cardiovascular health in obese children. This paper aims to establish the minimum change in body mass index standard deviation score (BMI-SDS) needed to improve lipid profile and blood pressure (BP) of obese children and adolescents, to aid future trials and guidelines.

Methods

Studies with participants involved in lifestyle interventions, aged 4–19 years, with a diagnosis of obesity according to defined BMI thresholds, were considered for inclusion in a large systematic review. Interventions had to report pre- and post-intervention (or mean change in) BMI-SDS, plus either systolic blood pressure (SBP), high-density lipoprotein (HDL), low-density lipoprotein (LDL), and/or triglycerides (TG). Random effects meta-regression quantified the relationship between mean change in BMI-SDS and mean change in cardiovascular outcomes.

Results

Seventy-one papers reported various cardiovascular measurements and mean change in BMI-SDS. Fifty-four, 59, 46, and 54 studies were analysed; reporting change in SBP, HDL, LDL, and TG respectively. Reduction in mean BMI-SDS was significantly related to improvements in SBP, LDL, TG, and HDL (p &lt; 0.05); BMI-SDS reductions of 1, 1.2, and 0.7 ensured a mean reduction of SBP, LDL, and TG respectively although an equivalent value for HDL improvement was indeterminate.

Conclusions

Reductions in mean BMI-SDS of &gt;1, &gt;1.2, or &gt;0.7 are likely to reduce SBP, LDL, and TG respectively. Further studies are needed to clarify the optimal duration, intensity, and setting for interventions.  Consistency is required regarding derived BMI values to facilitate future systematic reviews and meta-analyses.

Study recruitment factors in advanced cancer: the Prognosis in Palliative care Study II (PiPS2) - a multicentre, prospective, observational cohort project

OBJECTIVES

The Prognosis in Palliative care Study II (PiPS2) was a large multicentre observational study validating prognostic tools in patients with advanced cancer. Many palliative care studies fail to reach their recruitment target. To inform future studies, PiPS2 rigorously monitored and identified any potential recruitment barriers.

METHODS

Key recruitment stages (ie, whether patients were eligible for the study, approached by the researchers and whether consent was obtained for enrolment) were monitored via comprehensive screening logs at participating sites (inpatient hospices, hospitals and community palliative care teams). The reasons for patients' ineligibility, inaccessibility or decision not to consent were documented.

RESULTS

17 014 patients were screened across 27 participating sites over a 20-month recruitment period. Of those, 4642 (27%) were ineligible for participation in the study primarily due to non-cancer diagnoses. Of 12 372 eligible patients, 9073 (73%) were not approached, the most common reason being a clinical decision not to do so. Other reasons included patients' death or discharge before they were approached by the researchers. Of the 3299 approached patients, 1458 (44%) declined participation mainly because of feeling too unwell, experiencing severe distress or having other competing priorities. 11% (n=1841/17 014) of patients screened were enrolled in the study, representing 15% (n=1841/12 372) of eligible patients. Different recruitment patterns were observed across inpatient hospice, hospital and community palliative care teams.

CONCLUSIONS

The main barrier to recruitment was 'accessing' potentially eligible patients. Monitoring key recruitment stages may help to identify barriers and facilitators to enrolment and allow results to be put into better context.

TRIAL REGISTRATION NUMBER

ISRCTN13688211.

What makes palliative care needs "complex"? A multisite sequential explanatory mixed methods study of patients referred for specialist palliative care

BACKGROUND

Specialist palliative care (SPC) providers tend to use the term 'complex' to refer to the needs of patients who require SPC. However, little is known about complex needs on first referral to a SPC service. We examined which needs are present and sought the perspectives of healthcare professionals on the complexity of need on referral to a hospice service.

METHODS

Multi-site sequential explanatory mixed method study consisting of a case-note review and focus groups with healthcare professionals in four UK hospices.

RESULTS

Documentation relating to 239 new patient referrals to hospice was reviewed; and focus groups involving 22 healthcare professionals conducted. Most patients had two or more needs documented on referral (96%); and needs were recorded across two or more domains for 62%. Physical needs were recorded for 91% of patients; psychological needs were recorded for 59%. Spiritual needs were rarely documented. Referral forms were considered limited for capturing complex needs. Referrals were perceived to be influenced by the experience and confidence of the referrer and the local resource available to meet palliative care needs directly.

CONCLUSIONS

Complexity was hard to detail or to objectively define on referral documentation alone. It appeared to be a term used to describe patients whom primary or secondary care providers felt needed SPC knowledge or support to meet their needs. Hospices need to provide greater clarity regarding who should be referred, when and for what purpose. Education and training in palliative care for primary care nurses and doctors and hospital clinicians could reduce the need for referral and help ensure that hospices are available to those most in need of SPC input.

Understanding Contraceptive Needs of Women Who Inject Drugs in Orange County: A Qualitative Study

OBJECTIVES

Women with opioid use disorder experience higher rates of unintended pregnancy compared with the general US population. Our aim was to examine the factors that may affect access to desired contraception for women who use injection drugs.

METHODS

Using purposive sampling, we conducted semi-structured interviews pertaining to contraceptive use with 14 women ages 18 to 44 who were current users of injection drugs living in Orange County, CA between March and December 2019. Interviews were transcribed, coded, and analyzed using grounded theory.

RESULTS

Participants discussed logistical barriers, including homelessness and lack of transportation, as well as perceived barriers, such as a belief in the inability to become pregnant while using drugs, that affect access to contraceptive care. Women also discussed the factors that motivate them to use contraception despite these barriers, including the desire for sobriety before becoming pregnant and fear of harming a fetus while using substances. Some participants expressed feeling uncomfortable disclosing substance use to their healthcare providers out of concern for stigmatization. Several points of access for contraceptive care were elucidated, including visits for primary and postpartum care, as well as in carceral spaces. Finally, participants expressed a desire to obtain contraceptive services at a local syringe exchange program due to trusting relationships with providers and increased ease of access.

CONCLUSIONS

Our findings highlight several causative factors for the unmet contraceptive need among women who use injection drugs, and suggest that syringe exchange programs represent a unique access point for the provision of contraceptive care for this population.

Feasibility and safety study of 22-gauge endoscopic ultrasound (EUS) needles for portal vein sampling in a swine model

Background and study aims  Endoscopic ultrasound (EUS) has been used for portal vein sampling in patients with pancreaticobiliary cancers for enumerating circulating tumor cells but is not yet a standard procedure. Further evaluation is needed to refine the methodology. Therefore, we evaluated the feasibility and safety of 19-gauge (19G) versus a 22-gauge (22 G) EUS fine-needle aspiration needles for portal vein sampling in a swine model. Methods  Celiotomy was performed on two farm pigs. Portal vein sampling occurred transhepatically. We compared 19 G and 22 G needles coated interiorly with saline, heparin or ethylenediaminetetraacetic acid (EDTA). Small- (10 mL) and large- (25 mL) volume blood collections were evaluated. Two different collection methods were tested: direct-to-vial and suction syringe. A bleeding risk trial for saline-coated 19 G and 22 G needles was performed by puncturing the portal vein 20 times. Persistent bleeding after 3 minutes was considered significant. Results  All small-volume collection trials were successful except for 22 G saline-coated needles with direct-to-vial method. All large-volume collection trials were successful when using suction syringe; direct-to-vial method for both 19 G and 22 G needles were unsuccessful. Collection times were shorter for 19 G vs. 22 G needles for both small and large-volume collections ( P  < 0.05). Collection times for saline-coated 22 G needles were longer compared to heparin/EDTA-coated ( P  < 0.05). Bleeding occurred in 10 % punctures with 19 G needles compared to 0 % with 22 G needles. Conclusion  The results of this animal study demonstrate the feasibility and the safety of using 22 G needles for portal vein sampling and can form the basis for a pilot study in patients.

Body composition after allogeneic haematopoietic cell transplantation/total body irradiation in children and young people: a restricted systematic review

PURPOSE

To collate evidence of changes in body composition following treatment of leukaemia in children, teenagers and young adults (CTYA, 0-24 years) with allogeneic haematopoietic stem cell transplant and total body irradiation (HSCT+TBI).

METHODS

Papers were identified by searching Medline and Google Scholar, reference lists/citations and contacting key authors, with no date or language restrictions. Inclusion criteria were as follows: leukaemia, HSCT+TBI, aged ≤ 24 years at HSCT and changes in body composition (total fat, central adiposity, adipose tissue function, muscle mass, muscle function). Quality was assessed using a brief Newcastle-Ottawa scale.

RESULTS

Of 900 papers, 20 were included: seven controlled, five uncontrolled studies and eight case reports. Study quality appeared good. There was little evidence of differences in total fat/weight for HSCT + TBI groups (compared to healthy controls/population norms/short stature controls). There was some evidence of significantly higher central adiposity and differences in adipose tissue function (compared to leukaemic/non-leukaemic controls). Muscle mass was significantly lower (compared to healthy/obese controls). Muscle function results were inconclusive but suggested impairment. Case reports confirmed a lipodystrophic phenotype.

CONCLUSIONS

Early remodelling of adipose tissue and loss of skeletal muscle are evident following HSCT + TBI for CTYA leukaemia, with extreme phenotype of overt lipodystrophy. There is some evidence for reduced muscle effectiveness.

IMPLICATIONS FOR CANCER SURVIVORS

Body composition changes in patients after HSCT + TBI are apparent by early adult life and link with the risk of excess cardiometabolic morbidity seen in adult survivors. Interventions to improve muscle and/or adipose function, perhaps utilizing nutritional manipulation and/or targeted activity, should be investigated.

What Change in Body Mass Index Is Required to Improve Cardiovascular Outcomes in Childhood and Adolescent Obesity through Lifestyle Interventions: A Meta-Regression

Background: Using meta-regression, this article aims at establishing the minimum change in BMI-standard deviation score (SDS) needed to improve lipid profiles and blood pressure in children and adolescents with obesity, to aid future trials and guidelines. Methods: Studies with participants involved in lifestyle interventions, aged 4-19 years, with a diagnosis of obesity according to defined BMI thresholds, were considered for inclusion in a large systematic review. Interventions had to report pre- and post-intervention (or mean change in) BMI-SDS, plus either systolic blood pressure (SBP), high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and/or triglycerides (TGs). Random-effects meta-regression quantified the relationship between mean change in BMI-SDS and mean change in cardiovascular outcomes. Results: Seventy-one papers reported various cardiovascular measurements and mean change in BMI-SDS. Fifty-four, 59, 46, and 54 studies were analyzed, reporting a change in SBP, HDL, LDL, and TG, respectively. Reduction in mean BMI-SDS was significantly related to improvements in SBP, LDL, TG, and HDL (p < 0.05); BMI-SDS reductions of 1, 1.2, and 0.7 ensured a mean reduction of SBP, LDL, and TG, respectively, although an equivalent value for HDL improvement was indeterminate. Conclusion: Reductions in mean BMI-SDS of >1, >1.2, or >0.7 are likely to reduce SBP, LDL, and TG, respectively. Further studies are needed to clarify the optimal duration, intensity, and setting for interventions. Consistency is required regarding derived BMI values to facilitate future systematic reviews and meta-analyses.

Weight maintenance interventions for people with type 2 diabetes mellitus: a systematic review protocol

BACKGROUND

Weight loss maintenance is a challenge for people with type 2 diabetes mellitus (T2DM), which attenuates the long-term benefits of weight loss for diabetes management. Medication, specific dietary requirements and the psychosocial burden of T2DM signify that weight loss maintenance designed for obesity may not suit people with T2DM. The primary objective of this review is to comprehensively evaluate existing weight maintenance interventions for people with or at high risk of T2DM.

METHODS

We registered a protocol for the systematic review and meta-analysis of randomised and non-randomised weight maintenance interventions for T2DM. Studies included will have been carried out in adults with clinical diagnosis of T2DM or pre-diabetes. All intervention types will be accepted (e.g. behavioural/lifestyle change and pharmacological). The primary outcomes will be weight control, glycaemic control and adverse effects. Secondary outcomes will include cardiovascular risk factors (e.g. total cholesterol, LDL-cholesterol, blood pressure control), psychological wellbeing (including health-related quality of life), change in glucose medication and waist circumference. Multiple electronic databases will be searched such as MEDLINE, EMBASE, Web of Science, PsychINFO and international registers (e.g. Cochrane Central Register of Controlled Trials, WHO ICTRP). OpenGrey will be searched for grey literature. Two researchers will screen all citations and abstracts. This process will also be conducted by an additional researcher using a semi-automated tool to reduce human error. Full-text articles will be further examined by the researchers to select a final set for further analysis, and a narrative synthesis of the evidence will be presented. Potential sources of heterogeneity will be assessed, and a meta-analysis will be conducted if feasible. Risk of bias will be evaluated using the Cochrane risk of bias tool and the certainty of evidence using the GRADE (grading of recommendations, assessment, development and evaluation) approach.

DISCUSSION

This review will critically appraise existing weight maintenance interventions targeting T2DM. Findings will inform future intervention development to support people with T2DM delay weight regain and prolong successful diabetes management.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020168032.

Batch Reading and Interrupted Interpretation of Digital Screening Mammograms Without and With Tomosynthesis

OBJECTIVE

To compare batch reading and interrupted interpretation for modern screening mammography.

METHODS

We retrospectively reviewed digital mammograms without and with tomosynthesis that were originally interpreted with batch reading or interrupted interpretation between January 2015 and June 2017. The following performance metrics were compared: recall rate (per 100 examinations), cancer detection rate (per 1,000 examinations), and positive predictive values for recall and biopsy.

RESULTS

In all, 9,832 digital mammograms were batch read, yielding a recall rate of 9.98%, cancer detection rate of 4.27, and positive predictive values for recall and biopsy of 4.40% and 35.5%, respectively. There were 49,496 digital mammograms that were read with interrupted interpretation, yielding a recall rate of 11.3%, cancer detection rate of 4.44, and positive predictive values for recall and biopsy of 3.92% and 30.1%, respectively. Of the digital mammograms with tomosynthesis, 7,075 were batch read, yielding a recall rate of 6.98%, cancer detection rate of 5.37, and positive predictive values for recall and biopsy of 7.69% and 38.0%, respectively. Of the digital mammograms with tomosynthesis, 24,380 were read with interrupted interpretation, yielding a recall rate of 8.30%, cancer detection rate of 5.41, and positive predictive values for recall and biopsy of 6.52% and 33.3%, respectively. For both digital mammograms without and with tomosynthesis, recall rates improved with batch reading compared with interrupted interpretation (P < .001), but no significant differences were seen for other metrics.

DISCUSSION

Batch reading digital mammograms without and with tomosynthesis improves recall rates while maintaining cancer detection rates and positive predictive values compared with interrupted interpretation.

Preemptive cardiac resynchronization therapy to prevent cardiac arrest in peripartum cardiomyopathy: a case report

Select patients with peripartum cardiomyopathy are candidates for implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy (CRT) due to the increased risk for life threatening arrhythmias and sudden death. We present a case of peripartum cardiomyopathy awaiting CRT placement who suffered cardiac arrest during the surgical dilation and curettage (D&C) procedure for pregnancy termination.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Resilience and return-to-work pain interventions: systematic review

BACKGROUND

Resilience is a developing concept in relation to pain, but has not yet been reviewed in return-to-work (RTW) contexts.

AIMS

To explore the role of resilience enhancement in promoting work participation for chronic pain sufferers, by reviewing the effectiveness of existing interventions.

METHODS

Resilience was operationalized as: self-efficacy, active coping, positive affect, positive growth, positive reinforcement, optimism, purpose in life and acceptance. Five databases were searched for randomized controlled trials (RCTs) whose interventions included an element of resilience designed to help RTW/staying at work for chronic pain sufferers. Study appraisal comprised the Cochrane risk of bias (RoB) tool and additional quality assessment. Findings were synthesized narratively and between-group differences of outcomes were reported. Heterogeneous PICO (population, intervention, comparator, outcome) elements precluded meta-analysis.

RESULTS

Thirty-four papers from 24 RCTs were included. Interventions varied; most were multidisciplinary, combining behavioural, physical and psychological pain management and vocational rehabilitation. Four found RTW/staying at work improved with intensive multidisciplinary interventions compared with less intensive, or no, treatment. Of these, one had low RoB; three scored poorly on allocation concealment and selective outcome reporting. Four trials had mixed results, e.g. interventions enabling reduced sick leave for people on short-term not long-term leave; 16 showed no improvement. Five trials reported resilience outcomes were improved by interventions but these were not always trials in which RTW improved.

CONCLUSIONS

Effectiveness of resilience interventions for chronic pain sufferers on RTW is uncertain and not as helpful as anticipated. Further agreement on its conceptualization and terminology and that of RTW is needed.