O025 The epidemiology of gastroenteropancreatic neuroendocrine tumours (GEP-NETS) in the north-east of England and a systematic review of literature

Introduction

Gastroenteropancreatic neuroendocrine tumours (GEP-NETs) are rare, indolent malignancies with unknown aetiology and an increasing incidence was observed globally. With limited research on GEP-NET epidemiology, the reasons behind incidence disparities between countries remain unclear. Whether this increase was a true phenomenon or was confounded by factors including diagnostics advancement and classification evolution needs further enquiry. The aims are to evaluate all available literature on GEP-NET incidence rates (IR), and to determine GEP-NET incidence in the North-East and the association between survival and age, gender, grade, stage, and socioeconomic status (SES).

Methods

Systematic review of relevant literature using MEDLINE, Embase, Scopus and Web of Science. Quality of methodology was assessed using the Newcastle-Ottawa Scale. (2) 140 GEP-NET patients from 1996 to 2019 were identified. Crude IR, age-standardised IR and overall survival (OS) were determined. Outcome parameters were identified from Cox-proportional Hazard analysis.

Results

GEP-NET global incidence increased in the last decades, whereas Asia and various European countries reported no significant changes. Ethnic and gender differences were observed. (2) Over 23 years, IR increased by 40.5% per annum (0.08–5.94/1,000,000). 5- and 10-year OS were 71.0% and 28.9% respectively. SES had non-significant associations with the covariates. Age >70 yrs (HR=5.48 [2.20–13.66], p<0.001) and middle SES (HR=2.23 [1.05–3.75], p=0.038) were independent predictors for worse prognosis.

Conclusion

GEP-NETs continue to rise despite differences in reporting methods across the literatures and underlying factors not being captured in this population-based study. A prospective NET registry is necessary to elucidate accurate GEP-NET epidemiology in the UK.

Take-home message

GEP-NET incidence rates are evidently increasing both in the North-East and globally; yet, the reasons behind such increase remain unclear. This highlights the establishment of a prospective neuroendocrine tumour (NET) registry is imperative in the North-East or in the UK so that all GEPNETs can be captured and detect subtle incidence changes over time.

1055 SIMPLE APPROACHES TO CHARACTERISING MULTIPLE LONG-TERM CONDITIONS (MULTIMORBIDITY) AND RATES OF HOSPITAL ADMISSION IN UK BIOBANK

Introduction

Multiple approaches are used to describe MLTC, including counts and indices (weighted counts). However, few studies have directly compared different approaches which would be helpful for the design of future MLTC studies. We therefore aimed to compare the prevalence of MLTC and association with emergency hospital admission characterised using different approaches within the same dataset.

Method

We used baseline data from 501,596 UK Biobank participants (age 37-73y) combined with linked hospital episode statistics to characterise MLTC using four approaches: count of body systems affected (CB); count of 43 conditions (CC); Byles index (BI); and Charlson comorbidity index (CCI). For each we performed survival analyses to test associations to a combined endpoint of first emergency admission or death over five years from baseline interview, adjusting for age and sex. We used Harrell’s C-index to compare the discriminant value of the four approaches for the combined endpoint.

Results

Prevalence of two or more positive responses (indicating the presence of MLTC) was 45% for CB, 33% for CC, 6% for BI and 2% for CCI. 95,812 (19%) participants had one or more emergency admission or died in the first five years. All four approaches were associated with greater rates of admission/death. For example, using CC, compared to those with zero conditions those with one had 1.42 (95% CI 1.39,1.45), those with two 1.94 (95% CI 1.90,1.98), and those with 3+ conditions had 3.11 (95% CI 3.05,3.17) times greater rates. The predictive value of the four approaches was modest (C-indices ranging from 0.60 to 0.63).

Conclusion

The counts classified a greater proportion of the sample as having MLTC than the indices, highlighting that prevalence estimates of MLTC may vary depending on the approach used. All approaches had strong statistical associations with admission, but only moderate ability to identify individual participants at risk.

684 LONG-TERM CONDITIONS, MULTIMORBIDITY, LIFESTYLE FACTORS AND GRIP STRENGTH CHANGE OVER 9 YEARS IN 44,315 UK BIOBANK PARTICIPANTS

Introduction

Weak grip strength is associated with a range of adverse health outcomes, and an accelerated decline in grip strength confers an even greater risk. To date there has been limited research into the factors associated with change in grip strength in mid-life. Using data from UK Biobank our aim was to investigate the associations of long-term conditions (LTCs), multimorbidity and lifestyle factors with patterns of change in grip strength.

Methods

We used data from 44,315 UK Biobank participants with grip strength measured at baseline (2006–10) and a subsequent study visit around nine years later. At baseline, participants’ LTCs were self-reported and categorised against a hierarchy. Multimorbidity was characterised by the number of LTC categories present (0, 1, 2 and 3+). Lifestyle factors (body mass index (BMI), smoking, diet and physical activity) were also assessed. Change in grip strength was grouped into four patterns: decline, stable low, stable high or reference (no change or increase) and used as the outcome in multinomial logistic regression models.

Results

Most LTC categories were associated with adverse patterns of change in grip strength (stable low and/or decline): for example, musculoskeletal/trauma conditions were associated with an increased risk of the stable low pattern (Relative Risk Ratio [RRR] = 1.63; 95% Confidence Interval [CI] 1.49–1.79). Multimorbidity and lifestyle factors had independent associations with grip strength change: those with 3+ categories of LTCs were more likely to experience decline in grip strength (RRR = 1.18;95% CI 1.08–1.28) compared to those with no LTCs. Low physical activity was associated with adverse patterns of grip strength, while raised BMI had divergent associations (both the decline and stable high patterns of grip strength change).

Conclusion

Individuals living with multimorbidity and those with lifestyle risk factors such as low physical activity are at increased risk of loss of strength over time.

25 Sarcopenia, Long-Term Conditions, and Multimorbidity From Mid-Life to Later Life: Findings From 499,046 UK Biobank Participants

Introduction

Sarcopenia, the loss of muscle strength and mass, predicts adverse outcomes and becomes common with age. There is recognition that sarcopenia may occur at younger ages in those with long-term conditions (LTCs) as well as those with multimorbidity (the presence of two or more LTCs), but their relationships have been little explored. Our aims were to describe the prevalence of sarcopenia in UK Biobank, a large sample of men and women aged 40–70 years, and to explore relationships with different categories of LTCs and multimorbidity.

Methods

We used data from 499,046 participants in the baseline of UK Biobank. Our main outcome was probable sarcopenia based on maximum grip strength below sex-specific cut-points. Participants’ LTCs were recorded during an interview and categorised against a hierarchy. We used logistic regression to examine the independent associations between each category of LTCs and probable sarcopenia, including adjustment for age, sex, and body mass index. We also examined the association with multimorbidity.

Results

Probable sarcopenia had an overall prevalence of 5.3% and increased with age. The categories with the strongest associations with probable sarcopenia were musculoskeletal/trauma (OR 2.17 [95% CI: 2.11, 2.23]), endocrine/diabetes (OR 1.49 [95% CI: 1.45, 1.55]), and neurological/psychiatric (OR 1.39 [95% CI: 1.34, 1.43]) LTCs. Almost half of the sample (44.5%) had multimorbidity and they were at nearly twice the odds of probable sarcopenia (OR 1.96 [95% CI: 1.91, 2.02]) compared to those without.

Conclusions

We have shown an overall prevalence of 5.3% of probable sarcopenia at ages 40–70 in UK Biobank. The risk of probable sarcopenia was higher in those with some categories of LTCs, suggesting that these groups may stand to benefit from assessment of sarcopenia, during mid-life as well as old age.

15 What Influences Loss of Appetite in Older People? A Qualitative Study

Introduction

Appetite loss in older people is common and associated with malnutrition, sarcopenia and frailty. Management of appetite loss may prevent these health burdens but currently no effective clinical interventions exist. This is partly due to lack of knowledge about influences on appetite perceived by older individuals. These views may provide novel avenues for intervention on appetite loss. Aim: To understand older individual’s perceptions of influences on appetite loss.

Method

Semi-structured qualitative interviews with men and women aged ≥65 years, living in their own home, were audio-recorded and transcribed. Reflexive thematic analysis, with inductive coding, generated themes with data examples.

Results

13 individuals (8/13 female, 4/13 living alone) were recruited. Accounts of influences on appetite were grouped into three themes: physical, psychological and external factors. The physical theme related to a physical state of ageing, using energy and being active, and physical symptoms, illness and treatment. The psychological theme explained the influence of mood or wellbeing, the appeal of food, and reward in the activity of cooking. External factors related to influences of other people, coping with life experiences and transitions, and perceptions of health. Influences were perceived to impact on appetite loss in distinct ways, via a physical feeling of fullness (physical theme), or creating a negative experience with food and eating (psychological and external themes). Individuals tended to have either a physical or psychological focus. Importantly, illness and its treatment impacted on both appetite loss narratives.

Conclusions

A number of influences on appetite are described by older individuals, relating to their physical and psychological self, and social and environmental factors. These seem to impact on appetite loss in distinct ways, by precipitating either a physical feeling of fullness, or a negative experience with food and eating. Identifying factors affecting an individual’s appetite could facilitate person-centred approaches to management.

Infant milk feeding and bone health in later life: findings from the Hertfordshire cohort study

Using data from the Hertfordshire cohort study, this study examined the effect of breastfeeding and bottle feeding on adult lumbar spine and femoral neck bone mineral content (BMC) and bone mineral density (BMD). The type of infant milk feeding was significantly associated with lumbar spine BMD in males.

INTRODUCTION

Using data from the Hertfordshire cohort study (HCS), this study aims to examine the effect of infant milk feeding on bone health in later life by comparing the effect of breastfeeding and bottle feeding on lumbar spine and femoral neck BMC and BMD.

METHODS

Information about infant milk feeding, birth weight (kg) and weight at 1 (kg) was collected by health visitors between 1931 and 1939 in Hertfordshire. BMC and BMD measurements were taken by DXA scan between 1998 and 2004. Linear regression models adjusted for conditional weight at 1, age at DXA scan, sex, adult BMI, smoking behaviour, alcohol consumption, physical activity, dietary calcium, and prudent diet score.

RESULTS

Infant milk feeding was significantly associated with lumbar spine BMD (b = - 0.028; 95% CI, - 0.055; - 0.000; p value, 0.047) in males. On average, males who consumed breastmilk alternatives in infancy had lower lumbar spine BMD measurements than those who were fed only breastmilk. These associations remained significant in fully adjusted models. There were no significant associations between infant milk feeding and bone health for females.

CONCLUSIONS

Significant associations between infant milk feeding and lumbar spine BMD in males indicate that breastmilk may be protective for the bone health of male babies. The evidence presented here underscores the potential lifelong benefits of breastfeeding and may highlight the differences between osteoporotic risk factors for males and females.

Prospective assessment of resection margin status following pancreaticoduodenectomy for pancreatic ductal adenocarcinoma after standardisation of margin definitions

BACKGROUND

Surgical resection remains the only curative treatment for pancreatic ductal adenocarcinoma (PDAC). The prognostic value of resection margin status following pancreatoduodenectomy (PD) remains controversial. Standardised pathological assessment increases positive margins but limited data is available on the significance of involved margins. We investigated the impact of resection margin status in PDAC on patient outcome.

METHOD

We identified all patients with PD for PDAC at one pancreatic cancer centre between August 2008 and December 2014. Demographic, operative, adjuvant therapeutic and survival data was obtained. Pathology data including resection margin status of specific anatomic margins was collected and analysed.

RESULTS

107 patients were included, all pathologically staged as T3 with 102 N1. 87.9% of patients were R1 of which 53.3% showed direct extension to the resection margin. Median survival for R0 patients versus R1<1 mm and R1 = 0 mm was 28.4 versus 15.4 and 25.1 versus 13.4 months. R1 = 0 mm status remained a predictor of poor outcome on multivariate analysis. Evaluation of individual margins (R1<1 mm) showed the SMV and SMA margins were associated with poorer overall survival. Multiple involved margins impacted negatively on outcome. SMA margin patient outcome with R1 = 1-1.9 mm was similar to R1=>2 mm.

CONCLUSION

Using an R1 definition of <1 mm and standardised pathology we demonstrate that R1 rates in PDAC can approach 90%. R1 = 0 mm remained an independent prognostic factor for overall survival. Using R1<1 mm we have shown that involvement of medial margins and multiple margins has significant negative impact on overall survival. We conclude that not all margin positivity has the same prognostic significance.

108 Poor Appetite is Common in Hospitalised Older People and Associated with Subclinical Low Mood

Introduction

Appetite loss in older people -anorexia of ageing (AA) - is common. Recognised consequences include undernutrition, sarcopenia, frailty, and increased mortality after discharge from hospital. Identification and management of AA may prevent onset of these health burdens. Whilst appetite can be assessed, this is often not routine.

Methods

Cross-sectional data from three studies (carried out 2010-2017), with comparable data collection methods and drawn from the same population, were combined. Participants were over 70 years, admitted to acute wards within a large UK hospital. Appetite was assessed using the simple 4 item Simplified Nutritional Appetite Questionnaire (SNAQ); a score of ≤14/20 defines poor appetite. Correlates of SNAQ scores were evaluated.

Results

The dataset included 474 participants (64% female) with mean age 84 (6.5), median Barthel 78 (IQR 53-91), mini-mental state exam (MMSE) 27 (IQR 23-29) and comorbidity index 5 (IQR 4-7). The median GDS for the population was 4 (IQR 4-6). The mean SNAQ score was 13.9 (SD 2.6), and 265 (56%) participants scored ≤14 indicating poor appetite. There was no significant difference between mean SNAQ scores of men and women (P=.26), or those living alone and with others (P=.62).

Age, MMSE, comorbidity index, and total number of medications were not related to SNAQ score in continuous analyses but geriatric depression score (GDS-15) was (adjusted coefficient -.248; P&lt;.001); such that lower mood was associated with poorer appetite.

Conclusions

These findings highlight the importance of assessing appetite in hospitalised older people, as poor appetite is very common. Appetite can be assessed in hospital using the simple 4 item SNAQ tool. Subclinical low mood, measured by GDS-15, had the strongest association with SNAQ score whilst in hospital. Therefore, for those with poor appetite in hospital, clinicians should have a low threshold to evaluate and treat low mood.

Poor Appetite Is Associated with Six Month Mortality in Hospitalised Older Men and Women

OBJECTIVES

Appetite loss is common in hospitalised older individuals but not routinely assessed. Poor appetite in hospital has previously been identified as predictive of greater mortality in the six months following discharge in a single study of female patients. The present study aimed to assess this association in a larger sample including both hospitalised men and women.

DESIGN

Longitudinal observational study with six month follow up.

SETTING

Acute hospital wards in a single large hospital in England.

PARTICIPANTS

Older inpatients aged over 70 years.

MEASUREMENTS

Appetite was assessed using the Simplified Nutritional Appetite Questionnaire (SNAQ) during hospital stay. Deaths during six month follow-up period were recorded. Association between SNAQ score during hospital admission and death 6 months post-discharge was assessed using binary logistic regression in unadjusted and adjusted analysis.

RESULTS

296 participants (43% female, mean age 83 years (SD 6.9)) were included in this study. Prevalence of poor appetite (SNAQ score <14) was 41%. In unadjusted analysis a SNAQ score of <14 was associated with a 2.47 increase in odds of mortality at six months (OR 2.47 (95% CI 1.27,4.82)). This association remained after adjusting for number of comorbidities (Charlson index), length of stay and gender (OR 2.62 (95% CI 1.30, 5.27)). In unadjusted continuous analysis, every one point decrease in SNAQ score led to a 1.20 fold increase in odds of mortality at six months (OR 1.20 (95% CI 1.06-1.36)). This association remained in adjusted analysis (OR 1.22 (95% CI 1.07-1.39)).

CONCLUSION

Poor appetite is common in hospitalised older people. We have confirmed the association, previously reported in older women, between poor appetite during hospital stay and greater mortality at six months post-discharge but in a larger study including older men and women. Further research is needed to understand the mechanisms of poor appetite, which lead to increased mortality.

Diet Quality and Bone Measurements Using HRpQCT and pQCT in Older Community-Dwelling Adults from the Hertfordshire Cohort Study

There are few data describing associations between dietary patterns and bone microarchitecture. This study investigated the relationship between diet quality and HRpQCT and pQCT measures in older adults. Data were available for 184 men and 166 women. Dietary data were collected at baseline (1998-2003) using an administered food frequency questionnaire. A 'prudent' diet score (PDS) was identified using principal component analysis and used as an indicator of dietary quality. HRpQCT and pQCT images were acquired at follow-up in 2012, from the non-dominant distal radius and tibia using Scanco XtremeCT and Stratec XCT2000 instrument scanners, respectively. The mean (SD) PDS was - 0.24 (1.23) for men and 0.62 (1.14) for women. In women, a significant positive relationship was found between baseline dietary pattern and total and trabecular area at both the radius and the tibia, measured by HRpQCT. Similar trends were observed with pQCT parameters. Positive associations were observed for tibia total area (38% slice). At the radius, significant positive associations were found for total area (4% slice) and polar strength strain index (33% slice). All relationships remained robust to adjustment. For men, although patterns were similar, there were no significant associations for HRpQCT outcomes. Significant associations were observed for baseline PDS and polar strength strain and total area (66% slice) at the radius, measured by pQCT. Our data suggest that diets high in fruit, vegetables, oily fish and whole grain cereals in early old age are associated with greater bone size but not volumetric bone density or microarchitecture in later life in women.

Modifiable risk factors of maternal postpartum weight retention: an analysis of their combined impact and potential opportunities for prevention

BACKGROUND/OBJECTIVES

Pregnancy triggers a physiological change in weight status. Postpartum weight retention in the childbearing years can substantially alter a woman's weight gain trajectory, with several potential contributing factors identified. Most research has relied on women's recall of pre-pregnancy weight during pregnancy or later, and not considered risk factors in combination. Using measured pre-pregnancy weight, this study aimed to examine the associations of maternal postpartum weight retention with parity, pre-pregnancy BMI, excessive gestational weight gain (GWG), maternal serum vitamin D concentration and dietary Glycaemic Index in early and late pregnancy, and breastfeeding duration, including analysis of the combined impact of potentially modifiable risk factors.

SUBJECTS/METHODS

Prospective cohort study of 12 583 non-pregnant women aged 20-34 years in Southampton (UK) who were assessed prior to pregnancy, with those who subsequently became pregnant followed up in early and late gestation, and after delivery (n=2559 in the final sample). Linear regression models examined potential predictors of weight retention in adjusted individual and multivariate analyses, and as a risk factor score.

RESULTS

Compared with pre-pregnancy weight, 73% of women retained some weight at 6 months postpartum (mean (s.d.): 3.5 (6.2) kg). In the adjusted multivariate model, women who were primiparous, had a lower pre-pregnancy BMI, excessive GWG, a lower early pregnancy vitamin D concentration and breastfed for <6 months had greater weight retention 6 months postpartum (P<0.05 for all variables). For each additional modifiable risk factor (excessive GWG, low vitamin D concentration in early pregnancy and short breastfeeding duration; scale 0-3), women retained an additional 2.49 kg (95% CI: 2.16, 2.82; P<0.001).

CONCLUSIONS

Having a greater number of modifiable risk factors was associated with greater weight retention 6 months postpartum. Initiatives supporting women to target these risk factors in the years prior to, during and after pregnancy could impact on their weight gain trajectory and later risk of adverse weight-related outcomes.

Maternal stress and psychological distress preconception: association with offspring atopic eczema at age 12 months

BACKGROUND

Perinatal maternal stress and low mood have been linked to offspring atopic eczema.

OBJECTIVES

To examine the relation of maternal stress/mood with atopic eczema in the offspring, focusing particularly on stress/psychological distress preconception.

METHODS

At recruitment in the UK Southampton Women's Survey, preconception maternal reports of perceived stress in daily living and the effect of stress on health were recorded; in a subsample, psychological distress was assessed (12-item General Health Questionnaire). Infants were followed up at ages 6 (n = 2956) and 12 (n = 2872) months and atopic eczema ascertained (based on UK Working Party Criteria for the Definition of Atopic Dermatitis). At 6 months post-partum, mothers were asked if they had experienced symptoms of low mood since childbirth and completed the Edinburgh Postnatal Depression Scale.

RESULTS

Preconception perceived stress affecting health [OR 1.21 (95% CI 1.08-1.35), P = 0.001] and stress in daily living [OR 1.16 (1.03-1.30), P = 0.014] were associated with an increased risk of offspring atopic eczema at age 12 months but not at 6 months, robust to adjustment for potentially confounding variables. Findings were similar for maternal psychological distress preconception. Low maternal mood between delivery and 6 months post-partum was associated with an increased risk of infantile atopic eczema at age 12 months, but no significant association between post-natal mood and atopic eczema was seen after taking account of preconception stress.

CONCLUSION AND CLINICAL RELEVANCE

Our data provide novel evidence linking maternal stress at preconception to atopic eczema risk, supporting a developmental contribution to the aetiology of atopic eczema and pointing to potentially modifiable influences.

Development of a Short Questionnaire to Assess Diet Quality among Older Community-Dwelling Adults

OBJECTIVE

To evaluate the use of a short questionnaire to assess diet quality in older adults.

DESIGN

Cross-sectional study.

SETTING

Hertfordshire, UK.

PARTICIPANTS

3217 community-dwelling older adults (59-73 years).

MEASUREMENTS

Diet was assessed using an administered food frequency questionnaire (FFQ); two measures of diet quality were defined by calculating participants' 'prudent diet' scores, firstly from a principal component analysis of the data from the full FFQ (129 items) and, secondly, from a short version of the FFQ (including 24 indicator foods). Scores calculated from the full and short FFQ were compared with nutrient intake and blood concentrations of vitamin C and lipids.

RESULTS

Prudent diet scores calculated from the full FFQ and short FFQ were highly correlated (0.912 in men, 0.904 in women). The pattern of associations between nutrient intake (full FFQ) and diet scores calculated using the short and full FFQs were very similar, both for men and women. Prudent diet scores calculated from the full and short FFQs also showed comparable patterns of association with blood measurements: in men and women, both scores were positively associated with plasma vitamin C concentration and serum HDL; in women, an inverse association with serum triglycerides was also observed.

CONCLUSIONS

A short food-based questionnaire provides useful information about the diet quality of older adults. This simple tool does not require nutrient analysis, and has the potential to be of value to non-specialist researchers.

Higher maternal serum concentrations of nicotinamide and related metabolites in late pregnancy are associated with a lower risk of offspring atopic eczema at age 12 months

BACKGROUND

Evidence that atopic eczema partly originates in utero is increasing, with some studies linking the risk of developing the condition with aspects of maternal diet during pregnancy. Nicotinamide, a naturally occurring nutrient that is maintained through the dietary intakes of vitamin B3 and tryptophan, has been used in the treatment of some skin conditions including atopic eczema.

OBJECTIVE

To examine the relation of maternal serum concentrations of nicotinamide and related tryptophan metabolites to the risk of atopic eczema in the offspring.

METHODS

Within the UK Southampton Women Survey, infantile atopic eczema at ages 6 and 12 months was ascertained (modified UK Working Party Criteria for the Definition of Atopic Dermatitis). Maternal serum levels of kynurenine, kynurenic acid, anthranilic acid, tryptophan, nicotinamide and N1-methylnicotinamide were measured in late pregnancy by mass spectrometry (n = 497) and related to the odds ratio of infantile atopic eczema.

RESULTS

Maternal nicotinamide and related metabolite concentrations were not associated with offspring atopic eczema at age 6 months. Higher concentrations of nicotinamide and anthranilic acid were, however, associated with a lower risk of eczema at age 12 months (odds ratios 0.69, 95% CI 0.53-0.91/SD change, P = 0.007 and 0.63, 0.48-0.83, P = 0.001, respectively). The associations were robust to adjustment for potentially confounding variables.

CONCLUSION AND CLINICAL RELEVANCE

This is the first study linking maternal serum concentrations of nicotinamide and related metabolites to the risk of atopic eczema in the offspring. The findings point to potentially modifiable maternal influences on this complex and highly prevalent condition.

Attitudes to outcomes measured in clinical trials of cardiovascular prevention

BACKGROUND

Selecting outcome measures in cardiovascular prevention trials should be informed by their importance to selected populations. Major vascular event outcomes are usually prioritized in these trials with considerably less attention paid to cognitive and functional outcomes.

AIM

To examine views on importance of outcome measures used in clinical trials.

DESIGN

Cross-sectional survey.

METHODS

Of 367 individuals approached, 280 (76%) participated: outpatients attending cardiovascular prevention clinics (n = 97), active retirement groups members (n = 75), medical students (n = 108). Participants were asked to rank, in order of importance, outcome measures, which may be included in cardiovascular prevention trials. Results were compared between two groups: <65s (n = 157) and ≥65s (n = 104).

RESULTS

When asked what outcomes were most important to measure in cardiovascular prevention trials, respondents reported: death (31.6%) stroke (28.5%), dementia (26.9%), myocardial infarction (MI) (7.9%) and requiring nursing home (NH) care (5.1%). When asked the most relevant outcomes regarding successful ageing respondents reported; maintaining independence (32.4%), avoiding major illness (24.3%), good family life (23.6%), living as long as possible (15.8%), avoiding NH care (3.1%) and contributing to society (0.8%) as most important. When asked what outcome concerned them most about the future, respondents reported: dementia (32.6%), dependence (30.4%), death (12.8%), stroke (12.5%), cancer (6.2%) requiring NH care (4.8%) and MI (0.7%). Maintaining independence was considered most important in younger and older cohorts.

CONCLUSION

Cognitive and functional outcomes are important patient-relevant outcomes, sometimes more important than major vascular events. Incorporating these outcomes into trials may encourage patient participation and adherence to preventative regimens.

Measuring Appetite with the Simplified Nutritional Appetite Questionnaire Identifies Hospitalised Older People at Risk of Worse Health Outcomes

OBJECTIVES

Poor appetite is commonly reported by older people but is rarely measured. The Simplified Nutritional Appetite Questionnaire (SNAQ) was validated to predict weight loss in community dwelling older adults but has been little used in hospitals. We evaluated it in older women on admission to hospital and examined associations with healthcare outcomes.

DESIGN

Longitudinal observational with follow-up at six months.

SETTING

Female acute Medicine for Older People wards at a University hospital in England.

PARTICIPANTS

179 female inpatients.

MEASUREMENTS

Age, weight, Body Mass Index (BMI), grip strength, SNAQ, Barthel Index Score, Mini Mental State Examination (MMSE), Geriatric Depression Scale: Short Form (GDS-SF), Malnutrition Universal Screening Tool (MUST), category of domicile and receipt of care were measured soon after admission and repeated at six month follow-up. The length of hospital stay (LOS), hospital acquired infection, readmissions and deaths by follow-up were recorded.

RESULTS

179 female participants mean age 87 (SD 4.7) years were recruited. 42% of participants had a low SNAQ score (<14, indicating poor appetite). A low SNAQ score was associated with an increased risk of hospital acquired infection (OR 3.53; 95% CI: 1.48, 8.41; p=0.004) and with risk of death (HR 2.29; 95% CI: 1.12, 4.68; p = 0.023) by follow-up.

CONCLUSION

Poor appetite was common among the older hospitalised women studied, and was associated with higher risk of poor healthcare outcomes.

Port site metastases following laparoscopic liver resection for hepatocellular carcinoma

A laparoscopic approach is being used increasingly in specialist centres for the resection of hepatocellular carcinomas and compares favourably with the traditional open approach, in terms of perioperative morbidity and mortality as well as long-term survival. We present a case of port site recurrence in a patient who underwent a laparoscopic left lateral segmentectomy for a hepatocellular carcinoma diagnosed during investigation of symptomatic gallstones. Nearly three years following surgery, surveillance computed tomography demonstrated a suspicious lesion at the site of one of the laparoscopic ports. Further resection was carried out and the lesion was confirmed histologically to be an isolated recurrence of the primary hepatocellular carcinoma, involving peritoneum and adominal wall. This case demonstrates that it is possible to encounter port site metastasis following laparoscopic resection of primary liver tumours although the incidence is very rare.

Body size and body composition: a comparison of children in India and the UK through infancy and early childhood

BACKGROUND

Indian babies are characterised by the 'thin-fat phenotype' which comprises a 'muscle-thin but adipose' body composition compared with European babies. This body phenotype is of concern because it is associated with an increased risk of diabetes and cardiovascular disease. We examined whether the 'thin-fat phenotype' persists through early childhood, comparing Indian children with white Caucasians in the UK at birth, infancy and childhood, using comparable measurement protocols.

METHODS

We used data from two cohorts, the Pune Maternal Nutrition Study (N=631) and the Southampton Women's Survey (N=2643). Measurements of weight, head circumference, mid-upper arm circumference, height, triceps and subscapular skinfold thickness were compared at birth, 1, 2, 3 and 6 years of age. SD scores were generated for the Pune children, using the Southampton children as a reference. Generalised estimating equations were used to examine the changes in SD scores across the children's ages.

RESULTS

The Indian children were smaller at birth in all body measurements than the Southampton children and became relatively even smaller from birth to 2 years, before 'catching up' to some extent at 3 years, and more so by 6 years. The deficit for both skinfolds was markedly less than for other measurements at all ages; triceps skinfold showed the least difference between the two cohorts at birth, and subscapular skinfold at all ages after birth.

CONCLUSIONS

The 'thin-fat phenotype' previously found in Indian newborns, remains through infancy and early childhood. Despite being shorter and lighter than UK children, Indian children are relatively adipose.

Diet quality across early childhood and adiposity at 6 years: the Southampton Women's Survey

BACKGROUND

Poor diet quality in early childhood is inconsistently linked to obesity risk. Understanding may be limited by the use of cross-sectional data and the use of body mass index (BMI) to define adiposity in childhood.

OBJECTIVE

The objective of this study is to examine the effects of continued exposure to diets of varying quality across early childhood in relation to adiposity at 6 years.

METHODS

One thousand and eighteen children from a prospective UK birth cohort were studied. Diet was assessed using food frequency questionnaires when the children were aged 6 and 12 months, and 3 and 6 years; diet quality was determined according to scores for a principal component analysis-defined dietary pattern at each age (characterized by frequent consumption of fruits, vegetables and fish). At each age, children were allocated a value of 0/1/2 according to third of the distribution (bottom/middle/top) their diet quality score was in; values were summed to calculate an overall diet quality index (DQI) for early childhood (range 0-8). Obesity outcomes considered at 6 years were dual-energy X-ray absorptiometry-assessed fat mass and BMI.

RESULTS

One hundred and seven (11%) children had a DQI=0, indicating a consistently low diet quality, 339 (33%) had a DQI=1-3, 378 (37%) had a DQI=4-6 and 194 (19%) had a DQI=7-8. There was a strong association between lower DQI and higher fat mass z-score at 6 years that was robust to adjustment for confounders (fat mass s.d. per 1-unit DQI increase: β=-0.05 (95% confidence interval (CI): -0.09, -0.01), P=0.01). In comparison with children who had the highest diet quality (DQI=7-8), this amounted to a difference in fat mass of 14% (95% CI: 2%, 28%) at 6 years for children with the poorest diets (DQI=0). In contrast, no independent associations were observed between DQI and BMI.

CONCLUSIONS

Continued exposure to diets of low quality across early childhood is linked to adiposity at the age of 6 years.

Dietary total antioxidant capacity is related to glucose tolerance in older people: the Hertfordshire Cohort Study

BACKGROUND AND AIMS

Dietary antioxidants may play a protective role in the aetiology of type 2 diabetes. However, observational studies that examine the relationship between the antioxidant capacity of the diet and glucose metabolism are limited, particularly in older people. We aimed to examine the relationships between dietary total antioxidant capacity (TAC) and markers of glucose metabolism among 1441 men and 1253 women aged 59-73 years who participated in the Hertfordshire Cohort Study, UK.

METHODS AND RESULTS

Diet was assessed by food frequency questionnaire. Dietary TAC was estimated using published databases of TAC measured by four different assays: oxygen radical absorbance capacity (ORAC), ferric-reducing ability of plasma (FRAP), total radical-trapping antioxidant parameter (TRAP) and trolox equivalent antioxidant capacity (TEAC). Fasting and 120-min plasma glucose and insulin concentrations were measured during a standard 75-g oral glucose tolerance test. In men, dietary TAC estimated by all four assays was inversely associated with fasting insulin concentration and homoeostasis model assessment of insulin resistance (HOMA-IR); with the exception of ORAC, dietary TAC was also inversely related to 120-min glucose concentration. There were no associations with fasting glucose or 120-min insulin concentrations. In women, with the exception of the association between ORAC and 120-min insulin concentration, dietary TAC estimated by all assays showed consistent inverse associations with fasting and 120-min glucose and insulin concentrations and HOMA-IR. These associations were more marked among women with BMI ≥ 30 kg/m(2).

CONCLUSION

These findings suggest dietary TAC may have important protective effects on glucose tolerance, especially in older obese women.

Methods of haemostasis during liver resection--a UK national survey

BACKGROUND

Although haemorrhage is a major cause of morbidity and mortality in liver surgery, there is very little available guidance on its management.

METHODS

The aim of this study was to identify current practice in the UK in this regard. An online survey was created and hepatobiliary (HPB) specialists who were members of a specialist society and others who were known practitioners were invited by e-mail to complete the survey anonymously.

RESULTS

Fifty-one percent responded (n = 36/70), and most of these respondents worked at large HPB centres (>100 liver resections/year; n = 24, 66%). Not all questionnaires were fully completed by the individual surgeons. Thirty-eight percent of the surgeons routinely used Pringle's manoeuvre. Most surgeons used ligation of the inflow vessels (n = 16, 44%) and stapled the outflow vessels (n = 15, 42%). The Cavitron ultrasonic surgical aspirator (CUSA; 54%, 13/24) was preferred for parenchymal transection. The majority routinely used haemostatic adjuncts (n = 22, 62%), whilst 33% (n = 12) used them occasionally. Twenty-three (64%) felt manufactured haemostatic adjuncts played a major role in maintaining haemostasis and 19 preferred fibrin-based products.

CONCLUSION

The Pringle manoeuvre is a popular technique amongst specialist UK liver surgeons and the CUSA is used by nearly half of the surgeons. Despite the absence of definitive evidence for their benefit, manufactured haemostatic adjuncts are still widely used, especially the fibrin-based adjuncts.

Prognostic factors and survival after resection of colorectal liver metastasis in the era of preoperative chemotherapy: an 11-year single-centre study

INTRODUCTION

A variety of factors have been identified in the literature which influence survival following resection of colorectal liver metastases (CRLM). Much of this literature is historical, and its relevance to contemporary practice is not known. The aim of this study was to identify those factors which influence survival during the era of preoperative chemotherapy in patients undergoing resection of CRLM in a UK centre.

METHODS

All patients having liver resection for CRLM during an 11-year period up to 2011 were identified from a prospectively maintained database. Prognostic factors analysed included tumour size (≥5 or <5 cm), lymph node status of the primary tumour, margin positivity (R1; <1 mm), neo-adjuvant chemotherapy (for liver), tumour differentiation, number of liver metastases (≥4), preoperative carcinoembryonic antigen (CEA; ≥200 ng/ml) and whether metastases were synchronous (i.e. diagnosed within 12 months of colorectal resection) or metachronous to the primary tumour. Overall survival (OS) was compared using Kaplan-Meier plots and a log rank test for significance. Multivariate analysis was performed using a Cox regression model. Statistical analysis was performed in SPSS v19, and p < 0.05 was considered to be significant.

RESULTS

432 patients underwent resection of CRLM during this period (67% male; mean age 64.5 years), and of these, 54 (13.5%) had re-resections. The overall 5-year survival in this series was 43% with an actuarial 10-year survival of 40%. A preoperative CEA ≥200 ng/ml was present in 10% of patients and was associated with a poorer 5-year OS (24 vs. 45%; p < 0.001). A positive resection margin <1 mm was present in 16% of patients, and this had a negative impact on 5-year OS (15 vs. 47%; p < 0.001). Tumour differentiation, number, biliary or vascular invasion, size, relationship to primary disease, nodal status of the primary disease or the use of neo-adjuvant chemotherapy had no impact on OS. Multivariate analysis identified only the presence of a positive resection margin (OR 1.75; p < 0.05) and a preoperative CEA ≥200 ng/ml (OR 1.88; p < 0.01) as independent predictors of poor OS.

CONCLUSION

Despite the wide variety of prognostic factors reported in the literature, this study was only able to identify a preoperative CEA ≥200 ng/ml and the presence of tumour within 1 mm of the resection margin as being of value in predicting survival. These variables are likely to identify patients who may benefit from intensive follow-up to enable early aggressive treatment of recurrent disease.

Maternal plasma polyunsaturated fatty acid status in late pregnancy is associated with offspring body composition in childhood

CONTEXT

Maternal diet during pregnancy has been linked to offspring adiposity, but it is unclear whether maternal polyunsaturated fatty acid (PUFA) status during pregnancy affects offspring body composition.

OBJECTIVE

We investigated the associations between maternal plasma n-3 and n-6 PUFA status at 34 wk gestation and offspring body composition.

DESIGN AND SETTING

A prospective United Kingdom population-based mother-offspring cohort, the Southampton Women's Survey (SWS), was studied.

PARTICIPANTS

A total of 12,583 nonpregnant women were recruited into the SWS, among whom 1987 delivered a baby before December 31, 2003; 293 mother-child pairs had complete measurements of maternal plasma PUFA concentrations in late pregnancy and offspring body composition at both ages 4 and 6 yr.

MAIN OUTCOMES MEASURED

We measured offspring body composition by dual-energy x-ray absorptiometry, yielding fat mass, lean mass, percentage fat mass, and percentage lean mass. Results are presented as β-coefficients for standardized variables, therefore reflecting the sd change of the outcome for every 1 sd of the predictor.

RESULTS

After adjustment for maternal factors and child factors including height and duration of breast-feeding, maternal plasma n-6 PUFA concentration positively predicted offspring fat mass at 4 yr (β = 0.14 SD/SD; P = 0.01) and 6 yr (β = 0.11 SD/SD; P = 0.04), but there was no association with offspring lean mass at either age (β = 0.005 SD/SD, P = 0.89; and β = 0.008 SD/SD, P = 0.81, respectively). Maternal plasma n-3 PUFA concentration was not associated with offspring fat mass at 4 yr (β = 0.057 SD/SD; P = 0.34) or 6 yr (β = 0.069 SD/SD; P = 0.21). Maternal plasma n-3 PUFA status was positively associated with offspring lean mass on univariate analysis (4 yr, β = 0.11, P = 0.06; 6 yr, β = 0.14; P = 0.02); however, this was confounded by a positive association with offspring height.

CONCLUSIONS

This observational study suggests that maternal n-6 PUFA status during pregnancy might influence offspring adiposity in childhood.

Metastatic lymph node ratio as an important prognostic factor in pancreatic ductal adenocarcinoma

BACKGROUND

Overall five year survival following pancreaticoduodenectomy for ductal adenocarcinoma is poor with typical reported rates in the literature of 8-27%. The aim of this study was to identify the histological variables best able to predict long-term survival in these patients.

METHODS

A prospective database of patients undergoing pancreaticoduodenectomy between April 2002 and June 2009 was analysed to identify patients with histologically proven pancreatic ductal adenocarcinoma. Patients with ampullary tumours, cholangiocarcinoma, duodenal adenocarcinoma and neuroendocrine tumours were excluded. The histology reports for these patients were reviewed. Uni-variate and multi-variate survival analysis was performed to identify variables useful in predicting long-term outcome.

RESULTS

134 patients underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma during this period. 5 year survival in this series was 18.6%. Uni-variate analysis identified nodal status and the metastatic to resected lymph node ratio as predictors of survival. Using multi-variate Cox Regression analysis a metastatic to lymph node ratio of >15% (p < 0.01) and the presence of perineural invasion (p < 0.05) were identified as independent predictors of patient survival. Metastatic to resected lymph node ratio is better able to stratify prognosis than nodal status alone with 5 year survival of those with N0 disease being 55.6% and 12.9% for N1 disease. However for those with <15% of resected nodes positive, 5 year survival was 21.7% and in those with >15% nodes positive it was 5.2% (p = 0.0017).

CONCLUSION

The metastatic to resected lymph node ratio can provide significant prognostic information in those patients with node positive disease after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma.

Patterns of dietary supplement use among older men and women in the UK: findings from the Hertfordshire Cohort Study

OBJECTIVES

To determine patterns of supplement use in a UK community-dwelling older population, and to investigate the extent to which supplement user groups differ, in terms of their sociodemographic and lifestyle characteristics, diet and morbidity.

DESIGN

Cross-sectional cohort study.

SETTING

Home interview and clinic visit.

PARTICIPANTS

3217 Hertfordshire Cohort Study participants, aged 59 to 73.

MEASUREMENTS

Information was obtained on the participant's social and medical history by a trained research nurse. Diet over the preceding 3 months was assessed by Food Frequency Questionnaire; compliance with 'healthy' eating recommendations was defined using individual scores for a 'prudent' dietary pattern, identified using principal components analysis. Details of all dietary supplements taken in the preceding 3 months were recorded. Individual supplements were allocated to one of 10 types based on their nutrient composition. Cluster analysis was used to define groups of supplement users.

RESULTS

45.4% of men and 57.5% of women reported taking at least one dietary supplement in the previous 3 month period. There were 5 distinct clusters of supplement users; these were common to men and women. They were labelled according to the principal supplement taken; oils, glucosamine, single vitamins, vitamins and minerals, and herbal products. These groups differed in their social class and prudent diet score, but few other characteristics. With the exception of a difference in diagnosis of diabetes among the women, there were no differences in morbidity between the supplement groups in either men or women.

CONCLUSIONS

Dietary supplement use is high in this population. There are distinct patterns of supplement use, which are related to sociodemographic and lifestyle characteristics including diet, though there were few clear differences in morbidity.

Increased fat mass is associated with increased bone size but reduced volumetric density in pre pubertal children

Recent studies have shown that obesity is associated with an increased risk of fracture in both adults and children. It has been suggested that, despite greater bone size, obese individuals may have reduced true volumetric density; however this is difficult to assess using two dimensional techniques such as DXA. We evaluated the relationship between fat mass, and bone size and density, in a population cohort of children in whom DXA and pQCT measurements had been acquired. We recruited 530 children at 6 years old from the Southampton Women's Survey. The children underwent measurement of bone mass at the whole body, lumbar spine and hip, together with body composition, by DXA (Hologic Discovery, Hologic Inc., Bedford, MA, USA). In addition 132 of these children underwent pQCT measurements at the tibia (Stratec XCT2000, Stratec Biomedical Systems, Birkenfeld, Germany). Significant positive associations were observed between total fat mass and both bone area (BA) and bone mineral content (BMC) at the whole body minus head, lumbar spine and hip sites (all p<0.0001). When true volumetric density was assessed using pQCT data from the tibia, fat mass (adjusted for lean mass) was negatively associated with both trabecular and cortical density (β=-14.6 mg/mm(3) per sd, p=0.003; β=-7.7 mg/mm(3) per sd, p=0.02 respectively). These results suggest that fat mass is negatively associated with volumetric bone density at 6 years old, independent of lean mass, despite positive associations with bone size.

Physical activity, calcium intake and childhood bone mineral: a population-based cross-sectional study

In a free-living cohort of 4-year old children, mean daily time in moderate-vigorous physical activity and daily calcium intake at 3 years, were positively related to hip bone size and density. Relationships between physical activity and bone indices were stronger when calcium intake was above compared with below median (966 mg/day).

INTRODUCTION

We examined the cross-sectional relationships between childhood physical activity, dietary calcium intake and bone size and density.

METHODS

Children aged 4 years were recruited from the Southampton Women's Survey. They underwent measurement of bone mass by DXA (Hologic Discovery). Physical activity was assessed by accelerometry (Actiheart, Cambridge Neurotechnology Ltd, Cambridge, UK) for seven continuous days.

RESULTS

Four hundred twenty-two children (212 boys) participated. In a cross-sectional analysis, after adjusting for gender, daily mean time(minutes per day) spent in moderate to very vigorous activity (MVPA) was positively related to hip BA (R(2) = 3%, p < 0.001), BMC (R(2) = 4%, p < 0.001), aBMD (R (2) = 3%, p = 0.001) and estimated vBMD (R(2) = 2%, p = 0.01), but not height (r (s) = 0.04, p = 0.42) or weight (r(s) = 0.01, p = 0.76). Mean daily calcium intake (assessed at 3 years old) positively predicted bone indices in those with a calcium intake below the median (966 mg/day), but there was a much attenuated relationship in those above this. These associations persisted after inclusion of total energy, protein and phosphorus in multivariate models. The relationships between MVPA and bone indices were stronger in children with calcium intakes above the median. Thus, for aBMD, the variance explained by MVPA when daily calcium intake was below the median was 2% (p = 0.1) and above median was 6% (p = 0.001).

CONCLUSIONS

These results support the notion that adequate calcium intake may be required for optimal action of physical activity on bone development and that improving levels of physical activity and calcium intake in childhood may help to optimise accrual of bone mass.

Facilitated transporters mediate net efflux of amino acids to the fetus across the basal membrane of the placental syncytiotrophoblast

Fetal growth depends on placental transfer of amino acids from maternal to fetal blood. The mechanisms of net amino acid efflux across the basal membrane (BM) of the placental syncytiotrophoblast to the fetus, although vital for amino acid transport, are poorly understood. We examined the hypothesis that facilitated diffusion by the amino acid transporters TAT1, LAT3 and LAT4 plays an important role in this process, with possible effects on fetal growth. Amino acid transfer was measured in isolated perfused human placental cotyledons (n = 5 per experiment) using techniques which distinguish between different transport processes. Placental TAT1, LAT3 and LAT4 proteins were measured, and mRNA expression levels (measured using real-time quantitative-PCR) were related to fetal and neonatal anthropometry and dual-energy X-ray absorptiometry measurements of neonatal lean mass in 102 Southampton Women's Survey (SWS) infants. Under conditions preventing transport by amino acid exchangers, all amino acids appearing in the fetal circulation were substrates of TAT1, LAT3 or LAT4. Western blots demonstrated the presence of TAT1, LAT3 and LAT4 in placental BM preparations. Placental TAT1 and LAT3 mRNA expression were positively associated with measures of fetal growth in SWS infants (P < 0.05). We provide evidence that the efflux transporters TAT1, LAT3 and LAT4 are present in the human placental BM, and may play an important role in the net efflux of amino acids to the fetus. Unlike other transporters they can increase fetal amino acid concentrations. Consistent with a role in placental amino acid transfer capacity and fetal growth TAT1 and LAT3 mRNA expression showed positive associations with infant size at birth.

The relationship of dietary patterns with adult lung function and COPD

Previous studies of diet and lung function have focused on associations with individual nutrients and foods, and not dietary patterns. The relationships between dietary patterns and lung function and spirometrically defined chronic obstructive pulmonary disease (COPD) were investigated in 1,551 males and 1,391 females in Hertfordshire, UK. Dietary information was obtained by food frequency questionnaire and dietary patterns were identified using principal components analysis. Using regression analysis, after controlling for confounders, a "prudent" pattern (high consumption of fruit, vegetables, oily fish and wholemeal cereals) was positively associated with forced expiratory volume in 1 s (FEV(1)) (trend p-value <0.001 in males, 0.008 in females) (difference in FEV(1) between top and bottom quintiles of pattern score, 0.18 L (95% CI 0.08-0.28 L) in males, 0.08 L (95% CI 0.00-0.16 L) in females). This pattern was also positively associated with forced vital capacity (FVC) in both sexes. Males with a higher "prudent" pattern score had a higher FEV(1)/FVC (trend p-value 0.002) and a lower prevalence of COPD (odds ratio comparing top versus bottom quintile 0.46, 95% CI 0.26-0.81; trend p-value 0.012). Associations in males were stronger in smokers than nonsmokers (interaction p-value for FEV(1)/FVC 0.002). A "prudent" dietary pattern may protect against impaired lung function and COPD, especially in male smokers.

Ten things your emergency department should consider to prepare for pandemic influenza

Pandemic influenza remains a potential major threat to global public health. It is essential for emergency departments to be involved in planning for the management of such a major event. It is also important for emergency departments to be clear on their internal arrangements for staff and for patient care. This paper outlines 10 suggestions for UK emergency departments based on the recent experience of emergency departments in Hong Kong and elsewhere.