Evaluating governance in a clinical and translational research organization

Institutional Development Awards for Clinical and Translational Research (IDeA-CTR) networks, funded by NIH/NIGMS, aim to advance CTR infrastructure to address historically unmet state and regional health needs. Success depends on the response to actionable feedback to IDeA-CTR leadership from network partners and governance groups through annual surveys, interviews, and governance body recommendations. The Great Plains IDeA-CTR applied internal formative meta-evaluation to evaluate dispositions of 172 governance recommendations from 2017 to 2021. Results provided insights to improve the classification and quality of recommendations, credibility of evaluation processes, responsiveness to recommendations, and communications and governance in a complex CTR network comprising multiple coalitions.

Returning to education after childhood acquired brain injury: Learning from lived parental experience

BACKGROUND

Returning to education (RtE) after an acquired brain injury (ABI) can be stressful for children/young people (CYP) and families. While much can be done to support RtE, there has been limited exploration of the lived experience of parents/carers about what can both help and hinder the process.

OBJECTIVE

The aim was to understand more about RtE from parents' perspectives to inform best practice and facilitate improvements in service delivery.

METHODS

A service evaluation explored parent/carer views about the RtE process and the support received from healthcare professionals at a regional centre in the UK. Questionnaires (n = 59) were sent to parents of patients treated for an ABI in the last two years.

RESULTS

31 parents (response rate = 51%) completed the survey. Results highlight the many challenges of RtE. Thematic analysis of responses revealed six key themes: Parental mindset and growth; What do they need know?; Specialist support and information; Talk and share; Challenges of new and hidden needs; and Don't forget them!

CONCLUSION

Parents offer crucial insight into the challenges of the RtE process. Their feedback highlights important factors for service development and reminds professionals of the key components of an effective return.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Deltoid ligament repair versus trans-syndesmotic fixation for bimalleolar equivalent ankle fractures

INTRODUCTION

The role of deltoid ligament repair is controversial in the treatment of bimalleolar equivalent ankle injuries. Our purpose was to compare midterm functional outcomes and reoperation rates of unstable distal fibula fractures treated with open reduction internal fixation (ORIF) of the fibula and either deltoid ligament repair, trans-syndesmotic fixation, or combined fixation.

METHODS

Skeletally mature subjects were retrospectively identified after fixation of isolated unstable distal fibula fractures treated at a single academic level 1 hospital from January 2005 to May 2019. The AAOS Foot and Ankle Module outcomes questionnaire (AAOS-FAM) was obtained at a mean time from surgery of 4.6 +/- 3.1 years. Subjects underwent one of three methods of fixation including distal fibula ORIF and one of the following: trans-syndesmotic fixation (N = 66), deltoid ligament repair (N = 16), or combined trans-syndesmotic fixation and deltoid ligament repair (N = 26). Outcomes scores and Charlson Comorbidity Index scores were compared between groups by Kruskal-Wallis testing for non-normally distributed data. Rates of reoperation were compared by Fisher's exact test. Statistical significance was set to P < 0.05 for all comparisons.

RESULTS

There was no significant difference in AAOS-FAM scores between the three groups (P = 0.18). No subjects in the deltoid ligament repair group underwent reoperation compared to 17 (26%) in the trans-syndesmotic fixation group and six (23%) in the combined fixation group. The most common reason for reoperation was removal of hardware, which was performed in 12 (18%) subjects in the trans-syndesmotic fixation group and three (12%) subjects in the combined fixation group.

CONCLUSIONS

Direct deltoid ligament repair yields similar functional scores and fewer reoperations compared to trans-syndesmotic fixation at midterm follow up. Deltoid ligament repair may be a favorable treatment strategy when considering trans-syndesmotic fixation in the surgical treatment of unstable distal fibula fractures.

Treatment Outcomes in Spinal Metastatic Disease With Indeterminate Stability

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purpose of this study was to compare outcomes between different treatment modalities for metastatic disease with indeterminate instability (Spinal Instability Neoplastic Score [SINS] 7-12).

METHODS

We retrospectively reviewed neurologically intact patients treated for spinal metastatic disease with a SINS of 7 to 12. The cohort was stratified by treatment approach: external beam radiation therapy alone (EBRT), surgery + EBRT (S+E), and cement augmentation + EBRT (K+E). Kaplan-Meier analysis was used to assess differences in length of survival (LOS) and ability to ambulate at time of death. Multivariate analysis was performed to assess adjusted LOS and ability to ambulate at time of death.

RESULTS

The cohort included 211 patients, S+E (n = 57), EBRT (n = 128), and K+E (n = 27). In the S+E group, the median LOS was 430 days, which was statistically longer than the median LOS for the EBRT group (121 days) and the K+E group (169 days). In the S+E group, 52 patients (91.2%) and in the K+E group 24 patients (92.3%) retained the ability to ambulate at their time of death compared to 99 patients (77.3%) of the EBRT patients (P = .01). The overall rate of revision treatment at the spinal level initially treated was 17.5%, S+E (15.8%), EBRT (20.3%), and K+E (7.7%).

CONCLUSIONS

The length of survival, ability to maintain ambulatory ability, and revision treatment rates were all improved following surgical management and radiation therapy compared to radiation therapy alone. The authors' conclusion from these results are that patients with indeterminate spinal instability should be discussed in a multidisciplinary setting for the need of spinal stabilization in addition to radiation therapy.

18F-Sodium fluoride positron emission tomography, aortic disease activity and ischaemic stroke risk

Background

Arterial 18F-sodium fluoride (18F-NaF) activity on positron emission tomography (PET) is a marker of active microcalcification and atherosclerosis. Coronary 18F-NaF activity (CMA) predicts coronary artery disease progression and subsequent myocardial infarction.

Objective

To investigate whether aortic 18F-NaF activity (AMA) predicts thoracic aortic atherosclerotic disease progression and subsequent ischaemic stroke or myocardial infarction in patients with established cardiovascular disease.

Methods

In a post-hoc observational cohort study, we evaluated AMA and CMA in patients with stable coronary artery disease (n=239) or aortic stenosis (n=158) who had underwent thoracic 18F-NaF PET and computed tomography (CT). We assessed the associations between AMA or CMA and progression of calcified atherosclerotic plaque in both thoracic aortic and coronary territories on follow up CT, as well as subsequent ischaemic stroke or myocardial infarction.

Results

In 141 and 231 patients with repeat aortic and coronary CT imaging respectively at 12.7±2.7 months, AMA correlated with log progression of thoracic aortic calcium scores (r=0.21, p=0.011), volume (r=0.29, p&lt;0.01) and mass (r=0.29, P&lt;0.01) as well as log coronary calcium score progression (r=0.21, p=0.03). CMA correlated with log coronary (r=0.42, p&lt;0.01), but not log aortic (p&gt;0.80) calcium score progression. In 397 patients, 16 had an ischaemic stroke and 25 had a myocardial infarction after 4.7±1.6 years. After adjusting for clinical risk factors, CMA and calcium scoring, AMA was associated with stroke (hazard ratio, 1.71 [95% confidence interval 1.00–2.90], p=0.048]). AMA was superior to clinical risk and calcium scores in identifying patients with stroke (c-statistic 0.76 versus 0.58 versus 0.63 respectively, p&lt;0.05). Survival analysis demonstrated that AMA was associated with ischaemic stroke (p&lt;0.001) but not myocardial infarction (p=0.45), whereas CMA was associated with myocardial infarction (p&lt;0.001) but not stroke (p=0.39).

Conclusions

In patients with established cardiovascular disease, AMA is associated with progression of aortic atherosclerosis and future ischaemic stroke. Arterial 18F-NaF identifies localised areas of atherosclerotic disease activity that relate to regional atherothrombotic events.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): British Heart Foundation AMA, disease progression and outcomesVariables associated with stroke

Plasma desmosine as a biomarker in acute aortic syndrome

Introduction

Acute aortic syndromes (AAS) include aortic dissection, intramural haematoma and penetrating aortic ulcer, all of which are caused by aortic wall failure and associated with significant mortality. Although, treatment options currently include early surgical intervention or aggressive medical management, disease progression and devastating complications remain commonplace. Early diagnosis of AAS as well as ability to predict those at the highest risk of disease progression would represent significant progress in the care these patients receive. Desmosine is the cross-link component in the elastin molecule and is exclusively released from mature elastin breakdown, thus is a physiologically relevant biomarker of aortic elastin degradation. The aim of the study was to test the hypothesis that plasma desmosine (pDES) concentrations are elevated in AAS and has prognostic value in indentifying those at risk of significant disease progression.

Method

Patients over 25 years old with radiologically confirmed acute aortic syndrome were recruited as part of a prospective observational study (NCT03647566). Demographic details, AAS sub-category, time from index acute aortic syndrome event and pDES concentrations measured by stable isotope dilution LC-MS/MS were recorded at baseline. Baseline and follow up maximal aortic diameters were measured on contrast-enhanced computed tomography (CT) and change in aortic diameter over time was calculated. Control plasma desmosine samples were obtained at a 2:1 ratio control subjects participating in the United Kingdom Aneurysm Growth Study. Data presented as mean±standard deviation or median [interquartile range].

Results

Plasma desmosine concentrations were measured in 53 patients (64 [53 to 71] years) with acute aortic syndromes and 106 control subjects (53 [44 to 60] years). In patients with AAS, pDES concentrations were almost twice those of control subjects (0.58±0.26 vs 0.27±0.07, p&lt;0.001). In those with AAS, plasma desmosine concentrations were seen to be highest at presentation, and reduced over time from the aortic syndrome event (R=0.51, p=0.003). Plasma desmosine concentration was the only variable associated with increasing aortic diameter over time (R=0.34, p=0.014).

Conclusion

Plasma desmosine concentrations are elevated in patients with AAS, peak at the time of presentation and represents a promising biomarker for early identification and risk stratification in patients with AAS.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): British Heart FoundationTenovus Scotland Major Research GrantChief Scientist Office Catalytic Grant Plasma desmosine, time and expansionBaseline characteristics

Remote delivery of cardiac rehabilitation can achieve equivalent health-related quality of life outcomes to in-person methods in patients with coronary heart disease: a multi-site study

Funding Acknowledgements

Type of funding sources: None.

Background In-person exercise-based cardiac rehabilitation (CR) has well-established benefits for health-related quality of life (HRQL) for patients with coronary heart disease (CHD). During COVID-19 pandemic restrictions, remote delivery replaced in-person CR, but the impact on HRQL is unclear. This study addresses this gap.

Methods Consecutive patients commencing CR at four sites in one Local Health District in Sydney were recruited (n = 194), recruited from December 2019 to October 2020. Remote delivery from March 2020 created a natural comparison group to in-person CR. HRQL was measured at CR entry and completion using the SF-12v2 and linear regression was used for analyses.

Results Participants were aged mean 65.94 (SD 10.45) years, were 80.9% male and diagnoses included elective PCI (37.9%), CABG (26.7%), and MI (34.9%) either with PCI (23.6%) or alone (11.3%). Participants received remote (n = 103, 53.1%) or in-person (n = 91, 46.9%; ≥ assessment + 2 sessions) CR, with more completions for in-person (75.8% vs 63.1%, p=.03). Remote participants were more likely to be white than ethnic minority (35.2% vs 13.6% p&lt;.001), however, there were no differences in baseline HRQL for delivery group after adjustment.

HRQL improved from CR entry to completion regardless of delivery mode (adjusted). Most improvements occurred in physical function (SMD 6.37, 95% CI 4.81,7.92), role physical (SMD 5.72, 95% CI 4.29. 7.16) and physical component (SMD 5.77 95% CI 4.43, 7.12) scores. Least improvement occurred in mental component scores (SMD 1.65, 95%CI .53, 2.78).

Conclusion Remotely delivered CR provides comparable HRQL outcomes to in-person delivery, thus providing a promising alternative. Data are needed on cost-effectiveness, as well as staff and patient preferences.

Intermediate-term Patient-Reported Outcomes and Radiographic Evaluation Following Intramedullary- vs Extramedullary-Referenced Total Ankle Replacement

BACKGROUND

The purpose of this study was to report on the radiographic outcomes, clinical outcomes, and implant survivorship following extramedullary-referenced (EMr) vs intramedullary-referenced (IMr) total ankle replacement (TAR).

METHODS

From May 2007 to February 2018, a consecutive series of patients with end-stage tibiotalar osteoarthritis undergoing TAR was enrolled in this study. Analyses were performed comparing IMr vs EMr components for patient-reported outcomes data, pre- and postoperative radiographic ankle alignment, concomitant procedures, and complications. Kaplan-Meier survivorship analyses served to determine implant reoperation and revision surgery. A total of 340 TARs were included with 105 IMr TAR and 235 EMr TAR. The mean follow-up was 5.3 years (±2.5, range 2-12).

RESULTS

The absolute value for preoperative coronal alignment was significantly greater for IMr compared to EMr TAR (13.0 vs 6.4 degrees; P < .0001), but both groups achieved near neutral alignment postoperatively (1.4 vs 1.5 degrees; P = .6655). The odds of having a concomitant procedure was 2.7 times higher in patients with an IMr TAR (OR 2.7, CI 1.7-4.4; P < .0001). There were similar improvements in patient-reported outcome scores at 1 year and final follow-up (all P > .05). The 5-year implant survivorship was 98.6% for IMr vs 97.5% for EMr at final follow-up.

CONCLUSION

The IMr and EMr TAR components had comparable postoperative alignment, patient-reported outcome scores, and complications. The 5-year implant survivorship was similar between the IMr and EMr groups.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Arthroscopic Double-Row Bony Bankart Bridge Repair Using a Tensionable Knotless System

Posterior labral pathology is common in contact athletes; however, posterior glenoid avulsion fractures, also known as posterior bony Bankart lesions, are less common. Posterior instability affects approximately 10% of all patients with shoulder instability. Diagnosis in these high-risk individuals often follows a traumatic posterior dislocation. The patient feels grossly unstable but may or may not have recurrent dislocations beyond the initial trauma. Surgical correction and favorable surgical outcomes require a full understanding of both the soft-tissue and bony components of the injury. Stable osseous fixation is required to restore appropriate glenoid version, depth, and to prevent malunion. We present a technique to mobilize and stabilize a posterior bony Bankart lesion with a knotless suture bridge construct. We feel that this technique is reliable and reproducible and allows for a superior quality of fragment reduction when compared with systems using larger anchors and knotted systems.

Clinical Outcomes and Complications Following Limited Open Achilles Repair Without an Instrumented Guide

BACKGROUND

We report the clinical outcomes and complications following our limited open incision Achilles tendon repair technique without instrument guides.

METHODS

A total of 33 patients were included in this study. We recorded pre- and postoperative scores on the Foot and Ankle Disability Index (FADI), visual analog scale (VAS), and the Foot and Ankle Outcome Score (FAOS). Subgroup analyses were performed for acute (<2 weeks) and subacute (2-6 weeks) Achilles tendon repairs. A P value <.05 was considered significant for all statistical analyses.

RESULTS

The median time from injury to surgery was 10.0 days (range, 1-45 days). At a median follow-up of 3.7 years (range, 1.0-9.8 years), the average pre- and postoperative outcome scores improved significantly for the following: FADI index (49.1-98.4, P < .001), VAS (4.8-0.2, P < .001), FAOS Pain (54.8-99.2, P < .001), FAOS Symptoms (84.6-97.0, P < .001), FAOS activities of daily living (61.4-97.2, P < .001), FAOS Sports and Recreational Activity (39.5-98.5, P < .001), and FAOS quality of life (39.7-88.7, P < .001). There were no significant differences between pre- and postoperative outcome scores between the acute and subacute Achilles repair groups. There were no wound complication, reruptures, or reoperations in the entire cohort.

CONCLUSION

Patients showed improvements in postoperative patient-reported outcome scores with minimal complications. There was no significant difference in outcomes for acute vs subacute repairs. Our limited open incision Achilles tendon repair, which required no additional targeting instrumentation, had favorable midterm results.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Hybrid 18f-sodium fluoride PET/CT of the thoracic aorta identifies patients at increased risk of stroke

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): British Heart Foundation Clinical Research Training Fellowship

Background

Calcification of the thoracic aorta is associated with poor vessel wall health. Early detection of this disease process may highlight those at risk of future cardiovascular events.

Purpose

To investigate the potential of hybrid 18F-sodium fluoride (18F-NaF, a marker of vascular disease and microcalcification activity) positron emission tomography/computed tomography (PET/CT) to predict aortic disease progression and adverse cardiovascular events in patients with established risk factors.

Methods

Between 2015 and 2017, 197 patients underwent 18F-NaF PET/CT of the thoracic aorta as part of a randomised controlled trial.  Baseline 18F-NaF aortic microcalcification activity (AMA) was calculated as the cumulative uptake in a standardised volume of interest of the arch and ascending aorta.  Thirty-seven patients underwent follow up CT enabling aortic calcium score progression calculation.  Fatal/non-fatal stroke (primary endpoint) and fatal/non-fatal myocardial infarction (MI, secondary endpoint) were recorded up to May 2020.  The association between baseline AMA and both the progression of aortic calcium score and defined endpoints was analysed.  AMA was stratified into tertiles (low, moderate or high). Data is presented as mean(SD) or median [IQR].

Results

18F-NaF AMA correlated with the progression of aortic calcium score (R = 0.42, P = 0.01).  During 3.8 (0.9) years of follow up, 14 patients experienced the primary (stroke, n = 5) or secondary (MI, n = 9) endpoint.  Patients who experienced stroke had higher AMA (171 [162-176] vs 150 [141 - 157], P = 0.0015). Increased cumulative incidence of stroke was seen in the highest AMA tertile (Figure, P = 0.019).  There was no association between AMA and MI (P &gt; 0.05).

Conclusion

Aortic microcalcification activity, as measured using 18F-NaF PET/CT, predicts the progression of aortic wall calcification and is associated with an increased risk of stroke but not MI.  Consolidating these findings in further studies will improve stroke risk prediction using 18F-NaF PET/CT.

Table Baseline characteristics Overall n = 197 Low AMA (&lt;144) n = 66 Moderate AMA (144-155) n = 66 High AMA (&gt;155) n = 65 p-value (ANOVA / X2) Age (±sd) 65.17 (8.30) 64.02 (9.43) 65.47 (7.40) 66.03 (7.95) 0.364 Male Sex (%) 157 (80.5) 54 (83.1) 52 (78.8) 51 (79.7) 0.808 Ever Smoked (%) 101 (60.5) 37 (71.2) 32 (56.1) 32 (55.2) 0.164 Hypertension (%) 110 (56.4) 31 (47.7) 35 (53.0) 44 (68.8) 0.043 High Cholesterol (%) 188 (96.4) 60 (92.3) 65 (98.5) 63 (98.4) 0.093 Type II Diabetes (%) 37 (19.0) 16 (24.6) 9 (13.6) 12 (18.8) 0.277 AMA = aortic microcalcification activity, MI = myocardial infarction, sd = standard deviation, TIA = transient ischaemic attack, X2 = Chi squared Abstract Figure: AMA and Stroke

18F-Sodium fluoride PET/CT detects transcatheter aortic valve degeneration

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by the British Heart Foundation, London, United Kingdom

Background

Early detection of transcatheter aortic valve implantation (TAVI) degeneration is challenging and only feasible when advanced haemodynamic valve dysfunction is apparent. 

Purpose

We tested whether 18F-sodium fluoride (18F-NaF) positron emission tomography and computed tomography (PET/CT) could detect structural TAVI degeneration and haemodynamic valve dysfunction. 

Methods

After TAVI implantation, patients underwent baseline echocardiography, CT angiography and 18F-NaF PET/CT (Figure). We assessed for morphological changes, stenosis or regurgitation on Doppler echocardiography, CT (hypoattenuated leaflet thickening [HALT] or spotty calcification) and PET (18F-NaF uptake; maximum target-to-background ratio, TBRmax). We categorised structural valve degeneration (SVD) according to the standardised definition for surgical and transcatheter bioprosthetic valves, as proposed in a recent consensus statement. 

Results

We recruited 47 patients (81 ± 6 years old, 79% male) 1 month (n = 9), 2 years (n = 22) or 5 years (n = 16) after TAVI: 25 (53%) had received a balloon expanded bioprosthesis and 22 (47%) a self-expanding valve. There was moderate valve dysfunction on Doppler echocardiography in 3 (6%) patients, HALT on CT in 6 (13%) patients, spotty calcification in one patient and 18F-NaF uptake in 7 patients (15%) (TBRmax range: 1.59-5.88); all enrolled 5 years post-TAVI.

All patients with increased 18F-NaF uptake (TBRmax ≥1.59) demonstrated either SVD without haemodynamic valve dysfunction (stage 1, n = 4) or structural valve dysfunction with moderate valve dysfunction and mean transprosthetic pressure gradients &gt;20 mmHg (stage 2, n = 3). In patients without increased 18F-NaF uptake there was no evidence of structural valve degeneration (n = 40).

Within the increased 18F-NaF uptake (n = 7) group, patients with stage 2 SVD (n = 3) demonstrated higher uptake compared to patients with stage 1 SVD (TBRmax 4.3 [3.02-5.88] versus 1.8 [1.59-2.28]). Patients with stage 2 SVD (n = 3) had over 3 times higher TBRmax than those without SVD (n = 40) (4.30 [3.02, 5.88] versus 1.31 [1.21, 1.46]; p &lt; 0.001); Figure).

Conclusion

18F-NaF PET/CT detects patients with SVD and potentially identifies those at risk of valve failure.

Abstract Figure.

Aortic wall stiffness and microcalcification in inherited thoracic aortopathies

Background

Inherited thoracic aortic diseases are at substantially increased risk of aneurysm formation, aortic dissection or rupture. Importantly, up to 70% of dissections occur in aortas with a diameter below the threshold for prophylactic surgical replacement. Increased aortic stiffness and microcalcification have previously been identified as features of aortopathy and both indicate worsening vessel wall health. Improvement in our understanding of the disease processes that underpin high risk thoracic aortic aneurysms would be a major clinical advance.

Purpose

To investigate aortic wall microcalcification in a group of patients with inherited thoracic aortopathy and examine its relationship to both aortic stiffness and aortic diameter.

Methods

As part of an ongoing clinical study, 26 patients with thoracic aortopathy (14 congenital bicuspid aortic valve [BAV], 6 Marfan syndrome [MFS], 6 Turner syndrome [TS]) underwent aortic magnetic resonance imaging (MRI). Ascending aortic diameter and circumferential strain were determined by MRI at the level of the right pulmonary artery. Aortic pulse pressure was determined using applanation tomography. Aortic stiffness was calculated as circumferential aortic distensibility (circumferential strain/aortic pulse pressure). Microcalcification activity was measured using 18F-sodium fluoride positron emission tomography/computed tomography (18F-NaF PET/CT). 18F-NaF uptake was deemed “positive” if it was above the 95th centile of blood pool. A volume of interest was drawn around the ascending aorta and the volume of “positive” signal was indexed to patient height (indexed aortic microcalcification [iAMC] score).

Results

Distensibility differed between subgroups (BAV 0.06 [0.03], MFS 0.13 [0.07], TS 0.19 [0.09] mm/mmHg, p=0.011) was associated with body-mass index (r=0.46, p=0.025), and was inversely associated with age (R=−0.45, p=0.024) and aortic diameter (R=−0.61, p=0.001), but did not differ between sex, hypertension, hypercholesterolaemia or smoking status (all p&gt;0.05). 18F-NaF uptake co-localised with the aortic wall of ascending thoracic aneurysms (Figure). The iAMC score was associated with aortic diameter (R=0.43, p=0.033), and aortic distensibility (R=−0.42, p=0.048), and appeared to carry a borderline association with age (R=0.39, p=0.064). There was no difference in iAMC between aortopathy subtypes, hypertension, smoking status, hypercholesterolaemia, or sex (all p&gt;0.05).

Conclusion

In patients with inherited thoracic aortopathy, increased aortic wall stiffness and diameters, but not cardiovascular risk factors, are associated with increased aortic wall microcalcification. Further longitudinal and ex vivo studies are required to corroborate and validate these findings and determine if 18F-NaF uptake can predict disease progression and prognosis.

Distensibility and Microcalcification

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): British Heart Foundation clinical research training fellowship

Early Outcomes of 3D Printed Total Talus Arthroplasty

BACKGROUND

Patients with talar avascular necrosis (AVN) have limited treatment options to manage their symptoms. Historically, surgical options have been limited and can leave patients with little ankle motion and have high failure rates. The use of custom 3D printed total talar replacements (TTRs) has arisen as a treatment option for these patients, possibly allowing better preservation of hindfoot motion. We hypothesized that patients undergoing TTR will demonstrate a statistically significant improvement in Foot and Ankle Outcome Score (FAOS) at 1 year after surgery.

METHODS

We retrospectively reviewed 15 patients who underwent a TTR over a 2-year period. Patient outcomes were reviewed, including age, sex, comorbidities, etiology of talar pathology, number and type of prior surgeries, radiographic alignment, FAOS and Visual Analog Scale (VAS) score, and range of motion. Data analysis was performed with Student t-tests and multivariate regression.

RESULTS

FAOSs and VAS scores showed statistically significant improvements postoperatively as compared with preoperative scores. There was a statistically significant decrease in VAS pain scores from 7.0 preoperatively to 3.6 (P < .001). Average follow-up was 12.8 months. With the number of patients available, there was no statistically significant change in radiographic alignment parameters postoperatively as compared with preoperatively (P values ranged from .225 to .617).

CONCLUSION

Our hypothesis that these patients show statistically significant improvements in FAOSs at 1 year was confirmed. TTR represents an exciting treatment option for patients with talar AVN, though longer-term follow-up is needed.Level of Evidence: Level IV: Case series.

Understanding further education as a context for public health intervention: qualitative findings from a study process evaluation

BACKGROUND

Over 1.2 million 16-18 year-olds are enrolled in further education (FE-advanced secondary education) in England. Life course transitions provide opportunities to change, establish or reinforce health behaviours. FE presents an opportunity for public health improvement, yet few interventions target this setting. Using a smoking prevention intervention, we explore how young people were viewed in FE and how this affected intervention acceptability.

METHODS

Eleven student and five staff focus groups were conducted in three intervention institutions (two colleges, one school sixth-form), as part of the process evaluation of a smoking prevention feasibility study. FE managers in intervention and control institutions were also interviewed (n = 5). Data were analysed using thematic analysis.

RESULTS

In both colleges and the sixth-form, students were viewed as emergent adults and treated differently from 'school-children', in practice if not in policy. Colleges permitted smoking in designated areas; in the school sixth-form smoking was unofficially tolerated but concealed from younger students. Using staff to deliver anti-smoking messages reintroduced an unwanted power dynamic which disrupted perceptions of students as young adults.

CONCLUSIONS

FE is an important setting for young people's health. Understanding the culture and context of FE is critical in designing acceptable and effective public health interventions.

Evidence for angiotensin mediation of the late histopathological effects of pulmonary fat embolism: Protection by losartan in a rat model

PURPOSE

In a model of fat embolism using triolein-treated rats, we have reported that the acute pulmonary histopathological changes at 48 hrs were ameliorated by the angiotensin AT1 receptor blocker losartan, the angiotensin converting enzyme inhibitor captopril, and the direct renin inhibitor aliskiren. Although much of the pathology had declined by 3 weeks, the changes persisted at 6 weeks. The purpose of the study was to extends the time course investigation to 10 weeks and to examines whether the fat embolism effects continue to be blocked by losartan when given at a late time period.

MATERIALS AND METHODS

Unanesthetized rats were challenged with i.v. triolein or saline. After 6 weeks, one group received saline or losartan i.p. and the losartan group also received losartan in the drinking water. At 10 weeks, the experiment was terminated.

RESULTS

Confirming previous results, the fat embolism group showed normal weight gain at 6 weeks without apparent distress and also appeared normal at 10 weeks. However, at 10 weeks the lungs showed inflammatory and fibrotic changes that were greater than those found at 6 weeks. These changes were reduced by losartan.

CONCLUSIONS

These findings show that the effects of fat embolism continue to progress to 10 weeks after the initial insult with triolein. The fact that the protective effects of losartan treatment started at 6 weeks supports the involvement of the renin-angiotensin system in late as well as early stages of the histopathological changes following fat embolism. It also supports the use of angiotensin blockade in clinical situations even long after an initial trauma where fat embolism is suspected.

Preoperative Hypoalbuminemia Predicts Poor Short-term Outcomes for Hip Fracture Surgery

Hip fractures are common in elderly patients, and which surgical modality to pursue is often debated. Malnutrition, which cannot be corrected preoperatively in this population, is often not considered. Therefore, the authors sought to investigate the association between hypoalbuminemia and postoperative outcomes based on surgical intervention. Patients undergoing arthroplasty (hemiarthroplasty or total hip arthroplasty), open reduction and internal fixation, and intramedullary nailing placement for treatment of hip fractures were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by preoperative albumin level, with less than 3.5 g/dL indicating hypoalbuminemia. Albumin's association with postoperative complications was evaluated with multivariate logistic regression controlling for patient age, body mass index, American Society of Anesthesiologists score, and functional independence. A total of 20,278 patients with hip fractures and available albumin levels were included. Multivariate analysis revealed hypoalbuminemia was predictive of readmission, reintubation, mortality, and length of stay for all surgeries performed. When analyzing across surgical modalities, unique complications were identified for patients with hypoalbuminemia undergoing open reduction and internal fixation/prosthetic replacement (reoperation, P<.001) and arthroplasty (any infection, P=.028) compared with other treatment options. Hypoalbuminemia can predict postoperative complications for patients with hip fractures and should be considered preoperatively to guide surgical decision making in equivocal cases where multiple modalities may be used based on fracture pattern. This study supports that, compared with other interventions, intramedullary nailing is associated with fewer postoperative complications in patients with hypoalbuminemia. [Orthopedics. 2018; 41(6):e789-e796.].

Does integrated academic and health education prevent substance use? Systematic review and meta-analyses

BACKGROUND

Prevention of substance (alcohol, tobacco, illegal/legal drug) use in adolescents is a public health priority. As the scope for school-based health education is constrained in school timetables, interventions integrating academic and health education have gained traction in the UK and elsewhere, though evidence for their effectiveness remains unclear. We sought to synthesize the effectiveness of interventions integrating academic and health education for the prevention of substance use.

METHODS

We searched 19 databases between November and December 2015, among other methods. We included randomized trials of interventions integrating academic and health education targeting school students aged 4-18 and reporting substance use outcomes. We excluded interventions for specific health-related subpopulations (e.g., children with behavioural difficulties). Data were extracted independently in duplicate. Outcomes were synthesized by school key stage (KS) using multilevel meta-analyses, for substance use, overall and by type.

RESULTS

We identified 7 trials reporting substance use. Interventions reduced substance use generally in years 7-9 (KS3) based on 5 evaluations (d = -0.09, 95% CI [-0.17, -0.01], I²  = 35%), as well as in years 10-11 (KS4) based on 3 evaluations (-0.06, [-0.09, -0.02]; I²  = 0%). Interventions were broadly effective for reducing specific alcohol, tobacco, and drug use in both KS groups.

CONCLUSIONS

Evidence quality was highly variable. Findings for years 3-6 and 12-13 could not be meta-analysed, and we could not assess publication bias. Interventions appear to have a small but significant effect reducing substance use. Specific methods of integrating academic and health education remain poorly understood.

Integrating modelling and phenotyping approaches to identify and screen complex traits: transpiration efficiency in cereals

Following advances in genetics, genomics, and phenotyping, trait selection in breeding is limited by our ability to understand interactions within the plant and with the environment, and to identify traits of most relevance to the target population of environments. We propose an integrated approach that combines insights from crop modelling, physiology, genetics, and breeding to characterize traits valuable for yield gain in the target population of environments, develop relevant high-throughput phenotyping platforms, and identify genetic controls and their value in production environments. This paper uses transpiration efficiency (biomass produced per unit of water used) as an example of a complex trait of interest to illustrate how the approach can guide modelling, phenotyping, and selection in a breeding programme. We believe that this approach, by integrating insights from diverse disciplines, can increase the resource use efficiency of breeding programmes for improving yield gains in target populations of environments.

Treatment of Basal Cell Carcinoma with Intralesional Interferon Alpha-2b

We report a series of 11 basal cell carcinomas of various types treated with nine intra-lesional injections of 1.5 million units of interferon alpha-2b. The diagnosis was confirmed histologically in each case.

After 3 months' follow-up six tumours had resolved both clinically and histologically. In three cases the tumour size was reduced. One tumour grew larger. Side effects were well tolerated except by one subject who was withdrawn. Those cases which responded have now been followed-up for between 12 and 26 months with no clinical or histological evidence of tumour recurrence.

This is the longest period of follow-up so far reported for this novel treatment. The results are encouraging and, if maintained in future series, may indicate a useful role for interferon alpha in the management of this common cutaneous malignancy.

Multimodality quantitative assessments of myocardial perfusion using dynamic contrast enhanced magnetic resonance and 15O-labelled water positron emission tomography imaging

Kinetic modelling of myocardial perfusion imaging data allows the absolute quantification of myocardial blood flow (MBF) and can improve the diagnosis and clinical assessment of coronary artery disease (CAD). Positron emission tomography (PET) imaging is considered the reference standard technique for absolute quantification, whilst oxygen-15 (¹⁵O)-water has been extensively implemented for MBF quantification. Dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) has also been used for MBF quantification and showed comparable diagnostic performance against (¹⁵O)-water PET studies. We investigated for the first time the diagnostic performance of two different PET MBF analysis softwares PMOD and Carimas, for obstructive CAD detection against invasive clinical standard methods in 20 patients with known or suspected CAD. Fermi and distributed parameter modelling-derived MBF quantification from DCE-MRI was also compared against (¹⁵O)-water PET, in a subgroup of 6 patients. The sensitivity and specificity for PMOD was significantly superior for obstructive CAD detection in both per vessel (0.83, 0.90) and per patient (0.86, 0.75) analysis, against Carimas (0.75, 0.65), (0.81, 0.70), respectively. We showed strong, significant correlations between MR and PET MBF quantifications (r=0.83-0.92). However, DP and PMOD analysis demonstrated comparable and higher haemodynamic differences between obstructive versus (no, minor or non)-obstructive CAD, against Fermi and Carimas analysis. Our MR method assessments against the optimum PET reference standard technique for perfusion analysis showed promising results in per segment level and can support further multi-modality assessments in larger patient cohorts. Further MR against PET assessments may help to determine their comparative diagnostic performance for obstructive CAD detection.

Functional consequences of the first reported mutations of the proto-oncogene PTTG1IP/PBF

Pituitary tumor-transforming gene 1-binding factor (PTTG1IP; PBF) is a multifunctional glycoprotein, which is overexpressed in a wide range of tumours, and significantly associated with poorer oncological outcomes, such as early tumour recurrence, distant metastasis, extramural vascular invasion and decreased disease-specific survival. PBF transforms NIH 3T3 fibroblasts and induces tumours in nude mice, while mice harbouring transgenic thyroidal PBF expression show hyperplasia and macrofollicular lesions. Our assumption that PBF becomes an oncogene purely through increased expression has been challenged by the recent report of mutations in PBF within the Catalogue of Somatic Mutations in Cancer (COSMIC) database. We therefore sought to determine whether the first 10 PBF missense substitutions in human cancer might be oncogenic. Anisomycin half-life studies revealed that most mutations were associated with reduced protein stability compared to wild-type (WT) PBF. Proliferation assays narrowed our interest to two mutational events which significantly altered cell turnover: C51R and R140W. C51R was mainly confined to the endoplasmic reticulum while R140W was apparent in the Golgi apparatus. Both C51R and R140W lost the capacity to induce cellular migration and significantly reduced cell invasion. Colony formation and soft agar assays demonstrated that, in contrast to WT PBF, both mutants were unable to elicit significant colony formation or anchorage-independent growth. However, C51R and R140W retained the ability to repress radioiodide uptake, a functional hallmark of PBF. Our data reveal new insight into PBF function and confirm that, rather than being oncogenic, mutations in PBF are likely to be passenger effects, with overexpression of PBF the more important aetiological event in human cancer.

Congenital Tracheobronchomegaly (Mounier-Kuhn Syndrome) in a Woman with Human Immunodeficiency Virus: A Case Report

Congenital tracheobronchomegaly (Mounier-Kuhn Syndrome, MKS) is a rare idiopathic disorder characterized by dilation of the central airways, including the trachea and first through fourth order bronchi. MKS disproportionately affects men and results in chronic respiratory tract infections. The diagnosis is made through the synthesis of clinical and radiological data. Here we report a unique case of MKS in a patient with human immunodeficiency virus (HIV) infection. A 45-year-old African American woman with a past medical history of HIV, tobacco and recreational drug abuse, chronic obstructive pulmonary disease, sleep apnea, and a 15-year history of recurrent respiratory infections presented with dyspnea, wheezing, a productive cough, increased yellow-green sputum production, and subjective fevers. Computerized tomography (CT) of the chest revealed striking dilation of the trachea and central bronchi. Fiberoptic bronchoscopy demonstrated a dilated trachea and bronchial tree with complete collapse of the trachea and bilateral mainstem bronchi during expiration. Serial imaging over 14 years allowed the radiologist to confidently diagnose her underlying disorder and recommend appropriate clinical management, which included mucolytics, chest physiotherapy, prophylactic vaccinations, and antibiotics during infectious exacerbations. To the best of our knowledge, there is only one reported case of MKS in the setting of HIV in the English literature. We report the second such case and outline the clinical presentation, diagnostic criteria, and management of MKS with the hope that increased awareness will prevent delayed or misdiagnosis for patients with MKS. This case highlights the common diagnostic delay for MKS and the need to include MKS in the differential diagnosis of recurrent respiratory tract infections.

Do stronger school smoking policies make a difference? Analysis of the health behaviour in school-aged children survey

Background: Associations of the strength of school smoking policies with cigarette, e-cigarette and cannabis use in Wales were examined. Methods: Nationally representative cross-sectional survey of pupils aged 11–16 years (N=7376) in Wales. Senior management team members from 67 schools completed questionnaires about school smoking policies, substance use education and tobacco cessation initiatives. Multi-level, logistic regression analyses investigated self-reported cigarette, e-cigarette and cannabis use, for all students and those aged 15–16 years. Results: Prevalence of current smoking, e-cigarette use and cannabis use in the past month were 5.3%, 11.5% and 2.9%, respectively. Of schools that provided details about smoking policies (66/67), 39.4% were strong (written policy applied to everyone in all locations), 43.9% were moderate (written policy not applied to everyone in all locations) and 16.7% had no written policy. There was no evidence of an association of school smoking policies with pupils’ tobacco or e-cigarette use. However, students from schools with a moderate policy [OR = 0.47; 95% (confidence interval) CI: 0.26–0.84] were less likely to have used cannabis in the past month compared to schools with no written policy. This trend was stronger for students aged 15–16 years (moderate policy: OR = 0.42; 95% CI: 0.22–0.80; strong policy: OR = 0.45; 95% CI: 0.23–0.87). Conclusions: School smoking policies may exert less influence on young people’s smoking behaviours than they did during times of higher adolescent smoking prevalence. Longitudinal studies are needed to examine the potential influence of school smoking policies on cannabis use and mechanisms explaining this association.

Epithelial-specific A2B adenosine receptor signaling protects the colonic epithelial barrier during acute colitis

Central to inflammatory bowel disease (IBD) pathogenesis is loss of mucosal barrier function. Emerging evidence implicates extracellular adenosine signaling in attenuating mucosal inflammation. We hypothesized that adenosine-mediated protection from intestinal barrier dysfunction involves tissue-specific signaling through the A2B adenosine receptor (Adora2b) at the intestinal mucosal surface. To address this hypothesis, we combined pharmacologic studies and studies in mice with global or tissue-specific deletion of the Adora2b receptor. Adora2b(-/-) mice experienced a significantly heightened severity of colitis, associated with a more acute onset of disease and loss of intestinal epithelial barrier function. Comparison of mice with Adora2b deletion on vascular endothelial cells (Adora2b(fl/fl)VeCadCre(+)) or intestinal epithelia (Adora2b(fl/fl)VillinCre(+)) revealed a selective role for epithelial Adora2b signaling in attenuating colonic inflammation. In vitro studies with Adora2b knockdown in intestinal epithelial cultures or pharmacologic studies highlighted Adora2b-driven phosphorylation of vasodilator-stimulated phosphoprotein (VASP) as a specific barrier repair response. Similarly, in vivo studies in genetic mouse models or treatment studies with an Adora2b agonist (BAY 60-6583) recapitulate these findings. Taken together, our results suggest that intestinal epithelial Adora2b signaling provides protection during intestinal inflammation via enhancing mucosal barrier responses.

Randomized controlled trial of a telephone-based intervention for child fruit and vegetable intake: long-term follow-up

BACKGROUND

Telephone-based interventions can be effective in increasing child fruit and vegetable intake in the short term (<6 mo). The long-term efficacy of such interventions, however, is unknown.

OBJECTIVES

The primary aim of this study was to determine whether the short-term (<6 mo) impact of a telephone-based intervention on children's fruit and vegetable intake was sustained over a longer term. A secondary aim of the study was to assess the long-term impact of the intervention on the intake of foods high in fat, salt, or sugar (noncore foods).

DESIGN

The study used a cluster randomized controlled trial design. Parents were recruited from Australian preschools between February and August 2010 and allocated to receive an intervention consisting of print materials and 4 telephone-counseling calls delivered over 1 mo or to a print information-only control group. The primary endpoint for the trial was the 18-mo postbaseline follow-up. Linear regression models were used to assess between-group differences in child consumption of fruit and vegetables and noncore foods by subscales of the Children's Dietary Questionnaire.

RESULTS

Fruit and vegetable subscale scores were significantly higher, indicating greater child fruit and vegetable intake, among children in the intervention group at the 12-mo (16.77 compared with 14.89; P < 0.01) but not the 18-mo (15.98 compared with 16.82; P = 0.14) follow-up. There were no significant differences between groups at either of the follow-up periods in the noncore food subscale score.

CONCLUSION

Further research to identify effective maintenance strategies is required to maximize the benefits of telephone-based interventions on child diet.

Identifying the barriers and facilitators to optimal hearing aid self-efficacy

OBJECTIVE

Many older adults with hearing impairment are not confident in their ability to use hearing aids (i.e. experience low hearing aid self-efficacy), which has been found to be a barrier to hearing help-seeking and hearing aid use. This study aimed to determine what factors were associated with achieving adequate hearing aid self-efficacy.

DESIGN

A retrospective research design was employed wherein hearing aid self-efficacy was the primary outcome. Explanatory variables included personal demographics, visual disability, and experiences related to participants' hearing ability and hearing aids.

STUDY SAMPLE

A total of 307 older adults with hearing impairment participated in the study (147 non hearing aid owners and 160 hearing aid owners).

RESULTS

Non-hearing aid owners were more likely to report adequate hearing aid self-efficacy if they reported no visual disability, had experienced hearing loss for longer, reported more positive support from a significant other, and were not anxious about wearing hearing aids. Hearing aid owners were more likely to report adequate hearing aid self-efficacy if they had had a positive hearing aid experience and no visual disability.

CONCLUSIONS

More research is needed to develop and evaluate intervention approaches that promote optimal levels of hearing aid self-efficacy among older adults with hearing impairment.

Impact of early incentive spirometry in an enhanced recovery program after laparoscopic donor nephrectomy

BACKGROUND

This study aimed to assess the impact of early incentive spirometry on the incidence of chest infection in patients undergoing laparoscopic donor nephrectomy.

METHODS

A retrospective review on all consecutive laparoscopic donor nephrectomies (LDN) performed at a single institution from January 2008 to August 2012 was performed. We performed 84 LDN. Seventy patients had epidural analgesia continued for 48 hours postoperatively and 14 had a combination of spinal followed by oral analgesia. Incentive spirometry was introduced from July 2010 and 45 of the 84 donors used the spirometer as taught, both pre- and postoperatively.

RESULTS

We performed 84 LDN; 39 patients did not receive incentive spirometers and had postoperative chest physiotherapy started on postoperative day 1. Of the 45 patients given incentive spirometers, 44 started using their spirometers as taught, after recovery once they were settled in the ward, 1 patient started the exercises the following day. In the group who received no spirometer, 5 patients had a chest infection. In the group of patients who started using their spirometers in the early perioperative period (44/45), no patient developed a chest infection. One patient in this group was excluded from the analysis because he started spirometer exercises on postoperative day 1. This patient did develop a chest infection.

CONCLUSIONS

Our results suggest that early introduction of incentive spirometry after LDN significantly reduces the incidence of chest infection (P < .05); however, this benefit may be lost if the introduction of spirometry is delayed.

Theories of how the school environment impacts on student health: systematic review and synthesis

Public-health interventions informed by theory can be more effective but complex interventions often use insufficiently complex theories. We systematically reviewed theories of how school environments influence health. We included 37 reports drawing on 24 theories. Narrative synthesis summarised and categorised theories. We then produced an integrated theory of school environment influences on student health. This integrated theory could inform complex interventions such as health promoting schools programmes. Using systematic reviews to develop theories of change might be useful for other types of 'complex' public-health interventions addressing risks at the individual and community levels.

Systematic review of the effects of schools and school environment interventions on health: evidence mapping and synthesis

Background

In contrast to curriculum-based health education interventions in schools, the school environment approach promotes health by modifying schools' physical/social environment. This systematic review reports on the health effects of the school environment and processes by which these might occur. It includes theories, intervention outcome and process evaluations, quantitative studies and qualitative studies.

Research questions

Research question (RQ)1: What theories are used to inform school environment interventions or explain school-level health influences? What testable hypotheses are suggested? RQ2: What are the effects on student health/inequalities of school environment interventions addressing organisation/management; teaching/pastoral care/discipline; and the physical environment? What are the costs? RQ3: How feasible/acceptable and context dependent are such interventions? RQ4: What are the effects on student health/inequalities of school-level measures of organisation/management; teaching/pastoral care/discipline; and the physical environment? RQ5: Through what processes might such influences occur?

Data sources

A total of 16 databases were searched between 30 July 2010 and 23 September 2010 to identify relevant studies, including the British Educational Index, the Cumulative Index to Nursing and Allied Health Literature, the Health Management Information Consortium, EMBASE, MEDLINE and PsycINFO. In addition, references of included studies were checked and authors contacted.

Review methods

In stage 1, we mapped references concerning how the school environment affects health and consulted stakeholders to identify stage 2 priorities. In stage 2, we undertook five reviews corresponding to our RQs.

Results

Stage 1: A total of 82,775 references were retrieved and 1144 were descriptively mapped. Stage 2: A total of 24 theories were identified (RQ1). The human functioning and school organisation, social capital and social development theories were judged most useful. Ten outcome evaluations were included (RQ2). Four US randomised controlled trials (RCTs) and one UK quasi-experimental study examined interventions building school community/relationships. Studies reported benefits for some, but not all outcomes (e.g. aggression, conflict resolution, emotional health). Two US RCTs assessed interventions empowering students to contribute to modifying food/physical activity environments, reporting benefits for physical activity but not for diet. Three UK quasi-experimental evaluations examined playground improvements, reporting mixed findings, with benefits being greater for younger children and longer break times. Six process evaluations (RQ3) reported positively. One study suggested that implementation was facilitated when this built on existing ethos and when senior staff were supportive. We reviewed 42 multilevel studies, confining narrative synthesis to 10 that appropriately adjusted for confounders. Four UK/US reports suggested that schools with higher value-added attainment/attendance had lower rates of substance use and fighting. Three reports from different countries examined school policies on smoking/alcohol, with mixed results. One US study found that schools with more unobservable/unsupervised places reported increased substance use. Another US study reported that school size, age structure and staffing ratio did not correlate with student drinking. Twenty-one qualitative reports from different countries (RQ5) suggested that disengagement, lack of safety and lack of participation in decisions may predispose students to engage in health risks.

Limitations

We found no evidence regarding health inequalities or cost, and could not undertake meta-analysis.

Conclusions

There is non-definitive evidence for the feasibility and effectiveness of school environment interventions involving community/relationship building, empowering student participation in modifying schools' food/physical activity environments, and playground improvements. Multilevel studies suggest that schools that add value educationally may promote student health. Qualitative studies suggest pathways underlying these effects. This evidence lends broad support to theories of social development, social capital and human functioning and school organisation. Further trials to examine the effects of school environment modifications on student health are recommended.

Funding

The National Institute for Health Research Public Health Research programme.

The effects on student health of interventions modifying the school environment: systematic review

BACKGROUND

Owing to the limited effectiveness of traditional health education curricula in schools, there is increasing interest in interventions aiming to promote young people's health by modifying the school environment. Existing systematic reviews cannot determine whether environmental intervention is effective because they examine interventions combining environmental modifications and traditional health education. This gap is significant because school-environment interventions are complex to implement and may be sidelined in underfunded and attainment-focused school systems without evidence to support such an approach. This systematic review examined the effectiveness of school-environment interventions without health-education components on student health and inequalities.

METHODS

This was a systematic review of experimental/quasi-experimental studies of school-environment interventions. Sixteen databases were searched, eliciting 62 329 references which were screened, with included studies quality assessed, data extracted and narratively synthesised.

RESULTS

Sixteen reports of 10 studies were included, all from the USA and the UK. Five evaluations of interventions aiming to develop a stronger sense of community and/or improve relationships between staff and students suggested potential benefits particularly regarding violence and aggression. Two trials of interventions enabling students to advocate for changes in school catering and physical activity reported benefits for physical activity but not diet. Three evaluations of improvements to school playgrounds offered weak evidence of effects on physical activity.

CONCLUSIONS

School environment interventions show the potential to improve young people's health particularly regarding violence, aggression and physical activity. Further trials are required to provide a stronger and more generalisable evidence base.

A randomised controlled trial and mediation analysis of the 'Healthy Habits', telephone-based dietary intervention for preschool children

Background

Consumption of non-core foods in childhood is associated with excessive weight gain in childhood. Parents play a vital role in establishing healthy diet behaviours in young children. The aim of this study was to assess the effectiveness of a telephone-based intervention in reducing child consumption of non-core foods, and to examine parent and home food environment mediators of change in child consumption.

Methods

The ‘Healthy Habits’ trial utilised a clustered randomised controlled design.

Setting/participants

Parents were recruited from 30 preschools (N = 394 participants, mean age 35.2±5.6 years). Parents randomized to the intervention group received four telephone contacts and print materials. Parents allocated to the control condition receive generic print materials only. Non-core food consumption was assessed using a validated child dietary questionnaire at baseline, 2 and 6 months post recruitment in 2010.

Results

The intervention was effective in reducing child consumption of non-core foods at 2 months (intention to treat analysis: z=-2.83, p<.01), however this effect was not maintained at 6 months. Structural equation modelling using 2 month data indicated that child access to non-core foods in the home and child feeding strategies mediated the effect of the intervention.

Conclusion

The telephone-based intervention shows promise in improving short term dietary behaviour in preschool age children, however further development is needed to sustain the effect in the long-term.

Trial registration

Australian Clinical Trials Registry: ACTRN12609000820202