Clinical testing of transcriptome-wide expression profiles in high-risk localized and metastatic prostate cancer starting androgen deprivation therapy: an ancillary study of the STAMPEDE abiraterone Phase 3 trial

Metastatic and high-risk localized prostate cancer respond to hormone therapy but outcomes vary. Following a pre-specified statistical plan, we used Cox models adjusted for clinical variables to test associations with survival of multi-gene expression-based classifiers from 781 patients randomized to androgen deprivation with or without abiraterone in the STAMPEDE trial. Decipher score was strongly prognostic (p<2×10-5) and identified clinically-relevant differences in absolute benefit, especially for localized cancers. In metastatic disease, classifiers of proliferation, PTEN or TP53 loss and treatment-persistent cells were prognostic. In localized disease, androgen receptor activity was protective whilst interferon signaling (that strongly associated with tumor lymphocyte infiltration) was detrimental. Post-Operative Radiation-Therapy Outcomes Score was prognostic in localized but not metastatic disease (interaction p=0.0001) suggesting the impact of tumor biology on clinical outcome is context-dependent on metastatic state. Transcriptome-wide testing has clinical utility for advanced prostate cancer and identified worse outcomes for localized cancers with tumor-promoting inflammation.

Concurrent validity of an estimator of weekly alcohol consumption (EWAC) based on the extended AUDIT

BACKGROUND AND AIMS

The three-question Alcohol Use Disorders Identification Test (AUDIT-C) is frequently used in healthcare for screening and brief advice about levels of alcohol consumption. AUDIT-C scores (0-12) provide feedback as categories of risk rather than estimates of actual alcohol intake, an important metric for behaviour change. The study aimed to (i) develop a continuous metric from the Extended AUDIT-C expressed in United Kingdom (UK) units (8 g pure ethanol), offering equivalent accuracy, and providing a direct estimator of weekly alcohol consumption (EWAC) and (ii) evaluate the EWAC's bias and error using the graduated-frequency (GF) questionnaire as a reference standard of alcohol consumption.

DESIGN

Cross-sectional diagnostic study based on a nationally-representative survey.

SETTINGS

Community dwelling households in England.

PARTICIPANTS

A total of 22 404 household residents aged ≥16 years reporting drinking alcohol at least occasionally.

MEASUREMENTS

Computer-assisted personal interviews consisting of (i) AUDIT questionnaire with extended response items (the 'Extended AUDIT') and (ii) GF. Primary outcomes were: mean deviation <1 UK unit (metric of bias); root-mean-square deviation <2 UK units (metric of total error) between EWAC and GF. The secondary outcome was the receiver operating characteristic area under the curve for predicting alcohol consumption in excess of 14 and 35 UK units.

FINDINGS

EWAC had a positive bias of 0.2 UK units (95% CI = 0.08, 0.4) compared with GF. Deviations were skewed: whereas the mean error was ±11 UK units/week [9.5, 11.9], in half of participants the deviation between EWAC and GF was between 0 and ±2.1 UK units/week. EWAC predicted consumption in excess of 14 UK units/week with a significantly greater area under the curve (0.918 [0.914, 0.923]) than AUDIT-C (0.870 [0.864, 0.876]) or the full AUDIT (0.854 [0.847, 0.860]).

CONCLUSIONS

A new estimator of weekly alcohol consumption, which uses answers to the Extended AUDIT-C, meets the targeted bias tolerance. It is superior in accuracy to AUDIT-C and the full 10-item AUDIT when predicting consumption thresholds, making it a reliable complement to the Extended AUDIT-C for health promotion interventions.

Incidence, healthcare-seeking behaviours, antibiotic use and natural history of common infection syndromes in England: results from the Bug Watch community cohort study

BACKGROUND

Better information on the typical course and management of acute common infections in the community could inform antibiotic stewardship campaigns. We aimed to investigate the incidence, management, and natural history of a range of infection syndromes (respiratory, gastrointestinal, mouth/dental, skin/soft tissue, urinary tract, and eye).

METHODS

Bug Watch was an online prospective community cohort study of the general population in England (2018-2019) with weekly symptom reporting for 6 months. We combined symptom reports into infection syndromes, calculated incidence rates, described the proportion leading to healthcare-seeking behaviours and antibiotic use, and estimated duration and severity.

RESULTS

The cohort comprised 873 individuals with 23,111 person-weeks follow-up. The mean age was 54 years and 528 (60%) were female. We identified 1422 infection syndromes, comprising 40,590 symptom reports. The incidence of respiratory tract infection syndromes was two per person year; for all other categories it was less than one. 194/1422 (14%) syndromes led to GP (or dentist) consultation and 136/1422 (10%) to antibiotic use. Symptoms usually resolved within a week and the third day was the most severe.

CONCLUSIONS

Most people reported managing their symptoms without medical consultation. Interventions encouraging safe self-management across a range of acute infection syndromes could decrease pressure on primary healthcare services and support targets for reducing antibiotic prescribing.

Complementing chronic frailty assessment at hospital admission with an electronic frailty index (FI-Laboratory) comprising routine blood test results

BACKGROUND

Acutely ill and frail older adults have complex social and health care needs. It is important to understand how this complexity affects acute outcomes for admission to hospital. We validated a frailty index using routine admission laboratory tests with outcomes after patients were admitted to hospital.

METHODS

In a prospective cohort of older adults admitted to a large tertiary hospital in the United Kingdom, we created a frailty index from routine admission laboratory investigations (FI-Laboratory) linked to data comprising hospital outcomes. We evaluated the association between the FI-Laboratory and total days spent in hospital, discharge to a higher level of care, readmission and mortality.

RESULTS

Of 2552 admissions among 1750 older adults, we were able to generate FI-Laboratory values for 2254 admissions (88.3% of the cohort). More than half of admitted patients were women (55.3%) and the mean age was 84.6 (SD 14.0) years. We found that the FI-Laboratory correlated weakly with the Clinical Frailty Scale (CFS; r ² = 0.09). An increase in the CFS and the equivalent of 3 additional abnormal laboratory test results in the FI-Laboratory, respectively, were associated with an increased proportion of inpatient days (rate ratios [RRs] 1.43, 95% confidence interval [CI] 1.35-1.52; and 1.47, 95% CI 1.41-1.54), discharge to a higher level of care (odd ratios [ORs] 1.39, 95% CI 1.27-1.52; and 1.30, 95% CI 1.16-1.47) and increased readmission rate (hazard ratios [HRs] 1.26, 95% CI 1.17-1.37; and 1.18, 95% CI 1.11-1.26). Increases in the CFS and FI-Laboratory were associated with increased mortality HRs of 1.39 (95% CI 1.28-1.51) and 1.45 (95% CI 1.37-1.54), respectively.

INTERPRETATION

We determined that FI-Laboratory, distinct from baseline frailty, could be used to predict risk of many adverse outcomes. The score is therefore a useful way to quantify the degree of acute illness in frail older adults.

An interdisciplinary mixed-methods approach to developing antimicrobial stewardship interventions: Protocol for the Preserving Antibiotics through Safe Stewardship (PASS) Research Programme

Behaviour change is key to combating antimicrobial resistance. Antimicrobial stewardship (AMS) programmes promote and monitor judicious antibiotic use, but there is little consideration of behavioural and social influences when designing interventions.  We outline a programme of research which aims to co-design AMS interventions across healthcare settings, by integrating data-science, evidence- synthesis, behavioural-science and user-centred design. The project includes three work-packages (WP): WP1 (Identifying patterns of prescribing):  analysis of electronic health-records to identify prescribing patterns in care-homes, primary-care, and secondary-care. An online survey will investigate consulting/antibiotic-seeking behaviours in members of the public. WP2 (Barriers and enablers to prescribing in practice): Semi-structured interviews and observations of practice to identify barriers/enablers to prescribing, influences on antibiotic-seeking behaviour and the social/contextual factors underpinning prescribing. Systematic reviews of AMS interventions to identify the components of existing interventions associated with effectiveness. Design workshops to identify constraints influencing the form of the intervention. Interviews conducted with healthcare-professionals in community pharmacies, care-homes, primary-, and secondary-care and with members of the public. Topic guides and analysis based on the Theoretical Domains Framework.  Observations conducted in care-homes, primary and secondary-care with analysis drawing on grounded theory.  Systematic reviews of interventions in each setting will be conducted, and interventions described using the Behaviour Change Technique taxonomy v1. Design workshops in care-homes, primary-, and secondary care. WP3 (Co-production of interventions and dissemination). Findings will be integrated to identify opportunities for interventions, and assess whether existing interventions target influences on antibiotic use. Stakeholder panels will be assembled to co-design and refine interventions in each setting, applying the Affordability, Practicability, Effectiveness, Acceptability, Side-effects and Equity (APEASE) criteria to prioritise candidate interventions.  Outputs will inform development of new AMS interventions and/or optimisation of existing interventions.  We will also develop web-resources for stakeholders providing analyses of antibiotic prescribing patterns, prescribing behaviours, and evidence reviews.

Health Data Linkage for UK Public Interest Research: Key Obstacles and Solutions

INTRODUCTION

Analysis of linked health data can generate important, even life-saving, insights into population health. Yet obstacles both legal and organisational in nature can impede this work.

APPROACH

We focus on three UK infrastructures set up to link and share data for research: the Administrative Data Research Network, NHS Digital, and the Secure Anonymised Information Linkage Databank. Bringing an interdisciplinary perspective, we identify key issues underpinning their challenges and successes in linking health data for research.

RESULTS

We identify examples of uncertainty surrounding legal powers to share and link data, and around data protection obligations, as well as systemic delays and historic public backlash. These issues require updated official guidance on the relevant law, approaches to linkage which are planned for impact and ongoing utility, greater transparency between data providers and researchers, and engagement with the patient population which is both high-profile and carefully considered.

CONCLUSIONS

Health data linkage for research presents varied challenges, to which there can be no single solution. Our recommendations would require action from a number of data providers and regulators to be meaningfully advanced. This illustrates the scale and complexity of the challenge of health data linkage, in the UK and beyond: a challenge which our case studies suggest no single organisation can combat alone. Planned programmes of linkage are critical because they allow time for organisations to address these challenges without adversely affecting the feasibility of individual research projects.

Incidence of First Abortions: Integration of Administrative and Survey Data within a Joint Cohort Life Table Model

IntroductionIntegration of administrative and survey data to address sources of error is a fast-growing area of research. This paper examines the case of abortion, where survey data are susceptible to self-report bias, while administrative data provide crude but comprehensive and relatively unbiased information. Objectives and ApproachAlthough abortion is a common and legal procedure, information is lacking on the proportion of women having one or more abortions during their lifetime. A Bayesian joint cohort life table model estimates age-specific rates of incidence of a first abortion for cohorts of women born between 1936 and 2003 an residing in England and Wales. The model is fitted using (1) waves II and III of the British National Surveys of Sexual Attitudes and Lifestyles (NATSAL) and (2) administrative counts of first ever abortions published by the UK's Office for National Statistics and Department of Health. ResultsModel parameters controlling for underreporting indicate that survey reports are plausible for abortions occurring before the age of 20 years. Beyond that age, the model shows a fast increasing propensity to underreport abortions depending on the age at which they occurred. Underreporting also appears to be higher in NATSAL III. The study produces corrected estimates of the overall lifetime prevalence of an abortion in England and Wales, which is higher than previously thought. Conclusion/ImplicationsJoint modelling of survey and administrative data can provide robust statistics, while reducing the need for record linkage where it is not feasible or acceptable. This approach is relevant in other contexts to correct the bias of particular population datasets, when audit data exist (e.g. underascertained diagnoses/causes of death).

Outcomes of domestic violence screening at an acute London trust: are there missed opportunities for intervention?

OBJECTIVES

Domestic violence screening is advocated in some healthcare settings. Evidence that it increases referral to support agencies or improves health outcomes is limited. This study aimed to (1) investigate the proportion of hospital patients reporting domestic violence, (2) describe characteristics and previous hospital attendances of affected patients and (3) assess referrals to an in-house domestic violence advisor from Camden Safety Net.

DESIGN

A series of observational studies.

SETTING

Three outpatient clinics at the Royal Free London NHS Foundation Trust.

PARTICIPANTS

10,158 patients screened for domestic violence in community gynaecology, genitourinary medicine (GUM) and HIV medicine clinics between 1 October 2013 and 30 June 2014. Also 2253 Camden Safety Net referrals over the same period.

MAIN OUTCOME MEASURES

(1) Percentage reporting domestic violence by age group gender, ethnicity and clinic. (2) Rates of hospital attendances in the past 3 years for those screening positive and negative. (3) Characteristics, uptake and risk assessment results for hospital in-house domestic violence referrals compared with Camden Safety Net referrals from other sources.

RESULTS

Of the 10,158 patients screened, 57.4% were female with a median age of 30 years. Overall, 7.1% reported ever-experiencing domestic violence, ranging from 5.7% in GUM to 29.4% in HIV services. People screening positive for domestic violence had higher rates of previous emergency department attendances (rate ratio (RR) 1.63, 95% CI 1.09 to 2.48), emergency inpatient admissions (RR 2.27, 95% CI 1.37 to 3.84) and day-case admissions (RR 2.03, 95% CI 1.23 to 3.43) than those screening negative. The 77 hospital referrals to the hospital-based domestic violence advisor during the study period were more likely to be taken up and to be classified as high risk than referrals from elsewhere.

CONCLUSIONS

Selective screening for domestic violence in high-risk hospital clinic populations has the potential to identify affected patients and promote good uptake of referrals for in-house domestic violence support.