The role of depression in the association between mobilisation timing and live discharge after hip fracture surgery: Secondary analysis of the UK National Hip Fracture Database

PURPOSE

The aim was to compare the probability of discharge after hip fracture surgery conditional on being alive and in hospital between patients mobilised within and beyond 36-hours of surgery across groups defined by depression.

METHODS

Data were taken from the National Hip Fracture Database and included patients 60 years of age or older who underwent hip fracture surgery in England and Wales between 2014 and 2016. The conditional probability of postsurgical live discharge was estimated for patients mobilised early and for patients mobilised late across groups with and without depression. The association between mobilisation timing and the conditional probability of live discharge were also estimated separately through adjusted generalized linear models.

RESULTS

Data were analysed for 116,274 patients. A diagnosis of depression was present in 8.31% patients. In those with depression, 7,412 (76.7%) patients mobilised early. In those without depression, 84,085 (78.9%) patients mobilised early. By day 30 after surgery, the adjusted odds ratio of discharge among those who mobilised early compared to late was 1.79 (95% CI: 1.56-2.05, p<0.001) and 1.92 (95% CI: 1.84-2.00, p<0.001) for those with and without depression, respectively.

CONCLUSION

A similar proportion of patients with depression mobilised early after hip fracture surgery when compared to those without a diagnosis of depression. The association between mobilisation timing and time to live discharge was observed for patients with and without depression.

Associations between air pollutants and blood pressure in an ethnically diverse cohort of adolescents in London, England

Longitudinal evidence on the association between air pollution and blood pressure (BP) in adolescence is scarce. We explored this association in an ethnically diverse cohort of schoolchildren. Sex-stratified, linear random-effects modelling was used to examine how modelled residential exposure to annual average nitrogen dioxide (NO2), particulate matter (PM2.5, PM10) and ozone (O3), measures in μg/m3, associated with blood pressure. Estimates were based on 3,284 adolescents; 80% from ethnic minority groups, recruited from 51 schools, and followed up from 11-13 to 14-16 years old. Ethnic minorities were exposed to higher modelled annual average concentrations of pollution at residential postcode level than their White UK peers. A two-pollutant model (NO2 & PM2.5), adjusted for ethnicity, age, anthropometry, and pubertal status, highlighted associations with systolic, but not diastolic BP. A μg/m3 increase in NO2 was associated with a 0.30 mmHg (95% CI 0.18 to 0.40) decrease in systolic BP for girls and 0.19 mmHg (95% CI 0.07 to 0.31) decrease in systolic BP for boys. In contrast, a 1 μg/m3 increase in PM2.5 was associated with 1.34 mmHg (95% CI 0.85 to 1.82) increase in systolic BP for girls and 0.57 mmHg (95% CI 0.04 to 1.03) increase in systolic BP for boys. Associations did not vary by ethnicity, body size or socio-economic advantage. Associations were robust to adjustments for noise levels and lung function at 11-13 years. In summary, higher ambient levels of NO2 were associated with lower and PM2.5 with higher systolic BP across adolescence, with stronger associations for girls.

1174 THE ROLE OF HIP FRACTURE IN TRAJECTORIES OF DEPRESSIVE SYMPTOMS AMONG OLDER ADULTS: ANALYSIS FROM THE ENGLISH LONGITUDINAL STUDY

Introduction

Older adults experience ‘Late life depression’. Hip fractures may negatively influence trajectories of depressive symptoms in older adults. This study aimed to determine trajectories of depressive symptoms among older adults in England, overall and for those after hip fracture, and identify characteristics defining trajectory membership.

Methods

Analysis of adults aged 60 years or more (n=7,050), including a hip fracture subgroup (n = 384), from the English Longitudinal Study of Ageing. Latent class growth mixture modelling was completed. Depressive symptom prevalence was estimated at baseline. Chi-squared tests were completed to compare baseline characteristics across trajectories.

Results

Three trajectory groups were identified overall and for those with hip fracture: no-, mild-, and moderate-severe- symptoms. The moderate-severe group comprised 13.7% and 7% of participants for overall and hip fracture populations respectively. Overall, the proportion of participants with depressive symptoms were 0.4%, 12.4% and 65.4% for no-, mild-, and moderate-severe- symptom groups, respectively. For the hip fracture subgroup, these proportions were 0.7%, 28.8%, and 85.2%. Depressive symptoms were stable over time, with a weak trend towards increasing severity for the moderate-severe group. Individuals with moderate-severe trajectories were older, more likely to be female, live alone and had worse health outcomes (p &lt; 0.001).

Conclusions

Older adults, and those after hip fracture, follow one of three trajectories of depressive symptoms which are broadly stable over time. The prevalence of depressive symptoms was lower for those with hip fracture however, when present, the symptoms were more severe than the overall population. Results suggest a role of factors including age, gender, and marital status in depressive symptoms trajectories.

Effect of inpatient rehabilitation treatment ingredients on functioning, quality of life, length of stay, discharge destination, and mortality among older adults with unplanned admission: an overview review

BACKGROUND

To synthesise the evidence for the effectiveness of inpatient rehabilitation treatment ingredients (versus any comparison) on functioning, quality of life, length of stay, discharge destination, and mortality among older adults with an unplanned hospital admission.

METHODS

A systematic search of Cochrane Library, MEDLINE, Embase, PsychInfo, PEDro, BASE, and OpenGrey for published and unpublished systematic reviews of inpatient rehabilitation interventions for older adults following an unplanned admission to hospital from database inception to December 2020. Duplicate screening for eligibility, quality assessment, and data extraction including extraction of treatment components and their respective ingredients employing the Treatment Theory framework. Random effects meta-analyses were completed overall and by treatment ingredient. Statistical heterogeneity was assessed with the inconsistency-value (I2).

RESULTS

Systematic reviews (n = 12) of moderate to low quality, including 44 non-overlapping relevant RCTs were included. When incorporated in a rehabilitation intervention, there was a large effect of endurance exercise, early intervention and shaping knowledge on walking endurance after the inpatient stay versus comparison. Early intervention, repeated practice activities, goals and planning, increased medical care and/or discharge planning increased the likelihood of discharge home versus comparison. The evidence for activities of daily living (ADL) was conflicting. Rehabilitation interventions were not effective for functional mobility, strength, or quality of life, or reduce length of stay or mortality. Therefore, we did not explore the potential role of treatment ingredients for these outcomes.

CONCLUSION

Benefits observed were often for subgroups of the older adult population e.g., endurance exercise was effective for endurance in older adults with chronic obstructive pulmonary disease, and early intervention was effective for endurance for those with hip fracture. Future research should determine whether the effectiveness of these treatment ingredients observed in subgroups, are generalisable to older adults more broadly. There is a need for more transparent reporting of intervention components and ingredients according to established frameworks to enable future synthesis and/or replication.

TRIAL REGISTRATION

PROSPERO Registration CRD42018114323 .

The impact of the frequency, duration and type of physiotherapy on discharge after hip fracture surgery: a secondary analysis of UK national linked audit data

Additional physiotherapy in the first postoperative week was associated with fewer days to discharge after hip fracture surgery. A 7-day physiotherapy service in the first postoperative week should be considered as a new key performance indicator in evaluating the quality of care for patients admitted with a hip fracture.

INTRODUCTION

To examine the association between physiotherapy in the first week after hip fracture surgery and discharge from acute hospital.

METHODS

We linked data from the UK Physiotherapy Hip Fracture Sprint Audit to hospital records for 5395 patients with hip fracture in May and June 2017. We estimated the association between the number of days patients received physiotherapy in the first postoperative week; its overall duration (< 2 h, ≥ 2 h; 30-min increment) and type (mobilisation alone, mobilisation and exercise) and the cumulative probability of discharge from acute hospital over 30 days, using proportional odds regression adjusted for confounders and the competing risk of death.

RESULTS

The crude and adjusted odds ratios of discharge were 1.24 (95% CI 1.19-1.30) and 1.26 (95% CI 1.19-1.33) for an additional day of physiotherapy, 1.34 (95% CI 1.18-1.52) and 1.33 (95% CI 1.12-1.57) for ≥ 2 versus < 2 h physiotherapy, and 1.11 (95% CI 1.08-1.15) and 1.10 (95% CI 1.05-1.15) for an additional 30-min of physiotherapy. Physiotherapy type was not associated with discharge.

CONCLUSION

We report an association between physiotherapy and discharge after hip fracture. An average UK hospital admitting 375 patients annually may save 456 bed-days if current provision increased so all patients with hip fracture received physiotherapy on 6-7 days in the first postoperative week. A 7-day physiotherapy service totalling at least 2 h in the first postoperative week may be considered a key performance indicator of acute care quality after hip fracture.

661 PROGNOSTIC FACTORS OF DEPRESSION AFTER HIP FRACTURE SURGERY: SYSTEMATIC REVIEW

Introduction

Patients with hip fracture and depression are less likely to recover. This review aimed to identify prognostic factors of depression up to one year after hip fracture surgery in adults. Secondary aims were to determine whether identified factors are modifiable or non-modifiable and describe proposed underlying mechanisms for their association with depression.

Methods

We searched MEDLINE, Embase, PsychInfo, CINAHL and Web of Science Core Collection databases for published studies as well as grey literature. We did not impose any date, geographical, or language limitations. Two reviewers independently screened studies against predefined eligibility criteria to identify relevant papers. We included observational studies investigating prognostic factors of depression up to one year after surgery in adults surgically managed for non-pathological hip fracture. Two reviewers independently extracted data (Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies, adapted for use with prognostic factors studies Checklist) and completed quality appraisal (using Quality in Prognosis Studies tool).

Results

3,402 studies were identified; 2,915 studies were excluded leaving 13 studies included in this review. 3,769 patients were included across all studies with a mean age ranging from 76.21–81.82 years. A total of 39 prognostic factors were investigated and most studies failed to identify a primary prognostic factor of interest. Most of these factors were patient factors with only a few being process or structure factors.

Conclusion

Various potential prognostic factors of depression after hip fracture were identified however, Methodological quality and heterogeneity between studies limited the certainty of which prognostic factors were the strongest. High-quality research investigating prognostic factors using the same study design, Methodology and measurements is warranted to allow for comparisons of the predictive power of factors. As well as future research into the underlying mechanisms of prognostic factors.

660 PHYSIOTHERAPISTS PERCEPTIONS OF MECHANISMS FOR OBSERVED VARIATION IN PRACTICE DURING EARLY POSTOPERATIVE PHASE AFTER HIP FRACTURE

Objective

To explore physiotherapists’ perceptions of mechanisms to explain observed variation in early postoperative practice after hip fracture surgery demonstrated in a national audit.

Methods

A qualitative semi-structured interview study of 21 physiotherapists working on orthopaedic wards at 7 hospitals with different durations of physiotherapy during a recent audit. Thematic analysis of interviews drawing on Normalisation Process Theory to aid interpretation of findings.

Results

Four themes were identified: achieving protocolised and personalised care; patient and carer engagement; multidisciplinary team engagement across the care continuum; and strategies for service improvement. Most expressed variation from protocol was legitimate when driven by what is deemed clinically appropriate for a given patient. This tailored approach was deemed essential to optimise patient and carer engagement. Participants reported inconsistent degrees of engagement from the multidisciplinary team attributing this to competing workload priorities, interpreting ‘postoperative physiotherapy’ as a single professional activity rather than a care delivery approach, plus lack of integration between hospital and community care. All participants recognised changes needed at both structural and process levels to improve their services.

Conclusion

Physiotherapists highlighted an inherent conflict between their intention to deliver protocolised care while allowing for an individual patient-tailored approach. This conflict has implications for how audit results should be interpreted, how future clinical guidelines are written, and how physiotherapists are trained. Physiotherapists also described additional factors explaining variation in practice which may be addressed through increased engagement of the multidisciplinary team and resources for additional staffing and advanced clinical roles.

Prognostic factors of depression and depressive symptoms after hip fracture surgery: systematic review

Background

Patients with hip fracture and depression are less likely to recover functional ability. This review sought to identify prognostic factors of depression or depressive symptoms up to 1 year after hip fracture surgery in adults. This review also sought to describe proposed underlying mechanisms for their association with depression or depressive symptoms.

Methods

We searched for published (MEDLINE, Embase, PsychInfo, CINAHL and Web of Science Core Collection) and unpublished (OpenGrey, Greynet, BASE, conference proceedings) studies. We did not impose any date, geographical, or language limitations. Screening (Covidence), extraction (Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies, adapted for use with prognostic factors studies Checklist), and quality appraisal (Quality in Prognosis Studies tool) were completed in duplicate. Results were summarised narratively.

Results

In total, 37 prognostic factors were identified from 12 studies included in this review. The quality of the underlying evidence was poor, with all studies at high risk of bias in at least one domain. Most factors did not have a proposed mechanism for the association. Where factors were investigated by more than one study, the evidence was often conflicting.

Conclusion

Due to conflicting and low quality of available evidence it is not possible to make clinical recommendations based on factors prognostic of depression or depressive symptoms after hip fracture. Further high-quality research investigating prognostic factors is warranted to inform future intervention and/or stratified approaches to care after hip fracture.

Trial registration

Prospero registration: CRD42019138690.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02514-1.

500 30-DAY SURVIVAL AND RECOVERY AFTER HIP FRACTURE BY MOBILISATION TIMING AND DEMENTIA: A UK DATABASE STUDY

Introduction

To compare 30-day survival and recovery of prefracture ambulation between patients mobilised early (on the day of or day after surgery) and patients mobilised late (2 days of more after surgery) in England and Wales. To determine whether the presence of dementia influences the association between mobilisation timing and 30-day survival and recovery.

Methods

Secondary analysis of the UK National Hip Fracture Database linked to hospitalisation records for 126,897 patients 60 years or older who underwent surgery for nonpathological first hip fracture in England or Wales between 2014 and 2016. We used logistic regression to regress survival and ambulation recovery at 30-days with respect to mobilisation timing, overall and by dementia, with adjustment for confounding using a propensity score for mobilisation treatment with respect to confounders.

Results

Overall, 99,667 (79%) patients mobilised early. Among those who mobilised early compared to those who mobilised late, the weighted odds ratio of survival was 1.92 (95% CI 1.80–2.05), of recovering outdoor ambulation was 1.25 (95% CI 1.03–1.51), and of recovering indoor ambulation was 1.53 (95% CI 1.32–1.78) by 30 days. Early compared with late mobilisation led to a 3.8% increase in the weighted probability of survival, 22.8% increase in weighted probability of recovering outdoor ambulation and 10.0% increase in the weighted probability of recovering indoor ambulation, by 30-days. Patients with dementia were less likely to mobilise early but increases in survival and ambulation recovery were observed both for those with and without dementia.

Conclusion

Early mobilisation led to increase probability of survival and recovery for patients (with and without dementia) after hip fracture. Early mobilisation should be incorporated as a measured indicator of quality internationally. Reasons for failure to mobilise early should also be captured to inform quality improvement initiatives.

501 DISCHARGE AFTER HIP FRACTURE SURGERY IN RELATION TO MOBILISATION TIMING BY PATIENT CHARACTERISTICS: A NATIONAL DATABASE STUDY

Introduction

Early mobilisation leads to a two-fold increase in the odds of discharge by 30-days compared to late mobilisation. Whether this association varies by identified reasons for delayed mobilisation is unknown.

Methods

Audit data linked to hospitalisation records for patients 60 years or older surgically treated for hip fracture in England/Wales 2014–2016. Adjusted proportional odds regression models tested whether the cumulative incidences of discharge differed for early compared with late mobilisation across subgroups defined by dementia, delirium, hypotension, prefracture ambulation and residence, accounting for competing risk of death.

Results

Overall, 34,253 patients presented with dementia, 9,818 with delirium, and 10,123 with hypotension. Prefracture, 100,983 were ambulant outdoors, 30,834 were ambulant indoors only, 107,144 were admitted from home, and 23,588 from residential care. 10%, 8%, 8%, 12%, and 12% fewer patients with dementia, delirium, hypotension, ambulant indoors only prefracture, or from residential care mobilised early compared to those without dementia, delirium, hypotension, with outdoor ambulation prefracture, or from home. Adjusted odds ratios of discharge by 30-days for early compared with late mobilisation were 1.71 (95% CI 1.62–1.81) for those with dementia, 2.06 (95% CI 1.98–2.15) without dementia, 1.56 (95% CI 1.41–1.73) with delirium, 2.00 (95% CI 1.93–2.07) without delirium, 1.83 (95% CI, 1.66–2.02) with hypotension, 1.95 (95% CI, 1.89–2.02) without hypotension, 2.00 (95% CI 1.92–2.08) with outdoor ambulation prefracture, 1.80 (95% CI 1.70–1.91) with indoor ambulation only prefracture, 2.30 (95% CI 2.19–2.41) from home, and 1.64 (95% CI 1.51–1.77) from residential care.

Conclusion

Irrespective of dementia, delirium, hypotension, prefracture ambulation or residence, early compared to late mobilisation increased the likelihood of discharge by 30-days. Fewer patients with these conditions, poorer prefracture ambulation, or from residential care mobilised early. There is a need reduce this care gap by ensuring sufficient resource to enable all patients to benefit from early mobilisation.

34 Discharge After Hip Fracture Surgery by Mobilisation Timing: Secondary Analysis of the UK National Hip Fracture Database

Background

To maximise the benefits of hip fracture surgery the National Institute for Health and Care Excellence Clinical Guideline recommends mobilisation on the day after hip fracture surgery based a low to moderate quality trial with a small sample size. There is a need to generate additional evidence to support early mobilisation as a new UK Best Practice Tariff (BPT).

Objective

To determine whether mobilisation timing was associated with the cumulative incidence of hospital discharge by 30-days after hip fracture surgery, accounting for potential confounders and the competing risk of in-hospital death.

Method

We examined data for 135,105 patients 60 years or older who underwent surgery for nonpathological first hip fracture between January 2014 and December 2016 in any hospital in England or Wales. We tested whether the cumulative incidences of discharge differed between those mobilised early (within 36 hours of surgery) and those mobilised late accounting for potential confounders and the competing risk of in-hospital death.

Results

106,722 (79%) of patients first mobilised early. The average rate of discharge was 60.1 (95% CI 59.8–60.5) per 1,000 patient days, varying from 65.2 (95% CI 64.8–65.6) among those who mobilised early to 44.5 (95% CI 43.9–45.1) among those who mobilised late, accounting for the competing risk of death. By 30-days postoperatively, the crude and adjusted odds ratios of discharge were 2.26 (95% CI 2.2–2.32) and 1.93 (95% CI 1.86–1.99) respectively among those who first mobilised early compared to those who mobilised late, accounting for the competing risk of death.

Conclusion

Early mobilisation led to a near two fold increase in the adjusted odds of discharge by 30-days postoperatively. We recommend inclusion of mobilisation within 36 hours of surgery as a new UK BPT to help reduce delays to mobilisation currently experienced by one-fifth of patients surgically treated for hip fracture.

Inequity in rehabilitation interventions after hip fracture: a systematic review

OBJECTIVE

to determine the extent to which equity factors contributed to eligibility criteria of trials of rehabilitation interventions after hip fracture. We define equity factors as those that stratify healthcare opportunities and outcomes.

DESIGN

systematic search of MEDLINE, Embase, CINHAL, PEDro, Open Grey, BASE and ClinicalTrials.gov for randomised controlled trials of rehabilitation interventions after hip fracture published between 1 January 2008 and 30 May 2018. Trials not published in English, secondary prevention or new models of service delivery (e.g. orthogeriatric care pathway) were excluded. Duplicate screening for eligibility, risk of bias (Cochrane Risk of Bias Tool) and data extraction (Cochrane's PROGRESS-Plus framework).

RESULTS

twenty-three published, eight protocol, four registered ongoing randomised controlled trials (4,449 participants) were identified. A total of 69 equity factors contributed to eligibility criteria of the 35 trials. For more than 50% of trials, potential participants were excluded based on residency in a nursing home, cognitive impairment, mobility/functional impairment, minimum age and/or non-surgical candidacy. Where reported, this equated to the exclusion of 2,383 out of 8,736 (27.3%) potential participants based on equity factors. Residency in a nursing home and cognitive impairment were the main drivers of these exclusions.

CONCLUSION

the generalisability of trial results to the underlying population of frail older adults is limited. Yet, this is the evidence base underpinning current service design. Future trials should include participants with cognitive impairment and those admitted from nursing homes. For those excluded, an evidence-informed reasoning for the exclusion should be explicitly stated.

PROSPERO

CRD42018085930.

Total disc replacement versus anterior cervical discectomy and fusion: a systematic review with meta-analysis of data from a total of 3160 patients across 14 randomized controlled trials with both short- and medium- to long-term outcomes

Aims

The aim of this study was to determine how the short- and medium- to long-term outcome measures after total disc replacement (TDR) compare with those of anterior cervical discectomy and fusion (ACDF), using a systematic review and meta-analysis.

Patients and Methods

Databases including Medline, Embase, and Scopus were searched. Inclusion criteria involved prospective randomized control trials (RCTs) reporting the surgical treatment of patients with symptomatic degenerative cervical disc disease. Two independent investigators extracted the data. The strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. The primary outcome measures were overall and neurological success, and these were included in the meta-analysis. Standardized patient-reported outcomes, including the incidence of further surgery and adjacent segment disease, were summarized and discussed.

Results

A total of 22 papers published from 14 RCTs were included, representing 3160 patients with follow-up of up to ten years. Meta-analysis indicated that TDR is superior to ACDF at two years and between four and seven years. In the short-term, patients who underwent TDR had better patient-reported outcomes than those who underwent ACDF, but at two years this was typically not significant. Results between four and seven years showed significant differences in Neck Disability Index (NDI), 36-Item Short-Form Health Survey (SF-36) physical component scores, dysphagia, and satisfaction, all favouring TDR. Most trials found significantly less adjacent segment disease after TDR at both two years (short-term) and between four and seven years (medium- to long-term).

Conclusion

TDR is as effective as ACDF and superior for some outcomes. Disc replacement reduces the risk of adjacent segment disease. Continued uncertainty remains about degeneration of the prosthesis. Long-term surveillance of patients who undergo TDR may allow its routine use. Cite this article: Bone Joint J 2018;100-B:991-1001.

Risk of incident cardiovascular events amongst individuals with anxiety and depression: A prospective cohort study in the east London primary care database

BACKGROUND

It is unknown how risk of myocardial infarction and stroke differ for patients with and without anxiety or depression, and whether this risk can be explained by demographics, medication use, cardiovascular risk factors. The aim of this study is to quantify differences in risk of non-fatal MI or stroke among patients with anxiety or depression.

METHODS

Prospective cohort study examining risk of incident MI and stroke between March 2005 and March 2015 for 524,952 patients aged 30 and over from the east London primary care database for patients with anxiety or depression.

RESULTS

Amongst 21,811 individuals with depression at baseline, 1.2% had MI and 0.4% had stroke. Of 22,128 individuals with anxiety at baseline, 1.1% had MI and 0.3% had stroke. Depression was independently associated with both MI and stroke, whereas anxiety was associated with MI only before adjustment for cardiovascular risk factors. Antidepressant use increased risk for MI but not stroke. Mean age at first MI was lower in those with anxiety, while mean age at first stroke was lower in those with depression.

LIMITATIONS

The study was limited to patients currently registered in the database and thus we did not have any patients that died during the course of follow-up.

CONCLUSIONS

Patients with depression have increased risk of cardiovascular events. The finding of no increased cardiovascular risk in those with anxiety after adjusting for cardiovascular risk factors is of clinical importance and highlights that the adequate control of traditional risk factors is the cornerstone of cardiovascular disease prevention. Targeting management of classical cardiovascular risk factors and evaluating the risks of antidepressant prescribing should be prioritized.

Cardiovascular risk factors among patients with schizophrenia, bipolar, depressive, anxiety, and personality disorders

BACKGROUND

The evidence informing the management of cardiovascular risk in patients with psychiatric disorders is weak.

METHODS

This cohort study used data from all patients, aged≥30, registered in 140 primary care practices (n=524,952) in London to estimate the risk of developing diabetes, hypertension, hyperlipidemia, tobacco consumption, obesity, and physical inactivity, between 2005 and 2015, for patients with a previous diagnosis of schizophrenia, depression, anxiety, bipolar or personality disorder. The role of antidepressants, antipsychotics and social deprivation in these associations was also investigated. The age at detection of cardiovascular risk factor was compared between patients with and without psychiatric disorders. Variables, for exposures and outcomes, defined from general practitioners records, were analysed using multivariate regression.

RESULTS

Patients with psychiatric disorders had an increased risk for cardiovascular risk factors, especially diabetes, with hazard ratios: 2.42 (2.20-2.67) to 1.31 (1.25-1.37), hyperlipidemia, with hazard ratios: 1.78 (1.60-1.97) to 1.25 (1.23-1.28), and obesity. Antidepressants, antipsychotics and social deprivation did not change these associations, except for smoking and physical inactivity. Antidepressants were associated with higher risk of diabetes, hypertension and hyperlipidemia. Antipsychotics were associated with a higher risk of diabetes. Antidepressants and antipsychotics were associated with lower risk of other risk factors. Patients with psychiatric conditions have later detection of cardiovascular risk factors. The interpretation of these results should acknowledge the lower rates of detection of risk factors in mentally ill patients.

CONCLUSIONS

Cardiovascular risk factors require special clinical attention among patients with psychiatric disorders. Further research could study the effect of antidepressants and antipsychotics on cardiovascular risk factors.

Randomised clinical trial: A liquid multi-strain probiotic vs. placebo in the irritable bowel syndrome--a 12 week double-blind study

BACKGROUND

The importance of interactions between the host and gut microbiota in the pathogenesis of irritable bowel syndrome (IBS) is becoming increasingly apparent. Probiotics offer a potential new treatment for IBS, but current results are conflicting, largely as a result of poorly designed trials and nonstandardisation of outcome measures.

AIM

To assess the efficacy of a liquid, multi-strain probiotic (Symprove) in IBS.

METHODS

A single-centre, randomised, double-blind, placebo-controlled trial of adult patients with symptomatic IBS. Patients received 12 weeks of treatment with the probiotic or placebo (1 mL/kg/day). The primary efficacy measure was the difference in change in the IBS symptom severity score (IBS-SSS) between probiotic vs. placebo at week 12. Secondary outcome measures included change in the IBS quality of life (IBS-QOL) score and change in the IBS-SSS symptom component scores.

RESULTS

A total of 186 patients were randomised and 152 patients completed the study. The mean change in IBS-SSS was -63.3 probiotic vs. -28.3 placebo. The mean difference in the IBS-SSS was statistically significant [-35.0 (95% CI; -62.03, -7.87); P = 0.01]. There was no significant improvement in the IBS-QOL. No serious adverse events were reported.

CONCLUSIONS

The multi-strain probiotic was associated with a statistically significant improvement in overall symptom severity in patients with IBS, and was well tolerated. These results suggest this probiotic confers benefit in IBS and deserves further investigation (ISRCTN identifier: 77512412).

The long-term outcomes of depression up to 10 years after stroke; the South London Stroke Register

BACKGROUND

Post-stroke depression is a frequent chronic and recurrent problem that starts shortly after stroke and affects patients in the long term. The health outcomes of depression after stroke are unclear.

AIMS

(1) To investigate the associations between depression at 3 months and mortality, stroke recurrence, disability, cognitive impairment, anxiety and quality of life (QoL), up to 5 years post-stroke. (2) To investigate these associations in patients recovering from depression by year 1. (3) To investigate associations between depression at 5 years and these outcomes up to 10 years.

METHODS

Data from the South London Stroke Register (1997-2010) were used. Patients (n at registration=3240) were assessed at stroke onset, 3 months after stroke and annually thereafter. Baseline data included sociodemographics and stroke severity measures. Follow-up assessments included anxiety and depression (Hospital Anxiety and Depression scale), disability, QoL and stroke recurrence. Multivariable regression models adjusted for age, gender, ethnicity, stroke severity and disability were used to investigate the association between depression and outcomes at follow-up.

RESULTS

Depression at 3 months was associated with: increased mortality (HR: 1.27 (1.04 to 1.55)), disability (RRs up to 4.71 (2.96 to 7.48)), anxiety (ORs up to 3.49 (1.71 to 7.12)) and lower QoL (coefficients up to -8.16 (-10.23-6.15)) up to year 5. Recovery from depression by 1 year did not alter these risks to 5 years. Depression in year 5 was associated with anxiety (ORs up to 4.06 (1.92 to 8.58)) and QoL (coefficients up to -11.36 (-14.86 to -7.85)) up to year 10.

CONCLUSIONS

Depression is independently associated with poor health outcomes.

Expression of TGF beta in the placental bed is not altered in sporadic miscarriage

Extravillous trophoblast invasion of uterine stroma and spiral arteries (SA) is essential for normal pregnancy and is reduced in preeclampsia and late miscarriage. The control mechanisms are not understood, but transforming growth factor-beta (TGF-beta) may be a candidate. Placental and placental bed biopsies were obtained from early (8(+0)-12(+6) weeks) euploid miscarriages (n = 10), early aneuploid miscarriages (n = 10), late (13(+0)-19(+6) weeks) euploid miscarriages (n = 10) and controls of the same gestation (n = 20). Frozen sections were immunostained for TGF-beta1, 2 and 3. Immunoreactivity of trophoblast and uterine cell populations was assessed semi-quantitatively. TGF-beta1 immunolocalization was limited to extracellular matrix in cytotrophoblast islands and cytotrophoblast shell, perivascular fibrinoid and interstitial trophoblast and did not differ in miscarriage compared with controls. TGF-beta2 was expressed additionally in endovascular trophoblast and multinucleate trophoblast giant cells. There was no aberrant TGF-beta2 immunolocalization in late miscarriage, but TGF-beta2 immunoreactivity was increased in extracellular matrix in cytotrophoblast islands in early miscarriage. TGF-beta3 was absent from all cell populations. Stromal and extravillous trophoblast TGF-beta2 immunolocalization suggests a more important role in trophoblast invasion than TGF-beta1, but neither isoform was altered in miscarriage. Altered TGF-beta localization is therefore unlikely to play a role in abnormal trophoblast invasion and SA transformation in miscarriage.

Predicting catastrophic decline in mobility among older people

OBJECTIVE

to investigate the associations between chronic health conditions, psychosocial and environmental factors and catastrophic decline in mobility among older people.

DESIGN

longitudinal cohort.

SETTING

national sample living in private households.

PARTICIPANTS

nine hundred and ninety-nine adults aged > or = 65 years at initial interview, of which 786 agreed to take part in a follow-up survey 12 months later, and 531 responded to the questionnaire.

MEASUREMENTS

catastrophic decline in mobility: inability to do any of the three activities of daily living items-walking 400 yards, climbing up and down stairs or steps and getting on a bus-having been capable of independently doing all three one year earlier.

RESULTS

similar annual rates of catastrophic decline were reported for men and women: 4.8 [95% confidence interval (CI) 2.7-8.3] and 4.6% (2.4-8.6), respectively. Strong associations were found between catastrophic decline and age > 70 years, hearing problems and health deterioration, odds ratio (OR) 3.7 (95% CI 1.1-11.8), 2.8 (1.1-7.3) and 4.3 (1.2-14.7), respectively. Poor perceptions of health, loss of control and feeling fearful also appeared to be important: below average summary psychological status, OR 6.5 (1.9-22.3). Inability to do heavy housework, carry heavy shopping or bend to cut own toenails, indicating poor functional reserve capacity, was strongly associated with decline, OR 6.8 (2.2-20.8).

CONCLUSION

psychosocial factors are as strongly associated with catastrophic decline as deterioration in health status. Interventions to reduce the risk of catastrophic decline may require management of psychosocial problems as well as health condition components.

Early embryonic demise: no evidence of abnormal spiral artery transformation or trophoblast invasion

Invasion by extravillous trophoblast of uterine decidua and myometrium and the associated spiral artery 'transformation' are essential for the development of normal pregnancy. Small pilot studies of placental bed and basal plate tissues from miscarriages have suggested that impaired interstitial and endovascular trophoblast invasion may play a role in the pathogenesis of miscarriage. The hypothesis that early miscarriage is associated with reduced extravillous trophoblast invasion and spiral artery transformation was tested in a large series of placental bed biopsies containing decidua and myometrium and at least one spiral artery from early, karyotyped embryonic miscarriages (<or=12 weeks' gestation; n = 50) dated from the last menstrual period and ultrasound scan dated normal pregnancies (n = 78). Frozen sections were immunostained to demonstrate trophoblast (cytokeratin), myometrium and spiral artery medial smooth muscle (desmin), and endothelium (von Willebrand factor). Trophoblast invasion and individual features of spiral artery transformation were assessed histologically in spiral arteries of miscarriages (n = 176) and controls (n = 246) and analysed statistically using a logistic regression model. Trophoblast invasion of uterine tissues and spiral artery transformation did not differ between euploid and aneuploid early miscarriage and also did not differ significantly from normal pregnancy. These findings suggest that failed trophoblast invasion and spiral artery transformation do not have a pivotal role in the pathogenesis of early miscarriage.

Late sporadic miscarriage is associated with abnormalities in spiral artery transformation and trophoblast invasion

Trophoblast invasion of uterine decidua and myometrium, and spiral artery transformation, are essential for the development of normal pregnancy; this process is impaired in pre-eclampsia, fetal growth restriction, and pre-term labour. The hypothesis that late miscarriage is associated with reduced trophoblast invasion and spiral artery transformation was tested in a large series of placental bed biopsies containing decidua and myometrium from late, karyotyped, embryonic miscarriage (>or=13 weeks' gestation; n = 26; n = 96 spiral arteries) and gestationally matched ultrasound-dated normal pregnancies (n = 74; n = 236 spiral arteries). Cryostat sections were immunostained using an avidin-biotin peroxidase technique for cytokeratin, desmin, and von Willebrand factor to detect trophoblast, myometrium, and vascular smooth muscle and endothelium, respectively. Trophoblast invasion and individual features of spiral artery transformation were assessed and analysed using a logistic regression model. Compared with normal pregnancy, myometrial spiral arteries in late miscarriage showed reduced endovascular (4% vs. 31%, p = 0.001) and intramural trophoblast (76% vs. 88%, p = 0.05), and less extensive fibrinoid change (4% vs. 18%, p = 0.01). In contrast, endovascular trophoblast in decidual spiral arteries was increased (40% vs. 66%, p = 0.04). These findings suggest that, in common with pre-eclampsia, late sporadic miscarriage may be associated with reduced trophoblast invasion and inadequate transformation of myometrial spiral arteries.

Risk factors for the development of Clostridium difficile toxin-associated diarrhoea: a pilot study

This study was a pilot investigation of risk factors for the development of Clostridium difficile toxin-associated diarrhoea and in particular the differential influence of antimicrobial agents. The study was a retrospective case-control design conducted at Freeman Hospital, Newcastle upon Tyne. Cases were inpatients with stool positive C. difficile toxin diarrhoea and two controls were drawn for each case matched for age (+/- 5 years) and type of admission (emergency or elective). Using conditional logistic regression analysis, cephalosporins and erythromycin were found to be statistically significantly associated with Clostridium difficile toxin associated-diarrhoea. The results form the basis for designing a larger, prospective study.