Codesign and Launch of 'On the Ball': An Inclusive Community-Based 'Testicular Awareness' Campaign

INTRODUCTION

Increased awareness of testicular diseases can lead to early diagnosis. Evidence suggests that men's awareness of testicular diseases is low, with many expressing their willingness to delay help-seeking for symptoms of concern. The risk of testicular diseases is higher in gender and sexual minority groups. In this study, we discuss the codesign, refinement and launch of 'On the Ball', an inclusive community-based 'testicular awareness' campaign.

METHODS

The World Café participatory research methodology was used. Individuals from Lesbian, Gay, Bisexual, Transgender and Queer+ friendly organisations, testicular cancer survivors, policymakers, media/marketing experts and graphic designers were recruited. Participants were handed a brief for 'On the Ball', which was designed based on feedback from a previous World Café workshop. They were assigned to three tables. Participants rotated tables at random for three 20-min rounds of conversations. Each table had a facilitator who focussed on one element of the campaign brief. Data were collected using audio recorders and in writing and were analysed thematically.

RESULTS

Thirteen individuals participated in the workshop. The following themes emerged from the data: (i) campaign identity, (ii) campaign delivery and (iii) campaign impact. Participants recommended enhancements to the campaign logo, slogan, social media posts and poster. They suggested delivering the campaign online via social media and offline using various print and broadcast media. Participants recommended targeting areas with a large number of men such as workplaces. To help measure the impact of the campaign, participants proposed capturing social media analytics and tracking statistics relating to testicular diseases. Recommendations were used to refine the 'On the Ball' campaign and launch it in a university. In total, 411 students engaged with the various elements of the campaign during the soft launch.

CONCLUSIONS

'On the Ball' campaign visuals ought to be inclusive. Online and offline campaign delivery is warranted to reach out to a wider cohort. Campaign impact can be captured using social media analytics as well as measuring clinical outcomes relating to testicular diseases. Future research is needed to implement the campaign online and offline, explore its impact and evaluate its feasibility, acceptability, cost and effect on promoting testicular awareness.

PATIENT OR PUBLIC CONTRIBUTION

The 'On the Ball' campaign was codesigned and refined with members of Lesbian, Gay, Bisexual, Transgender and Queer+ friendly organisations, testicular cancer survivors, health policymakers, media and marketing experts and graphic designers using the World Café participatory research methodology.

Impact of Post Manufacturing Handling of Protein-Based Biologic Drugs on Product Quality and User Centricity

This article evaluates the current gaps around the impact of post-manufacturing processes on the product qualities of protein-based biologics, with a focus on user centricity. It includes the evaluation of the regulatory guidance available, describes a collection of scientific literature and case studies to showcase the impact of post-manufacturing stresses on product and dosing solution quality. It also outlines the complexity of clinical handling and the need for communication, and alignment between drug providers, healthcare professionals, users, and patients. Regulatory agencies provide clear expectations for drug manufacturing processes, however, guidance supporting post-product manufacturing handling is less defined and often misaligned. This is problematic as the pharmaceutical products experience numerous stresses and processes which can potentially impact drug quality, safety and efficacy. This article aims to stimulate discussion amongst pharmaceutical developers, health care providers, device manufacturers, and public researchers to improve these processes. Patients and caregivers' awareness can be achieved by providing relevant educational material on pharmaceutical product handling.

Promoting 'testicular awareness': Co-design of an inclusive campaign using the World Café Methodology

INTRODUCTION

Testicular cancer is the most common cancer in men aged 15-44 years in many countries. Most men with testicular cancer present with a lump. Testicular symptoms are more likely to occur secondary to benign diseases like epididymo-orchitis, a common sexually transmitted infection. Gender and sexual minorities are at an increased risk of testicular diseases and health disparities. The aim of this study was to co-design an inclusive community-based campaign to promote testicular awareness.

METHODS

This study uses the World Café methodology. Participation was sought from Lesbian, Gay, Bisexual, Transgender and Queer+ friendly organisations, testicular cancer survivors, health policy makers, media and marketing experts and graphic designers. Participants engaged in three rounds of conversations to co-design the campaign. Data were collected using drawing sheets, artefact cards, sticky notes, coloured markers and a voice recorder. Deductive thematic analysis was conducted.

RESULTS

Seventeen individuals participated in the study. Six themes emerged from the analysis as follows: (i) online communication; (ii) offline communication; (iii) behavioural targeting and education; (iv) campaign frequency and reach; (v) demographic segmentation; and (vi) campaign identity. The use of social media for campaign delivery featured strongly in all conversations. Participants also recommended offline communication using posters and radio/television advertisements to scale up the campaign and achieve wider reach. Advertisements to overcome embarrassment surrounding testicular health were particularly recommended. Participants emphasised that campaign delivery must be dynamic whilst ensuring that the health-promoting messages are not diluted or lost. They stressed the importance of being inclusive and tailoring the campaign to different age groups, gender identities and sexual orientations.

CONCLUSIONS

Study recommendations will be used to design and deliver the campaign. Future research will be needed to evaluate the feasibility, acceptability, cost and effect of the campaign on promoting testicular awareness and early detection of testicular diseases.

PATIENT OR PUBLIC CONTRIBUTION

A participatory research approach was used to co-design the campaign with members of Lesbian, Gay, Bisexual, Transgender and Queer+ (LGBTQ+) friendly organisations, LGBTQ+ student bodies, LGBTQ+ staff networks, LGBTQ+ sports clubs, men's health organisations, testicular cancer survivors, health policy makers, media and marketing experts and graphic designers.

Association between maternal adiposity measures and infant health outcomes: A systematic review and meta-analysis

Maternal obesity increases risks of adverse fetal and infant outcomes. Guidelines use body mass index to diagnose maternal obesity. Evidence suggests body fat distribution might better predict individual risk, but there is a lack of robust evidence during pregnancy. We explored associations between maternal adiposity and infant health. Searches included six databases, references, citations, and contacting authors. Screening and quality assessment were carried out by two authors independently. Random effects meta-analysis and narrative synthesis were conducted. We included 34 studies (n = 40,143 pregnancies). Meta-analysis showed a significant association between maternal fat-free mass and birthweight (average effect [AE] 18.07 g, 95%CI 12.75, 23.38) but not fat mass (AE 8.76 g, 95%CI -4.84, 22.36). Women with macrosomic infants had higher waist circumference than controls (mean difference 4.93 cm, 95% confidence interval [CI] 1.05, 8.82). There was no significant association between subcutaneous fat and large for gestational age (odds ratio 1.06 95% CI 0.91, 1.25). Waist-to-hip ratio, neck circumference, skinfolds, and visceral fat were significantly associated with several infant outcomes including small for gestational age, preterm delivery, neonatal morbidity, and mortality, although meta-analysis was not possible for these variables. Our findings suggest that some measures of maternal adiposity may be useful for risk prediction of infant outcomes. Individual participant data meta-analysis could overcome some limitations in our ability to pool published data.

P06.01.A Deconvolution of immunotherapy-treated glioblastoma identifies cellular heterogeneity and plasticity at the single-cell level

Background

Glioblastoma is the most aggressive cancer originating in the brain with an average survival of 15 months. One of the characteristics of glioblastoma is the high level of intra-tumour heterogeneity (ITH), but the composition and complexity at the single-cell level is poorly understood. Here, we aimed to assess the effects and consequences of immune checkpoint inhibitor (ICI) on the cellular and molecular heterogeneity of glioblastoma tumours using at the single cell level.

Material and Methods

In collaboration with the phase I trials unit at Rigshospitalet, we performed paired molecular analysis of glioma cells from primary and relapse surgery after ICI treatment. Samples were analysed using single-cell RNA sequencing (scRNA-seq) as well as bulk RNA sequencing and whole exome DNA sequencing.

Results

In an effort to trace cellular lineages we developed and refined methods to a identify copy number changes using scRNA-seq. To this end, we identified clonal and subclonal tumour cell populations in each sample. We found high levels of ITH prior to treatment, both with respect to the glioblastoma subtype enrichment and the cell type-specific gene expression. Using expression-based cell-type classification, we found defined recurrent cell-type populations present at both surgery time points. The immune checkpoint treatment had consequences on the cellular phenotypes and proportions of tumour cells, suggesting a level of plasticity in the neoplastic cells. Moreover, we identified examples of clonal dynamics and sweeps following ICI treatment, pointing to potential treatment response and resistance in these population.

Conclusion

In summary, we pursued single cell-focused analysis of ICI treated glioblastoma patients to study the cellular and molecular heterogeneity within and between glioblastoma patients, which pointed to recurrent patterns of cellular responses following ICI treatment.

Longitudinal phenotyping of maternal antenatal depression in obese pregnant women supports multiple-hit hypothesis for fetal brain development, a secondary analysis of the UPBEAT study

BACKGROUND

Maternal antenatal depression is associated with offspring psychological disorders, but obesity is also widely implicated in maternal depression and neurodevelopment. In pregnant women with obesity we explored interrelationships between antenatal depressive symptom trajectories and multiple exposures implicated in fetal neurodevelopment which could explain these associations, as a prelude to exploring associations with infant mental health.

METHODS

The UK Pregnancies Better Eating and Activity Trial (UPBEAT) recruited multi-ethnic pregnant women with obesity (BMI >= 30kg/m²) between March 2009 and June 2014 from 8 UK sites and 1369 were included to model longitudinal antenatal depressive symptoms from Edinburgh Postnatal Depression Scale (EPDS) scores using Latent Class Growth Analysis. Classes were compared on maternal baseline demography, biomarkers of metabolism, inflammation and placental function, infection, diet and by pregnancy and birth outcomes. Odds ratios, mean differences and 95% Confidence Intervals were calculated using robust auxiliary modelling techniques.

FINDINGS

The chosen model produced four classes: "Not Depressed" (n=575 [42%], "reference"), "Mild" (n=523 [37·5%]), "Moderate" (n=219 [16%]) and "Severe" (n=62 [4·5%]) symptom trajectories. Socio-economic deprivation and ethnic diversity were greater in Severe and Moderate classes. Dietary glycaemic load and saturated fat intake were higher in Severe and Moderate classes (at 17 and 27 weeks). Higher Interleukin-6, glycoprotein acetyls (17 weeks), glucose (34 weeks) and lower placental growth factor (PlGF, 17 and 27 weeks) was found in the Severe class. PlGF was lower in the Moderate class (27 weeks). Infection was least likely in the Not Depressed class across gestation. Risks of preterm birth were associated with Severe depressive symptoms (aOR 3·05[1·11 to 8·36]).

INTERPRETATION

Comprehensive phenotyping exposes important fetal exposures implicated in adverse neurodevelopment, differing by depression class. This study expands substantially on causal models of suboptimal fetal neurodevelopment and offers potential new targets for intervention in obese pregnant women.

FUNDING

JNS was funded by a PhD studentship from the National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London. UPBEAT was supported by the European Union's 7th Framework Programme (FP7/2007-2013), project EarlyNutrition; grant agreement no. 289346 and the National Institute for Health Research (NIHR) (UK) Programme Grants for Applied Research Programme (RP-0407-10452), Medical Research Council UK Project Grant (MR/L002477/1). Support was also provided by the Chief Scientist Office Scotland, Guy's and St Thomas' Charity and Tommy's Charity (Registered charity no. 1060508). LP and SLW are funded by Tommy's Charity.

Association between maternal adiposity measures and adverse maternal outcomes of pregnancy: Systematic review and meta-analysis

Maternal obesity increases pregnancy-related risks. Women with a body mass index (BMI) ≥ 30 kg/m² are considered to be at risk and should receive additional care, although approximately half will have uncomplicated pregnancies. This systematic review aimed to identify early pregnancy measures of adiposity associated with adverse maternal health outcomes. Searches included six databases, reference lists, citations, and contacting authors. Screening and quality assessment were carried out by two authors independently. Random effects meta-analysis and narrative synthesis were conducted. Seventy studies were included with a pooled sample of 89,588 women. Meta-analysis showed significantly increased odds of gestational diabetes mellitus (GDM) with higher waist circumference (WC) categories (1.40, 95% confidence interval [CI] 1.04, 1.88) and per unit increase in WC (1.31, 95% CI 1.03, 1.67). Women with GDM had higher WC than controls (mean difference [MD] 6.18 cm, 95% CI 3.92, 8.44). WC was significantly associated with hypertensive disorders, delivery-related outcomes, metabolic syndrome, and composite pregnancy outcomes. Waist to hip ratio was significantly associated with GDM, hypertensive disorders, and delivery-related outcomes. Fat mass, neck circumference, skinfolds, and visceral fat were significantly associated with adverse outcomes, although limited data were available. Our findings identify the need to explore how useful adiposity measures are at predicting risk in pregnancy, compared with BMI, to direct care to women with the greatest need.

The physical-mental health interface during pregnancy planning

Introduction

The physical and mental health of women prior to conception can have a significant impact on pregnancy and child outcomes. Given the rising burden of non-communicable diseases, the aim of this analysis was to explore the relationship between mental health, physical health and health behaviour in women planning a pregnancy.

Objectives

To investigate the association between indices of physical and mental health in a large population of women in the UK planning a pregnancy.

Methods

Responses to a preconception health digital education tool provided data on the physical and mental health and health behaviour of 131,182 women planning pregnancy. Logistic regression was used to explore associations between mental health and physical health variables. Multiple imputation by chained equations was implemented to handle missing data.

Results

There was evidence for an association between physical and mental health conditions (OR 2.22; 95% CI 2.14, 2.3). There was also an association between having a mental disorder and physical inactivity (OR 1.14; 95% CI 1.11, 1.18), substance misuse (OR 2.4; 95% CI 2.25, 2.55) and less folic acid use (OR 0.89; 95% CI 0.86,0.92).

Conclusions

There is a need for greater integration of physical and mental healthcare for women in the preconception period, which could support women, including those who wish to conceive, to optimise their health during this time.

Disclosure

No significant relationships.

Evaluating Diuretics in Normal Care (EVIDENCE): a feasibility report of a pilot cluster randomised trial of prescribing policy in primary care to compare the effectiveness of thiazide-type diuretics in hypertension

Background

Obtaining evidence on comparative effectiveness and safety of widely prescribed drugs in a timely and cost-effective way is a major challenge for healthcare systems. Here, we describe the feasibility of the Evaluating Diuretics in Normal Care (EVIDENCE) study that compares a thiazide and thiazide-like diuretics for hypertension as an exemplar of a more general framework for efficient generation of such evidence. In 2011, the UK NICE hypertension guideline included a recommendation that thiazide-like diuretics (such as indapamide) be used in preference to thiazide diuretics (such as bendroflumethiazide) for hypertension. There is sparse evidence backing this recommendation, and bendroflumethiazide remains widely used in the UK.

Methods

Patients prescribed indapamide or bendroflumethiazide regularly for hypertension were identified in participating general practices. Allocation of a prescribing policy favouring one of these drugs was then randomly applied to the practice and, where required to comply with the policy, repeat prescriptions switched by pharmacy staff. Patients were informed of the potential switch by letter and given the opportunity to opt out. Practice adherence to the randomised policy was assessed by measuring the amount of policy drug prescribed as a proportion of total combined indapamide and bendroflumethiazide. Routinely collected hospitalisation and death data in the NHS will be used to compare cardiovascular event rates between the two policies.

Results

This pilot recruited 30 primary care practices in five Scottish National Health Service (NHS) Boards. Fifteen practices were randomised to indapamide (2682 patients) and 15 to bendroflumethiazide (3437 patients), a study population of 6119 patients. Prior to randomisation, bendroflumethiazide was prescribed to 78% of patients prescribed either of these drugs. Only 1.6% of patients opted out of the proposed medication switch.

Conclusion

The pilot and subsequent recruitment confirms the methodology is scalable within NHS Scotland for a fully powered larger study; currently, 102 GP practices (> 12,700 patients) are participating in this study. It has the potential to efficiently produce externally valid comparative effectiveness data with minimal disruption to practice staff or patients. Streamlining this pragmatic trial approach has demonstrated the feasibility of a random prescribing policy design framework that can be adapted to other therapeutic areas.

Trial registration

ISRCTN Registry, ISRCTN46635087. Registered on 11 August 2017

Evaluating Diuretics in Normal Care (EVIDENCE): protocol of a cluster randomised controlled equivalence trial of prescribing policy to compare the effectiveness of thiazide-type diuretics in hypertension

INTRODUCTION

Healthcare systems must use treatments that are effective and safe. Regulators licensed many currently used older medications before introducing the stringent evidential requirements imposed on modern treatments. Also, there has been little encouragement to carry out within-class, head-to-head comparisons of licensed medicines. For commonly prescribed drugs, even small differences in effectiveness or safety could have significant public health implications. However, conventional clinical trials that randomise individual subjects are costly and unwieldy. Such trials are also often criticised as having low external validity. We describe an approach to rapidly generate externally valid evidence of comparative safety and effectiveness using the example of two widely used diuretics for the management of hypertension.

METHODS AND ANALYSIS

The EVIDENCE (Evaluating Diuretics in Normal Care) study has a prospective, cluster-randomised, open-label, blinded end-point design. By randomising prescribing policy in primary care practices, the study compares the safety and effectiveness of commonly used diuretics in treating hypertension. Participating practices are randomised 1:1 to a policy of prescribing either indapamide or bendroflumethiazide when clinically indicated. Suitable patients who are not already taking the policy diuretic are switched accordingly. All patients taking the study medications are written to explaining the rationale for changing the prescribing policy and notifying them they can opt-out of any switch. The prescribing policies' effectiveness and safety will be compared using rates of major adverse cardiovascular events (hospitalisation with myocardial infarction, heart failure or stroke or cardiovascular death), routinely collected in national healthcare administrative datasets. The study will seek to recruit 250 practices to provide a study population of approximately 50,000 individuals with a mean follow-up time of two years. A primary intention-to-treat time-to-event analysis will be used to estimate the relative effect of the two policies.

ETHICS AND DISSEMINATION

EVIDENCE has been approved by the East of Scotland Research Ethics Service (17/ES/0016, current approved protocol version 5, 26 August 2021). The results will be disseminated widely in peer reviewed journals, guideline committees, National Health Service (NHS) organisations and patient groups.

TRIAL REGISTRATION

ISRCTN 46635087 . Registered on 11 August 2017 (pre-recruitment).

Cohort profile: the eLIXIR Partnership-a maternity-child data linkage for life course research in South London, UK

PURPOSE

Linked maternity, neonatal and maternal mental health records were created to support research into the early life origins of physical and mental health, in mothers and children. The Early Life Cross Linkage in Research (eLIXIR) Partnership was developed in 2018, generating a repository of real-time, pseudonymised, structured data derived from the electronic health record systems of two acute and one Mental Health Care National Health Service (NHS) Provider in South London. We present early descriptive data for the linkage database and the robust data security and governance structures, and describe the intended expansion of the database from its original development. Additionally, we report details of the accompanying eLIXIR Research Tissue Bank of maternal and neonatal blood samples.

PARTICIPANTS

Descriptive data were generated from the eLIXIR database from 1 October 2018 to 30 June 2019. Over 17 000 electronic patient records were included.

FINDINGS TO DATE

10 207 women accessed antenatal care from the 2 NHS maternity services, with 8405 deliveries (8772 infants). This diverse, inner-city maternity service population was born in over 170 countries with an ethnic profile of 46.1% white, 19.1% black, 7.0% Asian, 4.1% mixed and 4.1% other. Of the 10 207 women, 11.6% had a clinical record in mental health services with 3.0% being treated during their pregnancy. This first data extract included 947 infants treated in the neonatal intensive care unit, of whom 19.1% were postnatal transfers from external healthcare providers.

FUTURE PLANS

Electronic health records provide potentially transformative information for life course research, integrating physical and mental health disorders and outcomes in routine clinical care. The eLIXIR database will grow by ~14 000 new maternity cases annually, in addition to providing child follow-up data. Additional datasets will supplement the current linkage from other local and national resources, including primary care and hospital inpatient data for mothers and their children.

Cluster randomised trials of prescribing policy: an ethical approach to generating drug safety evidence? A discussion of the ethical application of a new research method

For most chronic medical conditions, multiple medications are available and prescribers often have limited evidence about which therapy is likely to be the most effective and safe for an individual patient. As many patients are exposed every day to medicines that may be less effective than available alternatives, this is of public health importance. Cluster randomised trials of prescribing policy offer an opportunity to rapidly obtain evidence of comparative effectiveness and safety. These trials can pose a low risk to patients and cause minimal disruption to usual care. Despite the potential scientific value of this approach, there remain valid concerns about consent, medication switching and the use of routinely collected data in research. We discuss these concerns with reference to an ongoing pilot study (Evaluating Diuretics in Normal Care (EVIDENCE) - a cluster randomised evaluation of hypertension prescribing policy, ISRCTN 46635087, registered 11 August 2017).

313 Caring for Older Persons with Dementia in an Acute Medical Care Setting: An Exploration of Nurses’ Experiences and Perceptions

Background

Presently in Ireland there are 55,000 people with dementia, with figures projected to rise to 130,000 by 2041. In acute hospitals, ensuring the provision of high standard, person-centred care for people with dementia is an essential part of policy and practice development. While nurses are key in implementing safe, effective and evidenced based care it is unclear at this moment what their experiences are, when caring for patients with dementia. It is twelve years since the last study was conducted in Ireland in a purpose-built unit for older patients so will not be reflective of an acute care setting. Therefore, it is timely to gather a current description of nurses’ experiences and perceptions in caring for patients with dementia in an acute care setting.

Methods

A purposeful sample of nine nurses working in an acute medical ward caring for patients with dementia participated in the study. Data was collected using semi-structured interviews, transcribed verbatim and analysed using content analysis.

Results

The findings are current and highlight that nurse’s display immense respect and empathy to patients with dementia and see beyond the dementia to the individuality of the person. This demonstrates positive attitudes towards these patients, despite organisational and environmental constraints. The findings further identify that staffing levels are inadequate and that nurses require specific education on dementia. Furthermore, the organisational culture and environmental design are not conducive for patients with dementia and changes need implementing in line with the Irish National Dementia Strategy and the Dementia Friendly Hospital Design Guideline.

Conclusion

These findings have provided a current view of nurses’ experiences and perceptions of caring for patients with dementia in an acute medical ward and support previous study findings. Strategies are now required to address these issues, with a focus on the six priority action areas from The Irish National Dementia Strategy.

DNA barcoding and real-time PCR detection of Bactrocera xanthodes (Tephritidae: Diptera) complex

Immature fruit fly stages of the family Tephritidae are commonly intercepted on breadfruit from Pacific countries at the New Zealand border but are unable to be identified to the species level using morphological characters. Subsequent molecular identification showed that they belong to Bactrocera xanthodes, which is part of a species complex that includes Bactrocera paraxanthodes, Bactrocera neoxanthodes and an undescribed species. To establish a more reliable molecular identification system for B. xanthodes, a reference database of DNA barcode sequences for the 5'-fragment of COI gene region was constructed for B. xanthodes from Fiji, Samoa and Tonga. To better understand the species complex, B. neoxanthodes from Vanuatu and B. paraxanthodes from New Caledonia were also barcoded. Using the results of this analysis, real-time TaqMan polymerase chain reaction (PCR) assays for the detection of B. xanthodes complex and for the three individual species of the complex were developed and validated. The assay showed high specificity for the target species, with no cross-reaction observed for closely related organisms. Each of the real-time PCR assays is sensitive, detecting the target sequences at concentrations as low as ten copies µl-1 and can be used as either singleplex or multiplex formats. This real-time PCR assay for B. xanthodes has been successfully applied at the borders in New Zealand, leading to the rapid identification of intercepted Tephritidae eggs and larvae. The developed assays will be useful biosecurity tools for rapid detection of species in the B. xanthodes complex worldwide.

Dose Finding Study of a Low Molecular Weight Heparin, Innohep, in Haemodialysis

A pilot investigation was performed with Innohep, a low molecular weight (LMWH) preparation (peak maximum molecular mass 3,000-6,000), to determine possible dose regimens for patients undergoing regular maintenance haemodialysis for chronic renal failure. Results from this study suggested that suppression of macroscopic clot formation and fibrinopeptide A (FPA), a marker of fibrin formation, could be achieved following bolus injections rather than bolus injections and an infusion. On the basis of these preliminary findings, a randomised crossover study was performed in eight patients undergoing regular maintenance haemodialysis for 5-7 h to determine the effective antithrombotic dose of this LMWH. Single i.v. bolus doses of 1,250 AFXa u, 2,500 AFXa u and 5,000 AFXa u (n = 7-8) were compared to an UFH regime of 5,000 iu + 1,500 iu/h. Excessive clot formation in the dialyser bubble trap, necessitating additional UFH to enable completion of a prolonged (up to 7 h) dialysis, was observed in all patients on the 1,250 AFXa u dose (mean duration of dialysis prior to UFH, 3 h) but in a single patient only receiving the other LMWH doses. A dose-related response in the AFXa activity, measured by chromogenic substrate (CS) assay was seen in the three LMWH groups, with levels declining significantly (p <0.05) from 1-7 h. This contrasted with the constant levels maintained during dialysis with UFH. FPA levels were significantly elevated after 2 h following the 1,250 AFXa u bolus and after 4 h following the 2,500 AFXa u bolus. There was no significant difference in FPA levels between the 5,000 AFXa u bolus and UFH. β-thromboglobulin (pTG) levels rose significantly towards the end of dialysis in all LMWH groups and, at 5 h, were significantly increased following the 5,000 AFXa u and 2,500 AFXa u doses when compared to the UFH regime. AFXa levels correlated negatively with FPA levels (r = -0.62; p <0.01). In conclusion, for administration of Innohep, a bolus dose of 2,500 AFXa u would appear to be sufficient for dialyses of short duration (up to 4 h), whilst a 5,000 AFXa u bolus is as effective as UFH for a 6 h dialysis. AFXa activity measured by CS assay is related to inhibition of fibrin formation and can be used for monitoring purposes.

The Anticoagulant Effect of Heparinoid Org 10172 During Haemodialysis: An Objective Assessment

The heparinoid of natural origin Org 10172 has anti-factor Xa activity but minimal anti-thrombin activity, and little effect upon broad spectrum assays such as the KCCT in vitro. Its anticoagulant effects have been compared to those of commercial heparin in 7 patients undergoing haemodialysis for chronic renal failure. Commercial heparin was administered in a dose (5,000 iu bolus + 1,500 iu/hour continuous iv infusion) previously shown to inhibit fibrin formation during haemodialysis. This produced mean anti-factor Xa levels in plasma between 0.7-1.0 iu/ml and largely suppressed fibrin formation for 5 h dialysis measured as mean FPA levels in plasma. Administration of Org 10172 as a bolus of 1,350 anti-factor Xa u or 2,000-2,400 anti-factor Xa u produced plasma anti-factor Xa levels of less than 0.5 u/ml and allowed fibrin clot and FPA generation during dialysis. Org 10172 administered as a bolus dose of 4,000-4,800 anti-factor Xa u produced mean anti-factor Xa levels of greater than 0.5 u/ml, allowed dialysis of 6 patients for 5 h and appreciably suppressed FPA generation during dialysis, with little effect on the KCCT.

It is concluded that the anti-factor Xa activity of Org 10172 may reflect its ability to inhibit fibrin during dialysis and that single bolus injection of Org 10172 may be a useful alternative method of achieving anticoagulation.

Antithrombotic Properties of Dermatan Sulphate (MF 701) in Haemodialysis for Chronic Renal Failure

The therapeutic potential of the glycosaminoglycan (GAG), dermatan sulphate (DS), as an antithrombotic agent in humans has yet to be established. We have performed dose ranging studies of DS to determine its effectiveness as an antithrombotic agent in patients (n = 6–8) undergoing haemodialysis for chronic renal failure. In an initial study, Study 1, i.v. bolus doses of 2–4 mg/kg and 5–6 mg/kg DS were given to patients dialysing with polyacrylonitrile hollow fibre (PAN HF) membranes. In a second crossover study, Study 2, performed using cuprophane hollow fibre (CHF) membranes, i. v. bolus doses of 3 mg/kg and 6 mg/kg DS were compared to a standard unfractionated heparin (UFH) regime that has been shown previously to inhibit fibrin formation. Further infusion studies, Study 3 and Study 4 evaluated the antithrombotic efficacy of an i. v. DS bolus of 3 mg/kg plus an i. v. infusion of DS 0.6 mg kg-1 h-1 and a DS bolus of 5 mg/ kg plus an infusion of 1 mg kg-1 h-1 over 5 h, respectively. These studies were compared to standard UFH regimes in a randomised crossover design. Plasma levels of fibrinopeptide A (FPA) and thrombin-antithrombin (TAT) were used as markers of fibrin formation and thrombin generation during dialysis using both membranes.

The changes in DS concentration following administration of the different doses were similar in Studies 1 and 2. However, the effectiveness of DS as an anticoagulant appeared to depend markedly on the different dialyser types used in the two studies. In Study 1, 13/14 dialyses required additional UFH to complete a normal ~6 h session and DS was unable to prevent thrombin and fibrin formation, as determined by measurement of plasma FPA and TAT. However, some dose related effects were observed in the levels of these markers. Furthermore, DS levels correlated with those of FPA and TAT. In Study 2, increasing doses of DS (3 mg/kg and 6 mg/kg), allowed longer dialysis sessions (mean 4.57 h c.f. 5.25 h), approaching that obtained with UFH regime (5.86 h). FPA and TAT generation were incompletely suppressed by both doses of DS; FPA rose significantly compared to that observed with the UFH regime, while TAT did not. While no significant differences in the activation markers were observed between the two DS doses, DS levels, taken as a whole, showed significant negative correlations with those of FPA and TAT Little effect on the KCCT was seen.

In Study 3, 3/6 patients required additional UFH (mean dialysis duration with DS 4.33 h c. f. 5.67 h with UFH). Mean DS levels were maintained between 35–40 µg/ml. Mean plasma FPA levels were maintained at constant levels throughout dialysis following DS administration but were higher than those observed following the UFH regime. In Study 4 mean DS levels were

Low Molecular Weight Heparin in Haemodialysis for Chronic Renal Failure: Dose Finding Study of CY222

A dose finding study of the very low molecular weight heparin CY222 (MW 2500) in patients (n = 8) with chronic renal failure undergoing dialysis has been carried out to (i) establish an effective dose and (ii) determine the relationship between ex vivo anti-factor Xa levels in plasma and the anticoagulant effect (in vivo suppression of FPA levels). Doses of CY222 were compared to a dose (5000 iu bolus + 1500 iu/hr) of unfractionated heparin (UFH) that has been shown to suppress FPA levels during prolonged (>5 hr) dialysis (Ireland et ah, J Lab Clin Med 103, 643, 1984). CY222 given iv in increasing doses produced a dose related increase in anti-factor Xa levels (measured as Institute Choay u/ml, with CY222 itself as standard) and suppression of FPA levels. When given in its highest dose, 20,000 Institute Choay u bolus + 1500 Institute Choay u/hr, there was little effect upon KCCT, FPA levels were statistically indistinguishable from those of the UFH regime (indicating comparable anticoagulant effect), but anti-factor Xa levels (expressed in Institute Choay u/ ml) were 2-3 times those of UFH (expressed in iu/ml). All samples were also assayed for anti-factor Xa level against the proposed low MW Heparin Standard. Plasma levels of CY222 were then found to be 2.78 times lower, so that the anti-factor Xa levels of CY222 required to produce comparable anticoagulant effect were then indistinguishable from those of UFH. Clinically, doses of CY222 exceeding 10,000 Institute Choay u bolus were effective, although increasing amounts of fibrin were visible in the drip chamber of the dialyser circuit with decreasing dose. These results indicate that CY222 is an effective anticoagulant for haemodialysis that can be monitored by its anti-factor Xa level in plasma (in conjunction with the appropriate standard). For prolonged dialysis a dose of 20,000 Institute Choay u bolus + 1500 Institute Choay u/hr is effective at suppressing fibrin formation, while the maintenance infusion may be unnecessary for short frequent dialyses.

Better guidelines for better care: accounting for multimorbidity in clinical guidelines – structured examination of exemplar guidelines and health economic modelling

Background

Multimorbidity is common but most clinical guidelines focus on single diseases.

Aim

To test the feasibility of new approaches to developing single-disease guidelines to better account for multimorbidity.

Design

Literature-based and economic modelling project focused on areas where multimorbidity makes guideline application problematic.

Methods

(1) Examination of accounting for multimorbidity in three exemplar National Institute for Health and Care Excellence guidelines (type 2 diabetes, depression, heart failure); (2) examination of the applicability of evidence in multimorbidity for the exemplar conditions; (3) exploration of methods for comparing absolute benefit of treatment; (4) incorporation of treatment pay-off time and competing risk of death in an exemplar economic model for long-term preventative treatments with slowly accruing benefit; and (5) development of a discrete event simulation model-based cost-effectiveness analysis for people with both depression and coronary heart disease.

Results

(1) Comorbidity was rarely accounted for in the clinical research questions that framed the development of the exemplar guidelines, and was rarely accounted for in treatment recommendations. Drug–disease interactions were common only for comorbid chronic kidney disease, but potentially serious drug–drug interactions between recommended drugs were common and rarely accounted for in guidelines. (2) For all three conditions, the trials underpinning treatment recommendations largely excluded older, more comorbid and more coprescribed patients. The implications of low applicability varied by condition, with type 2 diabetes having large differences in comorbidity, whereas potentially serious drug–drug interactions were more important for depression. (3) Comparing absolute benefit of treatments for different conditions was shown to be technically feasible, but only if guideline developers are willing to make a number of significant assumptions. (4) The lifetime absolute benefit of statins for primary prevention is highly sensitive to the presence of both the direct treatment disutility of taking a daily tablet and competing risk of death. (5) It was feasible to use a discrete event simulation-based model to represent the relevant care pathways to estimate the relative cost-effectiveness of pharmacological treatments of major depressive disorder in primary care for patients who are also likely to go on and receive treatment for coronary heart disease but the analysis was reliant on eliciting some parameter values from experts, which increases the inherent uncertainty in the results. The key limitation was that real-life use in guideline development was not examined.

Conclusions

Guideline developers could feasibly (1) use epidemiological data characterising the guideline population to inform consideration of applicability and interactions; (2) systematically compare the absolute benefit of long-term preventative treatments to inform decision-making in people with multimorbidity and high treatment burden; and (3) modify the output from economic models used in guideline development to examine time to benefit in terms of the pay-off time and varying competing risk of death from other conditions.

Future work

Further research is needed to optimise presentation of comparative absolute benefit information to clinicians and patients, to evaluate the use of epidemiological and time-to-benefit data in guideline development, to better quantify direct treatment disutility and to better quantify benefit and harm in people with multimorbidity.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Patterns of dairy food intake, body composition and markers of metabolic health in Ireland: results from the National Adult Nutrition Survey

Background:

Studies examining the association between dairy consumption and metabolic health have shown mixed results. This may be due, in part, to the use of different definitions of dairy, and to single types of dairy foods examined in isolation.

Objective:

The objective of the study was to examine associations between dairy food intake and metabolic health, identify patterns of dairy food consumption and determine whether dairy dietary patterns are associated with outcomes of metabolic health, in a cross-sectional survey.

Design:

A 4-day food diary was used to assess food and beverage consumption, including dairy (defined as milk, cheese, yogurt, cream and butter) in free-living, healthy Irish adults aged 18–90 years (n=1500). Fasting blood samples (n=897) were collected, and anthropometric measurements taken. Differences in metabolic health markers across patterns and tertiles of dairy consumption were tested via analysis of covariance. Patterns of dairy food consumption, of different fat contents, were identified using cluster analysis.

Results:

Higher (total) dairy was associated with lower body mass index, %body fat, waist circumference and waist-to-hip ratio (P<0.001), and lower systolic (P=0.02) and diastolic (P<0.001) blood pressure. Similar trends were observed when milk and yogurt intakes were considered separately. Higher cheese consumption was associated with higher C-peptide (P<0.001). Dietary pattern analysis identified three patterns (clusters) of dairy consumption; 'Whole milk', 'Reduced fat milks and yogurt' and 'Butter and cream'. The 'Reduced fat milks and yogurt' cluster had the highest scores on a Healthy Eating Index, and lower-fat and saturated fat intakes, but greater triglyceride levels (P=0.028) and total cholesterol (P=0.015). conclusion: Overall, these results suggest that while milk and yogurt consumption is associated with a favourable body phenotype, the blood lipid profiles are less favourable when eaten as part of a low-fat high-carbohydrate dietary pattern. More research is needed to better understand this association.

Conclusion:

Overall, these results suggest that although milk and yogurt consumption is associated with a favourable body phenotype, the blood lipid profiles are less favourable when eaten as part of a low-fat high-carbohydrate dietary pattern. More research is needed to better understand this association.