School Health Research Network Wales: Development, implementation & contributing to public health policy

The School Health Research Network (SHRN) was launched in Wales in 2013 as a strategic partnership between Cardiff University, Welsh Government, Public Health Wales (part of the National Health Service) and Cancer Research UK (a research-focused charity). SHRN is led by a multidisciplinary team in the Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer) at Cardiff University.

SHRN aims to: 1) provide health and well-being data from a biennial survey for national, regional and local stakeholders, including schools; 2) co-produce school-based health improvement research for Wales; and 3) build capacity for evidence-informed public health policy and practice.

Building on and integrating with HBSC infrastructure, a transdisciplinary complex adaptive systems (T-CAS) approach has been employed to develop SHRN, for a national culture of prevention for school health improvement. The T-CAS approach focuses on key stages and activities within a continuous network cycle to facilitate systems level change. The five key stages involve establishing transdisciplinary strategic partnerships, resource investment and linkage, network development, coproduction activities and reciprocal outputs.

SHRN has successfully established new cross-sector stakeholder partnerships at multiple levels, and embedded network activity within national and local policy. It has established a programme of school engagement activities to secure membership of 212 (100%) secondary schools in Wales and building on HBSC systems and structures has developed a national data infrastructure with the biennial collection of student and school-level health and wellbeing data. SHRN has co-produced scientific evidence and established a new data-led planning system (e.g. 56 research studies co-produced). It has also secured sustainability funding from health and education, while developing research capacity to generate evidence and support professional practice.

P4700Work during treadmill rehabilitation predicts clinical benefit and muscle mitochondrial improvements in intermittent claudication

Background

Supervised exercise training is recommended for intermittent claudication in peripheral artery disease (PAD), but the relationship between work achieved during exercise and clinical outcomes is not well described. As in other training modalities, increased effort measured by cumulative work production is expected to be translate into to positive performance adaptations. In settings of constrained limb blood flow, this relationship is unknown. In addition, the impact of exercise on skeletal muscle oxygen use capacity changes is unknown. Near infrared spectroscopy (NIRS) offers a method of characterizing skeletal muscle mitochondrial adaptations before and after training programs.

Methods

We enrolled subjects (n=17, age 71±8.8 years, 20% female) with PAD and intermittent claudication (ankle brachial index [ABI]=0.76±0.21) in a 12-week supervised training program, randomized to traditional pain-based training strategy versus hypoxia-based training (using NIRS to direct training). Muscle work was calculated based on training performance. NIRS-based determination of mitochondrial capacity and microvascular flow were measured at baseline and after 12 weeks.

Results

Subjects trained for an average of 32.9±5.9 sessions walking at 54.4±13.4 m/min per session. Subjects achieved a mean of average workload of 4767±5112 kilogram force meter (kpm) per session and an aggregate of 148536±148020 kpm for the training program. Baseline pain-free walking time of 2.95±2.10 minutes increased by a mean of 3.74±2.47 minutes. Increase in walking time was proportional to the average work level achieved per session, with a correlating trend to the overall work level performed over 12 weeks (r=0.543, p=0.024). There was no increase in blood flow measured by ABI or limb microcirculation perfusion index over the training period. Skeletal muscle mitochondrial capacity increased over the training period and correlated with the overall work performed (r=0.573, p=0.016).

Figure 1

Conclusions

Treadmill exercise rehabilitation for intermittent claudication may be guided by total dose of exercise and NIRS-based indices of mitochondrial capacity rather than pain-levels achieved or changes in perfusion measures.

Acknowledgement/Funding

American Heart Association

Small Differences in Everyday Hydration Status Influence Mood (P04-134-19)

Objectives

Reviews consistently find that a loss of about 2% of body mass was needed before either athletic or psychological functioning is disrupted. However, although it is usually assumed that the minor changes in hydration status, that occur during normal life, do not impact on performance, experimentally the topic has been virtually ignored. The impact of everyday variations in hydration was therefore examined.

Methods

168 subjects were randomly allocated to drinking water, or not drinking, and in addition consume capsules containing either 300 mg of sodium chloride or a placebo. Subjects were monitored over a three-hour period, during which urine osmolality, loss of body mass and urine production were monitored. Repeatedly subjects reported their mood.

Results

Subjects came having consumed their normal diet, without any restriction on fluid intake: on average 0.5% body mass was lost during the study. The major finding was that the hydration status on arrival had a greater influence, than subsequent fluid intake and changes in osmolality during the study. With ratings of being agreeable rather than hostile, those with lower baseline osmolality who drank water had better mood than if baseline osmolality was high. As another example, the mood of those who did not drink water only declined during the study when baseline osmolality was high rather than low. With measures of being composed rather than anxious, and being confidence rather than unsure, those who had lower baseline osmolality had a better mood, irrespective of whether water was consumed. Thus, baseline osmolality had an impact greater than drink induced changes in osmolality. Traditionally the normal range of urine osmolality has been said to be 200–800 mOsmoles/kg, yet the critical point at which the response to fluid intake changed was 600 mOsmoles/kg: 61% had a baseline osmolality over 600 and 38% over 800 mOsmoles/kg.

Conclusions

Some individuals are in a state of dehydration that adversely influences mood; a state not reversed by acute fluid consumption. The pattern of consumption associated with mild-dehydration and its functional consequences needs to be established.

Funding Sources

There was no funding external other than provided by ** University.

The Immediate Effect of Therapeutic Touch and Deep Touch Pressure on Range of Motion, Interoceptive Accuracy and Heart Rate Variability: A Randomized Controlled Trial With Moderation Analysis

Background: There is paucity in the literature regarding the role of the interoceptive pathway through the insular cortex (IC), as well as heart rate variability (HRV) in relation to Osteopathic Manipulative Therapy (OMT) and deep-touch.

Aims: The present study investigated whether both OMT treatment and deep-touch (a newly hypothesized treatment option) was effective at altering the interoceptive pathway and HRV, whilst OMT was only expected to be effective for increasing Range of Motion (ROM).

Methods: Thirty-five healthy volunteers were randomly allocated into three conditions in a repeated measures crossover design; a control (laying supine on a plinth); deep-touch (head cradling); and an osteopathic mobilization therapeutic technique on the temporomandibular joint (TMJ). Interoceptive accuracy (IAc), HRV, as well as range of motion (ROM) for the TMJ area as well as the cervical spine (Csp) right and left measures were taken pre and post each condition setting.

Results: Significant condition effects emerged from the deep-touch and mobilization interventions for IAc where increases were identified through planned comparisons. For the HRV measure (RMSSD), a significant effect emerged in the deep-touch condition (increase) but not in the mobilization or control conditions. ROM did not increase for any condition. IAc correlated with post-ROM outcomes in many cases and HRV moderated some of these relations.

Conclusion: These results are discussed in the context of clinical practice, where cranial deep-touch maybe an effective treatment and modulator of the parasympathetic nervous systems, as well as the interoceptive system.

We have had a gutful: The need for deprescribing proton pump inhibitors

WHAT IS KNOWN AND OBJECTIVE

Proton pump inhibitor (PPI) prescribing may often be inappropriate and expose patients to a risk of adverse effects, while incurring unnecessary healthcare expenditure. Our objective was to determine PPI usage in Australia since 2002 and review international studies investigating inappropriate PPI prescribing, including those that discussed interventions to address this issue.

METHODS

Australian Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) data were analysed. A narrative literature review relevant to the objective was conducted. Time series analysis was also used to examine the trend of reported PPI appropriate use across the international studies included in this review.

RESULTS AND DISCUSSION

Proton pump inhibitor use in Australia increased between 2002 and 2010 and then gradually decreased. Estimates of the extent of inappropriate use in the international literature had a wide variation (11-84%). There appeared to be little change in the extent of appropriate PPI use reported through 34 international studies from 2000 to 2016. Interventions to address inappropriate use included patient-centred deprescribing, academic detailing, educational programmes and drug safety notifications.

WHAT IS NEW AND CONCLUSION

Proton pump inhibitors continue to be overused worldwide and should be a focus for deprescribing programmes. Ongoing education and awareness campaigns for health professionals and patients, including electronic reminders at the point of prescribing, are strategies that have potential to reduce PPI use in individuals who do not have an evidence-based clinical indication for their long-term use.

'New to me': changing patient understanding of psoriasis and identifying mechanisms of change. The Pso Well® patient materials mixed-methods feasibility study

Background

Psoriasis is an inflammatory long‐term condition involving comorbidities, unhealthy lifestyle and significant life impact. Patients’ understanding of psoriasis is limited and support lacking. The Common‐Sense Model of Self‐Regulation of Health and Illness emphasizes the role of illness and treatment beliefs on coping and self‐management. New ‘Pso Well^®’ patient materials informed by the model, addressed psoriasis as a long‐term condition, medication management and lifestyle behaviours.

Objectives

To investigate whether Pso Well^® materials (i) broaden understanding of psoriasis without increasing anxiety; (ii) are acceptable; and (iii) comprise features that appear to effect change.

Methods

The Revised Illness Perceptions Questionnaire (IPQ‐R modified) and the Hospital Anxiety and Depression Scale (HADS) were administered in patients before and after intervention. Numerical rating scales assessed perceptions of change in understanding and anxiety resulting from engagement with the materials. Qualitative interviews explored acceptability and perceived ‘active ingredients’.

Results

Fifty‐five patients completed pre‐ and postintervention questionnaires (56% female; median age 59 years). Postintervention, a large effect size was indicated in two IPQ‐R domains – illness coherence [t(55) = −3·48, P = 0·001 (two‐tailed), η² = 0·19] and personal control [t(55) = −2·98, P = 0·004 (two‐tailed), η² = 0·14] – and a medium effect in one, treatment control [t(55) = −2·08, P = 0·042 (two‐tailed), η² = 0·08]. HADS scores did not change. For numerical rating scales, 80% of participants reported increased understanding of psoriasis and none reported increased anxiety. Interviews with 19 patients indicated the materials were acceptable and usable. Factors reported to broaden understanding and promote engagement with self‐management included linking of related disease aspects, personally relevant content and high‐quality design.

Conclusions

High‐quality, theory‐based psoriasis materials are acceptable to patients and can improve understanding and sense of control without increasing anxiety.

What's already known about this topic?

Psoriasis is associated with comorbidities, unhealthy lifestyle and significant life impact.

Patients’ understanding of psoriasis is limited, self‐management support is lacking and disengagement from healthcare services is common.

What does this study add?

The new, theory‐informed Pso Well^® patient materials address psoriasis as a long‐term condition; medications management and lifestyle behaviour.

The Pso Well^® patient materials can increase understanding of psoriasis, promote feelings of self‐worth and encourage a desire to engage in self‐management and behaviour change, without increasing anxiety or depression.

What are the clinical implications of this work?

The Pso Well^® patient materials could support clinical consultations by helping patients recognize the remitting–relapsing nature of psoriasis.

This will help to improve understanding of the disease, as well as providing a clearer rationale for treatment adherence and lifestyle behaviour change.

Linked Comment: Prinsen. Br J Dermatol 2017; 177:616–617

Biosimilars for psoriasis: clinical studies to determine similarity

Biosimilars are drugs that are similar, but not identical, to originator biologics. Preclinical analytical studies are required to show similarity on a molecular and structural level, but efficacy and safety studies in humans are essential to determining biosimilarity. In this review, written by members of the International Psoriasis Council, we discuss how biosimilars are evaluated in a clinical setting, with emphasis on extrapolation of indication, interchangeability and optimal clinical trial design.