Long-term follow-up of a randomized controlled trial of a text-message diabetes self-management support programme, SMS4BG

AIMS

To determine the long-term effectiveness of an individually tailored text-message diabetes self-management support programme, SMS4BG, on glycaemic control at 2 years in adults with diabetes with an HbA_1c concentration > 64 mmol/mol (8%).

METHODS

We conducted a 2-year follow-up of a two-arm, parallel, randomized controlled trial across health services in New Zealand. Participants were English-speaking adults with type 1 or 2 diabetes and with an HbA_1c >64 mmol/mol (8%). In the main trial participants randomized to the intervention group (N=183) received up to 9 months of an automated tailored text-message programme in addition to usual care. Participants in the control group (N=183) received usual care for 9 months. In this follow-up study, 293 (80%) of 366 randomized participants in the main trial were included. The primary outcome measure was change in glycaemic control (HbA_1c ) from baseline to 2 years. Mixed-effect models were used to compare the group differences at 3, 6, 9 and 24 months, adjusted for baseline HbA_1c and stratification factors (health district category, diabetes type and ethnicity).

RESULTS

The decrease in HbA_1c at 2 years was significantly greater in the intervention group [mean (sd) -10 (18) mmol/mol or -0.9 (1.6)%] compared with the control group [mean (sd) -1 (20) mmol/mol or -0.1 (1.8)%], with an adjusted mean difference of -9 mmol/mol (95% CI -14, -5) or -0.8% (95% CI -1.2, -0.4; P<0.0001).

CONCLUSIONS

Improvements in glycaemic control resulting from a text-message diabetes self-management support programme were sustained at 2 years after randomization. These findings support the implementation of SMS4BG in current practice.

Oral propranolol in the treatment of proliferating infantile haemangiomas: British Society for Paediatric Dermatology consensus guidelines

BACKGROUND

Infantile haemangiomas (IH) are the most common vascular tumours of infancy. Despite their frequency and potential complications, there are currently no unified U.K. guidelines for the treatment of IH with propranolol. There are still uncertainties and diverse opinions regarding indications, pretreatment investigations, its use in PHACES (posterior fossa malformations-haemangiomas-arterial anomalies-cardiac defects-eye abnormalities-sternal cleft and supraumbilical raphe) syndrome and cessation of treatment.

OBJECTIVES

To provide unified guidelines for the treatment of IH with propranolol.

METHODS

This study used a modified Delphi technique, which involved an international treatment survey, a systematic evidence review of the literature, a face-to-face multidisciplinary panel meeting and anonymous voting.

RESULTS

The expert panel achieved consensus on 47 statements in eight categories, including indications and contraindications for starting propranolol, pretreatment investigations, starting and target dose, monitoring of adverse effects, the use of propranolol in PHACES syndrome and how to stop treatment.

CONCLUSIONS

These consensus guidelines will help to standardize and simplify the treatment of IH with oral propranolol across the U.K. and assist in clinical decision-making.

Mapping the undergraduate dermatology curriculum: a useful tool towards implementation of national recommendations

BACKGROUND

Despite the high prevalence of skin complaints in primary care and secondary care, dermatology undergraduate (UG) education remains inconsistent across medical schools. The British Association of Dermatologists (BAD) published a revised national UG curriculum in 2016 to guide UK medical schools on the minimum competencies required in dermatology.

AIM

The aim of the study was to determine the alignment of the BAD UG curriculum with the dermatology curriculum of the University of Nottingham School of Medicine.

METHODS

A curriculum mapping study was undertaken with the development of an electronic searchable database tool to map key areas.

RESULTS

Of the 70 intended learning outcomes (ILOs) for dermatology in the medical school, 55 (79%) were mapped to the BAD curriculum, while 14 (20%) required modifications to align them with the BAD ILOs. Two BAD ILOs were unspecified in the current curriculum, and one was deemed redundant.

CONCLUSION

Curriculum mapping is a useful tool to standardize local dermatology ILOs to national recommendations and provides transparency to stakeholders for implementation of the dermatology curriculum.

First measurement of neutrino oscillation parameters using neutrinos and antineutrinos by NOvA

The NOvA experiment has seen a 4.4σ signal of ν[over ¯]_{e} appearance in a 2 GeV ν[over ¯]_{μ} beam at a distance of 810 km. Using 12.33×10^{20} protons on target delivered to the Fermilab NuMI neutrino beamline, the experiment recorded 27 ν[over ¯]_{μ}→ν[over ¯]_{e} candidates with a background of 10.3 and 102 ν[over ¯]_{μ}→ν[over ¯]_{μ} candidates. This new antineutrino data are combined with neutrino data to measure the parameters |Δm_{32}^{2}|=2.48_{-0.06}^{+0.11}×10^{-3}  eV^{2}/c^{4} and sin^{2}θ_{23} in the ranges from (0.53-0.60) and (0.45-0.48) in the normal neutrino mass hierarchy. The data exclude most values near δ_{CP}=π/2 for the inverted mass hierarchy by more than 3σ and favor the normal neutrino mass hierarchy by 1.9σ and θ_{23} values in the upper octant by 1.6σ.

Infective endocarditis: a retrospective cohort study

BACKGROUND

Infective endocarditis (IE) is a potentially life-threatening infection of the heart's endocardial surface. Despite advances in the diagnosis and management of IE, morbidity and mortality remain high.

AIM

To characterize the demographics, bacteriology and outcomes of IE cases presenting to an Irish tertiary referral centre.

DESIGN

Retrospective cohort study.

METHODS

Patients were identified using Hospital Inpatient Enquiry and Clinical Microbiology inpatient consult data, from January 2005 to January 2014. Patients were diagnosed with IE using Modified Duke Criteria. Standard Bayesian statistics were employed for analysis and cases were compared to contemporary international registries.

RESULTS

Two hundred and two patients were diagnosed with IE during this period. Mean age 54 years. Of these, 136 (67%) were native valve endocarditis (NVE), 50 (25%) were prosthetic valve endocarditis (PVE) and 22 (11%) were cardiovascular implantable electronic device-associated endocarditis. Culprit organism was identified in 176 (87.1%) cases and Staphylococcal species were the most common (57.5%). Fifty-nine per cent of NVE required surgery compared to 66% of PVE. Mean mortality rate was 17.3%, with NVE being the lowest (12.5%) and PVE the highest (32%). Increasing age was also associated with increased mortality. Fifty-three (26.2%) patients had embolic complications.

CONCLUSIONS

This Irish cohort exhibited first-world demographic patterns comparable to those published in contemporary international literature. PVE required surgery more often and was associated with higher rates of mortality than NVE. Embolic complications were relatively common and represent important sequelae, especially in the intravenous drug user population. It is also pertinent to aggressively treat older cohorts as they were associated with increased mortality.

Eczema-protective probiotic alters infant gut microbiome functional capacity but not composition: sub-sample analysis from a RCT

Probiotic Lactobacillus rhamnosus HN001 given in early life has been shown to reduce infant eczema risk, but its effect on gut microbiota development has not been quantitatively and functionally examined. The aim of this study was to investigate the impact of early life probiotic exposure on the composition and functional capacity of infant gut microbiota from birth to 2 years considering the effects of age, delivery mode, antibiotics, pets and eczema. We performed shotgun metagenomic sequencing analysis of 650 infant faecal samples, collected at birth, 3, 12, and 24 months, as part of a randomised, controlled, 3-arm trial assessing the effect of L. rhamnosus HN001, Bifidobacterium animalis subsp. lactis HN019 supplementation on eczema development in 474 infants. There was a 50% reduced eczema risk in the HN001 probiotic group compared to placebo. Both mothers (from 35 weeks gestation until 6 months post-partum if breastfeeding) and infants (from birth to 2 years) received either a placebo or one of two probiotics, L. rhamnosus HN001 (6×109 cfu), or B. animalis subsp. lactis HN019 (9×109 cfu). L. rhamnosus HN001 probiotic supplementation was associated with increased overall glycerol-3 phosphate transport capacity and enrichment of L. rhamnosus. There were no other significant changes in infant gut microbiota composition or diversity. Increased capacity to transport glycerol-3-phosphate was positively correlated with relative abundance of L. rhamnosus. Children who developed eczema had gut microbiota with increased capacity for glycosaminoglycan degradation and flagellum assembly but had no significant differences in microbiota composition or diversity. Early life HN001 probiotic use is associated with both increased L. rhamnosus and increased infant gut microbiota functional capacity to transport glycerol-3 phosphate. The mechanistic relationship of such functional alteration in gut microbiota with reduced eczema risk and long-term health merits further investigation.

Factors influencing patient uptake of an exercise referral scheme: a qualitative study

Exercise referral schemes aim to increase physical activity amongst inactive individuals with or at risk of long-term health conditions. Yet many patients referred to these schemes (by health professionals) fail to take up the exercise opportunities on offer. Understanding factors influencing uptake to exercise referral schemes may help improve future attendance. Using the Socio-Ecological Model as a framework, this qualitative study aimed to explore factors influencing uptake to an exercise referral scheme based in the North West of England. Semi-structured interviews were conducted with referred patients (n = 38) about their reasons for referral, interactions with referring health professionals, events following referral and ideas to improve future uptake. Data were analysed thematically and mapped onto the constructs of the Socio-Ecological Model. Factors reported to influence uptake included intrapersonal (past PA experiences, motivation, competing priorities), interpersonal (scheme explanations, support) and organizational influences (scheme promotion, communication between service, cost). Whilst several intrapersonal-level factors influenced patient decisions to uptake the exercise referral scheme, modifiable interpersonal and organizational factors were identified as potential targets for intervention. Recommendations are made for improving awareness of exercise referral schemes and for enhancing communication between referring practitioners, patients and referral scheme staff.

Review of primary and secondary erythromelalgia

Erythromelalgia is a condition characterized by episodic pain, erythema and temperature of the extremities, which is relieved by cooling and aggravated by warming. It is useful to review this topic in light of recent discoveries of the genetic mutations that now define primary erythromelalgia, as opposed to secondary erythromelalgia, which is often associated with underlying medical disorders.

Effect of early probiotic supplementation on childhood cognition, behaviour and mood a randomised, placebo-controlled trial

AIM

To determine whether probiotic supplementation in early life improves neurocognitive outcomes assessed at 11 years of age.

METHODS

A total of 474 children who were born March 2004-Aug 2005 participated in a two-centre randomised placebo-controlled trial of infants at risk of developing allergic disease. Pregnant women were randomised to take Lactobacillus rhamnosus strain HN001, Bifidobacterium animalis subsp. lactis strain HN019 or placebo daily from 35 weeks gestation until six months if breastfeeding, and their infants the same treatment from birth to two years. Intelligence, executive function, attention, depression and anxiety were assessed when the children were 11 years of age.

RESULTS

A total of 342 (72.2%) children were assessed (HN001 n = 109, HN019 n = 118 and placebo n = 115). Overall, there were no significant differences in the neurocognitive outcomes between the treatment groups.

CONCLUSION

HN001 and HN019 given in early life were not associated with neurocognitive outcomes at 11 years of age in this study. However, we cannot exclude that other probiotics may have a beneficial effect. Further clinical trials are indicated.

Who can decide? Prevalence of mental incapacity for treatment decisions in medical and surgical hospital inpatients in Ireland

BACKGROUND

The prevalence of mental incapacity for treatment decisions among medical and surgical hospital inpatients is poorly understood or not known in many countries, including Ireland.

AIM

To assess the prevalence of mental incapacity in hospital inpatients in Ireland.

DESIGN

Cross-sectional observational study of mental incapacity for treatment decisions.

METHODS

We assessed mental capacity in 300 randomly selected hospital inpatients in 2 general hospitals in Dublin (urban) and Portlaoise (rural), in Ireland, using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T).

RESULTS

Mean MacCAT-T score was 14.80 (SD: 8.40) out of a possible maximum of 20 (with a higher score indicating greater mental capacity). Over one quarter of participants (27.7%; n = 83) lacked the mental capacity for treatment decisions; 1.7% (n = 5) had partial capacity and 70.7% (n = 212) had full capacity. Scores for each of the four sub-scales of the MacCAT-T were generally consistent across the four key areas of understanding, appreciation, reasoning and expressing a choice.

CONCLUSIONS

Mental incapacity for treatment decisions is common in medical and surgical hospital inpatients in Ireland. This issue both merits and requires greater attention in clinical practice, research and legislation.

Infliximab is associated with an increased risk of serious infection in patients with psoriasis in the U.K. and Republic of Ireland: results from the British Association of Dermatologists Biologic Interventions Register (BADBIR)

Background

Patients with psoriasis and clinicians are concerned that infliximab may be associated with a risk of serious infections.

Objectives

To compare the risk of serious infections associated with infliximab in patients with chronic plaque psoriasis against a cohort on nonbiologic systemic therapies.

Methods

A prospective cohort study was performed using data from the British Association of Dermatologists Biologic Interventions Register (BADBIR). Infliximab was compared with nonbiologic systemic therapies, inclusive of any exposure to methotrexate, ciclosporin, acitretin, fumaric acid esters, psoralen‐ultraviolet A or hydroxycarbamide. Serious infections were those associated with hospitalization, the use of intravenous antimicrobial therapy and/or those that led to death. Propensity score inverse probability treatment weights were used to adjust for potential confounding from a priori identified covariates. Cox proportional hazards models were calculated to obtain hazard ratios (HRs).

Results

In total, 3843 participants were included for analysis up to October 2016. The incidence rates were significantly higher in the infliximab cohort (47·8 per 1000 person‐years) [95% confidence interval (CI) 35·7–64·0], compared with 14·2 per 1000 person‐years (95% CI 11·5–17·4) in the nonbiologic systemic cohort. Infliximab was associated with an overall increase in the risk of serious infection compared with nonbiologics [adjusted HR (adjHR) 1·95, 95% CI 1·01–3·75] and methotrexate only (adjHR 2·96, 95% CI 1·58–5·57) and a higher risk of serious infection in the first 6 months of therapy (adjHR 3·49, 95% CI 1·14–10·70).

Conclusions

Infliximab is associated with an increased risk of serious infections compared with nonbiologic systemic therapies in patients with psoriasis in the U.K. and the Republic of Ireland.

What's already known about this topic?

Randomized clinical trials are not sufficiently powered to investigate the risk of serious infection in patients with psoriasis who are undergoing treatment with infliximab.

Published observational studies have used different methods to adjust for confounding and different comparators.

Previous studies also lacked the adequate sample size to obtain a precise estimate of the risk of serious infection for infliximab.

What does this study add?

Using methods that better address bias and confounding, our study suggests that infliximab is associated with a higher risk of serious infections compared with nonbiologic systemic therapies in patients with psoriasis.

Patients should be counselled on the risk of serious infection before infliximab is prescribed.

Linked Comment: Puig. Br J Dermatol 2019; 180: 257–258.

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Obesity, underweight and BMI distribution characteristics of children by gross national income and income inequality: results from an international survey

BACKGROUND

Economic wealth and income inequality may impact on childhood BMI distribution by affecting overconsumption of food and sedentary forms of transportation and entertainment across the whole or some of the population.

OBJECTIVES

To determine whether BMI distribution of children differs by gross national income (GNI) per capita and Gini index derived from World Bank data.

METHODS

Secondary analysis of largely self-reported height and weight data from a multi-country, cross-sectional study (ISAAC), of 77,963 children aged 6-7 (from 19 countries) and 205,388 adolescents aged 13-14 (from 36 countries), were used to examine underweight vs obesity prevalence and BMI distribution skewness, median and dispersion.

RESULTS

Children and adolescents from 'lower' GNI countries had higher prevalence of underweight than those from 'higher' GNI countries (6% vs 3%, p = 0.03; 2% vs 1%, p = 0.05 respectively), but the prevalence of obesity was not different (2% vs 5%, p = 0.29; 2% vs 2%, p = 0.66). BMI distribution of participants from 'higher' GNI countries had higher median, without significant difference in skewness or dispersion compared to 'lower' GNI countries (higher medians +1.1 kg/m2 for 6-7 year olds, and + 0.7 kg/m2, +1.2 kg/m2 for 13-14 year old girls and boys respectively). Gini index was not associated with underweight or obesity prevalence in either children or adolescents, nor with any BMI distribution characteristics with one exception. Adolescent girls from higher income inequality countries had a greater median BMI (+0.7 kg/m2) and a less skewed BMI distribution.

CONCLUSIONS

It appears that the obesogenic impact of economic prosperity affects all children similarly. Income inequality may have a gender specific effect affecting BMI distribution in adolescent girls.

The role for cyclic Glycine-Proline, a biological regulator of insulin-like growth factor-1 in pregnancy-related obesity and weight changes

Cyclic Glycine-Proline (cGP) regulates the homeostasis of insulin-like growth factor (IGF)-1 function and cGP/IGF-1 ratio determines IGF-1 bioactivity in vitro and in vivo. Plasma IGF-1 represents largely inactive IGF-1 and weakly associated with human obesity and hypertension. We evaluated the regulatory role for cGP in pregnancy-related obesity and hypertension, and in obesity status between pregnancy and postpartum. Women were recruited in their first pregnancy. A cross-sectional study compared plasma concentration of cGP, IGF-1 and IGF binding protein (IGFBP)-3 in women with obesity and/or hypertension to normal controls 6-year postpartum using UPLC-MS and ELISA. A longitudinal study compared the changes of these peptides from 15-week gestation to 6-year post-partum in the women who remained normal weight, remained obese or changed to obese or to normal respectively. Study 1 is a cross-sectional study. The obese group had lower IGF-1(p = 0.001), higher cGP/IGF-1 ratio (p = 0.0055) and the hypertensive group had lower IGFBP-3 (p = 0.046) and cGP (p = 0.043) than the controls. Study 2 is a longitudinal study. Women with weight loss had increased cGP/IGF-1 ratio (p = 0.0026) and decreased IGFBP-3 (p = 0.0001) compared with women whose weight remained normal. Women with weight gain had lower IGFBP-3 (p less than 0.0001) only. Women who remained obese had increased cGP/IGF-1 ratio (p = 0.006) only. Increase in cGP/IGF-1 ratio is associated with obesity, but not hypertension. Changes of IGFBP-3 and/or cGP/IGF-1 ratio are associated with weight changes. The data suggest the role for cGP in obesity through autocrine regulation of IGF-1.

The Overseas Registration Examination of the General Dental Council

The Overseas Registration Examination is a route to entry to the UK Dentists Register for dentists who have qualified outside the European Economic Area. The role of the examination is to protect the public by ensuring that such dentists meet minimum standards of competence. Candidates invest considerable time and resource in attempting the examination. For these reasons it is essential that the examination is both robust and fair. This paper describes the fundamental principles of assessment underpinning the design of the examination and the steps taken by the General Dental Council's ORE Advisory Group to assure its ongoing quality.

Effect of Lactobacillus rhamnosus HN001 in Pregnancy on Postpartum Symptoms of Depression and Anxiety: A Randomised Double-blind Placebo-controlled Trial

Background

Probiotics may help to prevent symptoms of anxiety and depression through several putative mechanisms.

Objective

The aim of this study was to evaluate the effect of Lactobacillus rhamnosus HN001 (HN001) given in pregnancy and postpartum on symptoms of maternal depression and anxiety in the postpartum period. This was a secondary outcome, the primary outcome being eczema in the offspring at 12 months of age.

Design, Setting, Participants

A randomised, double-blind, placebo-controlled trial of the effect of HN001 on postnatal mood was conducted in 423 women in Auckland and Wellington, New Zealand. Women were recruited at 14–16 weeks gestation.

Intervention

Women were randomised to receive either placebo or HN001 daily from enrolment until 6 months postpartum if breastfeeding.

Outcome Measures

Modified versions of the Edinburgh Postnatal Depression Scale and State Trait Anxiety Inventory were used to assess symptoms of depression and anxiety postpartum.

Trial Registration

Australia NZ Clinical Trials Registry: ACTRN12612000196842.

Findings

423 women were recruited between December 2012 and November 2014. 212 women were randomised to HN001 and 211 to placebo. 380 women (89.8%) completed the questionnaire on psychological outcomes, 193 (91.0%) in the treatment group and 187 (88.6%) in the placebo group. Mothers in the probiotic treatment group reported significantly lower depression scores (HN001 mean = 7·7 (SD = 5·4), placebo 9·0 (6·0); effect size -1·2, (95% CI -2·3, -0·1), p = 0·037) and anxiety scores (HN001 12·0 (4·0), placebo 13·0 (4·0); effect size -1·0 (-1·9, -0·2), p = 0·014) than those in the placebo group. Rates of clinically relevant anxiety on screening (score > 15) were significantly lower in the HN001 treated mothers (OR = 0·44 (0·26, 0·73), p = 0·002).

Interpretation

Women who received HN001 had significantly lower depression and anxiety scores in the postpartum period. This probiotic may be useful for the prevention or treatment of symptoms of depression and anxiety postpartum.

Funding Source

Health Research Council of New Zealand (11/318) and Fonterra Co-operative Group Ltd.

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The microbiome-gut-brain axis may be important for mental health.

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We conducted a study of probiotic supplementation in pregnancy and 6 months after delivery if breastfeeding.

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The probiotic treatment group reported significantly lower depression and anxiety scores than those in the placebo group.

There is mounting evidence from animal studies that the microbiome-gut-brain axis may be important for mental health. Depression and anxiety in pregnancy and after birth affects 10–15% of women, although many are not recognised or treated. We conducted a double-blind placebo-controlled study of probiotic (Lactobacillus rhamnosus HN001) supplementation (from early pregnancy through to 6 months after delivery if breastfeeding) on postnatal symptoms of depression and anxiety in a group (n = 380) of healthy women. Mothers in the probiotic treatment group reported significantly lower depression and anxiety scores than those in the placebo group.

Birth weight and subsequent body mass index in children: an international cross-sectional study

BACKGROUND

The reported association between birth weight and subsequent body mass index (BMI) is conflicting.

OBJECTIVES

To examine the relationship between birth weight and BMI in children aged 6-7 years.

METHODS

Secondary analysis of data from a multi-centre, multi-country, cross-sectional study (International Study of Asthma and Allergies in Childhood (ISAAC) Phase Three). Parents/guardians of children aged 6-7 years completed questionnaires about their children's birth weight, current height and weight and whether their mother smoked in the first year of the child's life. A general linear mixed model was used to determine the association between BMI and birth weight.

RESULTS

A total of 72 111 children (17 countries) were included in the analysis. There was a positive association of birth weight with BMI (for each kg increase in birth weight the BMI at 6-7 increased by 0.47 (SE 0.02) kg/m² ; p < 0.0001) with a clear gradient by birth weight category. There was no statistically significant interaction between birth weight and Gross National Income (GNI).

CONCLUSIONS

There is a positive linear relationship between birth weight and BMI in 6-7 year old children, which is present in both high and low income countries.

Measurement of the Neutrino Mixing Angle θ_{23} in NOvA

This Letter reports new results on muon neutrino disappearance from NOvA, using a 14 kton detector equivalent exposure of 6.05×10^{20} protons on target from the NuMI beam at the Fermi National Accelerator Laboratory. The measurement probes the muon-tau symmetry hypothesis that requires maximal θ_{23} mixing (θ_{23}=π/4). Assuming the normal mass hierarchy, we find Δm_{32}^{2}=(2.67±0.11)×10^{-3}  eV^{2} and sin^{2}θ_{23} at the two statistically degenerate values 0.404_{-0.022}^{+0.030} and 0.624_{-0.030}^{+0.022}, both at the 68% confidence level. Our data disfavor the maximal mixing scenario with 2.6σ significance.