Increasing access to essential medicines through partnership: experience in developing and delivering chlorhexidine gel for newborn cord care

Sustainable access to essential medicines in low-income and middle-income countries requires innovative cross-sectoral collaboration throughout the lifecycle of a medicine. Partnerships are essential to address the systemic challenges of global health and health inequity. Pharmaceutical companies, funders, governments, international non-governmental organisations (I-NGOs) and other key stakeholders can leverage, through effective partnership working, their unique expertise to help drive innovation and share learnings and risks. Here, we reflect on one approach taken in the development and supply of chlorhexidine digluconate 7.1% w/w gel (equivalent to 4% w/w chlorhexidine) for neonatal cord care. We describe and analyse the steps taken by GSK to increase access to chlorhexidine gel, including partnering with the I-NGO Save the Children in Western Kenya. Learning points gained along the journey are shared, together with subsequent steps taken to increase access, with the aim of making recommendations that may be applicable to similar enterprises in the future.

Prevalence and correlates of suicidal ideation in World Trade Center responders: Results from a population-based health monitoring cohort

BACKGROUND

Suicidal ideation (SI) is an early risk factor for suicide among disaster responders. To date, however, no known study has examined the prevalence, and pre-, peri-, and post-disaster risk correlates of SI in World Trade Center (WTC) responders, one of the largest disaster response populations in U.S.

METHODS

The prevalence, and pre-, peri- and post-event correlates of SI were assessed in a population-based health monitoring cohort of 14,314 police responders and 16,389 non-traditional responders (e.g., construction workers) who engaged in response, recovery, and clean-up efforts following the 9/11/2001 terrorist attacks on the WTC. Multivariable analyses were conducted to identify correlates and individual psychiatric symptoms associated with SI in each group.

RESULTS

A total 12.5% of non-traditional and 2.2% of police WTC responders reported SI. Depression, functional impairment, alcohol use problems, and lower family support while working at the WTC site were associated with SI in both groups of responders. Symptom-level analyses revealed that three symptoms accounted for approximately half of the variance in SI for both groups-feeling bad about oneself, or that one has let down oneself or family; feeling down, depressed, or hopeless; and sense of foreshortened future (44.7% in non-traditional and 71% in police).

LIMITATIONS

Use of self-report measures and potentially limited generalizability.

CONCLUSIONS

SI is prevalent in WTC disaster responders, particularly non-traditional responders. Post-9/11 psychiatric symptoms reflecting guilt, shame, hopelessness, and associated functional impairment are most strongly linked to SI, suggesting that interventions targeting these factors may help mitigate suicide risk in this population.

Blood pressure interactions with the DASH dietary pattern, sodium, and potassium: The International Study of Macro-/Micronutrients and Blood Pressure (INTERMAP)

BACKGROUND

Adherence to the Dietary Approaches to Stop Hypertension (DASH) diet enhances potassium intake and reduces sodium intake and blood pressure (BP), but the underlying metabolic pathways are unclear.

OBJECTIVES

Among free-living populations, we delineated metabolic signatures associated with the DASH diet adherence, 24-hour urinary sodium and potassium excretions, and the potential metabolic pathways involved.

METHODS

We used 24-hour urinary metabolic profiling by proton nuclear magnetic resonance spectroscopy to characterize the metabolic signatures associated with the DASH dietary pattern score (DASH score) and 24-hour excretion of sodium and potassium among participants in the United States (n = 2164) and United Kingdom (n = 496) enrolled in the International Study of Macro- and Micronutrients and Blood Pressure (INTERMAP). Multiple linear regression and cross-tabulation analyses were used to investigate the DASH-BP relation and its modulation by sodium and potassium. Potential pathways associated with DASH adherence, sodium and potassium excretion, and BP were identified using mediation analyses and metabolic reaction networks.

RESULTS

Adherence to the DASH diet was associated with urinary potassium excretion (correlation coefficient, r = 0.42; P < 0.0001). In multivariable regression analyses, a 5-point higher DASH score (range, 7 to 35) was associated with a lower systolic BP by 1.35 mmHg (95% CI, -1.95 to -0.80 mmHg; P = 1.2 × 10-5); control of the model for potassium but not sodium attenuated the DASH-BP relation. Two common metabolites (hippurate and citrate) mediated the potassium-BP and DASH-BP relationships, while 5 metabolites (succinate, alanine, S-methyl cysteine sulfoxide, 4-hydroxyhippurate, and phenylacetylglutamine) were found to be specific to the DASH-BP relation.

CONCLUSIONS

Greater adherence to the DASH diet is associated with lower BP and higher potassium intake across levels of sodium intake. The DASH diet recommends greater intake of fruits, vegetables, and other potassium-rich foods that may replace sodium-rich processed foods and thereby influence BP through overlapping metabolic pathways. Possible DASH-specific pathways are speculated but confirmation requires further study. INTERMAP is registered as NCT00005271 at www.clinicaltrials.gov.

Towards targeted dietary support for shift workers with type 2 diabetes (Shift-Diabetes study): A mixed-methods case study protocol

BACKGROUND

Blood glucose is higher in people working night shifts compared to day workers. Changes to eating behaviour, activity and sleep patterns in addition to circadian disruption are likely to impact glucose management in night-shift workers with type 2 diabetes.

AIM

To investigate current dietary intake and glucose variability during night work, including barriers and facilitators to dietary behaviour in this context.

METHODS

A mixed-methods case study will be conducted. Shift workers with type 2 diabetes working in a hospital setting will be recruited to this two-part study. Part 1: 70 participants will complete a 10-day observational study collecting data on continuous glucose, diet (self-report diary), sleep and physical activity during a period covering night work, rest days and non-night workdays. Mean glucose concentration and variability, and the mean healthy diet index score, will be compared between days of night work, non-night work and rest, after adjusting for other individual factors (sleep/physical activity/demographics). Part 2: A sample (n~13) will complete semi-structured interviews based on behavioural science frameworks to explore barriers/enablers to dietary behaviour when working night shifts. This will inform a quantitative survey to explore the generalisability of interview findings.

DISCUSSION

Findings from Part 1 and 2 will be triangulated to identify potential intervention strategies to address key barriers and enablers to healthier eating, and in turn improved glucose control, in shift workers with type 2 diabetes. This will be facilitated through stakeholder consultation and application of behavioural science frameworks. Shift-Diabetes study registration: ISRCTN11764942.

Characterisation, procedures and heritability of acute dietary intake in the Twins UK cohort: an observational study

BACKGROUND

Estimated food records (EFR) are a common dietary assessment method. This investigation aimed to; (1) define the reporting quality of the EFR, (2) characterise acute dietary intake and eating behaviours, (3) describe diet heritability.

METHODS

A total of 1974 one-day EFR were collected from 1858 participants in the TwinsUK cohort between 2012 and 2017. EFR were assessed using a six-point scoring system to determine reporting quality. The frequency and co-occurrence of food items was examined using word clouds and co-occurrence networks. The impact of eating behaviours on weight, BMI and nutrient intake were explored using mixed-effect linear regression models. Finally, diet heritability was estimated using ACE modelling.

RESULTS

We observed that 75% of EFR are of acceptable reporting quality (score > 5). Black tea and semi-skimmed milk were the most consumed items, on an individual basis (respectively 8.27, 6.25%) and paired (0.21%) as co-occurring items. Breakfast consumption had a significantly (p = 5.99 × 10- 7) greater impact on energy (kcal) (mean 1874.67 (±SD 532.42)) than skipping breakfast (1700.45 (±SD 620.98)), however only length of eating window was significantly associated with body weight (kg) (effect size 0.21 (±SD 0.10), p = 0.05) and BMI (effect size 0.08 (±SD 0.04), p = 0.04) after adjustment for relevant covariates. Lastly, we reported that both length of eating window (h2 = 33%, CI 0.24; 0.41), and breakfast consumption (h2 = 11%, CI 0.02; 0.21) were weakly heritable.

CONCLUSIONS

EFR describing acute dietary intake allow for eating behaviour characterisation and can supplement habitual diet intake assessments. Novel findings of heritability warrant further investigation.

Mechanisms of uptake and transport of particulate formulations in the small intestine

Micro- and nano-scale particulate formulations are widely investigated towards improving the oral bioavailability of both biologics and drugs with low solubility and/or low intestinal permeability. Particulate formulations harnessing physiological intestinal transport pathways have recently yielded remarkably high oral bioavailabilities, illustrating the need for better understanding the specific pathways underpinning particle small intestinal absorption and the relative role of intestinal cells. Mechanistic knowledge has been hampered by the well acknowledged limitations of current in vitro, in vivo and ex vivo models relevant to the human intestinal physiology and the lack of standardization in studies reporting absorption data. Here we review the relevant literature and critically discusses absorption pathways with a focus on the role of specific intestinal epithelial and immune cells. We conclude that while Microfold (M) cells are a valid target for oral vaccines, enterocytes play a greater role in the systemic bioavailability of orally administrated particulate formulations, particularly within the sub-micron size range. We also comment on less-reported mechanisms such as paracellular permeability of particles, persorption due to cell damage and uptake by migratory immune cells.

Body mass index mediates the effect of the DASH diet on hypertension: Common metabolites underlying the association

BACKGROUND

The Dietary Approaches to Stop Hypertension (DASH) diet is beneficial in reducing blood pressure; however, this may be a consequence of concurrent weight reduction. In the present study, we investigated whether body mass index (BMI) mediates the association between the DASH diet and hypertension and investigate common metabolic pathways.

METHODS

We included 2424 females from the cross-sectional TwinsUK cohort, with blood pressure, BMI and dietary intake measured within 1.01 (SD = 0.68) years and serum metabolomics profiling (591 metabolites). We constructed a mediation model to test the mediation effects of BMI on the total effect of the DASH diet on hypertension. To identify a metabolite panel associated with the DASH diet and BMI, we built random forest models for each trait, and selected the common metabolic contributors using five-fold cross-validation error.

RESULTS

We found that BMI fully mediates the association between the DASH diet and hypertension, explaining 39.1% of the variance in hypertension. We then identified a panel of six common metabolites predicting both the DASH diet and BMI with opposing effects. Interestingly, at the univariate level, the metabolites were also associated with hypertension in the same direction as BMI. The strongest feature, 1-nonadecanoyl-GPC (19:0), was positively associated with the DASH diet (β [SE] = 0.65 [0.12]) and negatively with BMI (β [SE] = -1.34 [0.12]) and hypertension (odds ratio = 0.71, 95% confidence interval = 0.6-0.84).

CONCLUSIONS

We highlight the role of BMI in the mechanisms by which the DASH diet influences hypertension and also highlight common metabolic pathways. Further studies should investigate the underlying molecular mechanisms to increase our understanding of the beneficial ways of treating hypertension.

Diet and lifestyle behaviour disruption related to the pandemic was varied and bidirectional among US and UK adults participating in the ZOE COVID Study

Evidence of the impact of the COVID-19 pandemic on health behaviours in the general population is limited. In this retrospective longitudinal study including UK and US participants, we collected diet and lifestyle data pre-pandemic (896,286) and peri-pandemic (291,871) using a mobile health app, and we computed a bidirectional health behaviour disruption index. Disruption of health behaviour was higher in younger, female and socio-economically deprived participants. Loss in body weight was greater in highly disrupted individuals than in those with low disruption. There were large inter-individual changes observed in 46 health and diet behaviours measured peri-pandemic compared with pre-pandemic, but no mean change in the total population. Individuals most adherent to less healthy pre-pandemic health behaviours improved their diet quality and weight compared with those reporting healthier pre-pandemic behaviours, irrespective of relative deprivation; therefore, for a proportion of the population, the pandemic may have provided an impetus to improve health behaviours. Public policies to tackle health inequalities widened by the pandemic should continue to prioritize diet and physical activity for all, as well as more targeted approaches to support younger females and those living in economically deprived areas.

Association between egg intake and blood pressure in the USA: the INTERnational study on MAcro/micronutrients and blood Pressure (INTERMAP)

OBJECTIVES

To investigate associations of egg intake with blood pressure (BP) and the role of dietary variables and other macro- and micro-nutrients in the association.

DESIGN

We used cross-sectional data for the USA as part of the INTERnational study on MAcro/micronutrients and blood Pressure (INTERMAP). INTERMAP was surveyed between 1996 and 1999, including four 24-h dietary recalls, two 24-h urine collections and eight measurements of systolic BP and diastolic BP (SBP, DBP). Average egg intake (g/d) was calculated. Multivariable linear regression models were used to estimate the association between egg intake (per each 50 g/d or per quintile) and BP. The roles of dietary variables and other macro- and micro-nutrients in this association were also investigated.

SETTING

In the USA.

PARTICIPANTS

In total, 2195 US INTERMAP men and women aged 40-59 years.

RESULTS

Participants were 50 % female, 54 % non-Hispanic White and 16 % non-Hispanic Black. Mean egg intake (sd) in men and women was 30·4(29·8) and 21·6(20·5) g/d, respectively. Adjusting for demographics, socio-economics, lifestyle and urinary Na:K excretion ratios, we found non-linear associations with BP in non-obese women (P-quadratic terms: 0·004 for SBP and 0·035 for DBP).The associations remained after adjusting for dietary variables, macro/micro nutrients or minerals. Dietary cholesterol was highly correlated with egg intake and may factor in the association. No association was found in obese women and in obese or non-obese men.

CONCLUSION

Egg intake was non-linearly associated with SBP and DBP in non-obese women, but not in obese women or men. Underlying mechanisms require additional study regarding the role of obesity and sex.

Improving the Dietary Intake of Healthcare Workers Through Workplace Dietary Interventions: A Systematic Review and Meta-Analysis

The workplace has been identified as a potential location for dietary intervention delivery due to the amount of time spent and the meals eaten in this setting. It is recommended that interventions are tailored to specific occupational groups, and to date, there is limited synthesis of the evidence relating to healthcare workers. This review characterises and evaluates the effectiveness of dietary interventions in healthcare workers to aid the design and implementation of interventions. The MEDLINE database was searched to September 2020. The reference list of an umbrella review was hand searched for additional titles against inclusion criteria. The search included i) population, ii) intervention and iii) work environment. Studies were assessed for risk of bias. Harvest plots and Forest plots were created to display study quality, direction and size of effect of selected primary (energy, fruit and vegetable and fat intake) and secondary outcomes (weight, body mass index, blood pressure and serum cholesterol levels). Thirty-nine articles assessing thirty-four interventions were eligible for inclusion. Intervention types most commonly used were environmental, educational, educational plus behavioural, and behavioural. Due to the heterogeneity in study design and intervention type, results were largely inconclusive. For dietary outcomes, interventions produced small-moderate favorable changes in fruit, vegetable and fat intake. Decreased fat intake was mainly observed in environmental interventions and increases in fruit and vegetable intake were observed when an educational or/and behavioral component was present. Interventions producing weight loss were mostly non-randomised trials involving education and physical activity. Total and low-density lipoprotein cholesterol decreased in interventions involving physical activity. Meta-analyses revealed significant decreases in energy intake, weight, blood pressure, total cholesterol, and LDL cholesterol in non-randomised trials where data were available. Much more research is needed into strategies to promote diet quality improvement in healthcare workers. Statement of significance: It is recommended that workplace dietary interventions are tailored to specific occupational groups. To our knowledge, this is the first review to examine the effects of dietary workplace interventions in healthcare professionals. Small-moderate favourable changes in fruit and vegetable intake can be achieved when an educational or/and behavioural component is included in the intervention. For weight loss, interventions involving nutrition education and physical activity in addition to a dietary component show benefit. In the studies reviewed, a high level of heterogeneity was evident and insufficient information reported to ascertain potential bias.

Diet quality and risk and severity of COVID-19: a prospective cohort study

OBJECTIVE

Poor metabolic health and unhealthy lifestyle factors have been associated with risk and severity of COVID-19, but data for diet are lacking. We aimed to investigate the association of diet quality with risk and severity of COVID-19 and its interaction with socioeconomic deprivation.

DESIGN

We used data from 592 571 participants of the smartphone-based COVID-19 Symptom Study. Diet information was collected for the prepandemic period using a short food frequency questionnaire, and diet quality was assessed using a healthful Plant-Based Diet Score, which emphasises healthy plant foods such as fruits or vegetables. Multivariable Cox models were fitted to calculate HRs and 95% CIs for COVID-19 risk and severity defined using a validated symptom-based algorithm or hospitalisation with oxygen support, respectively.

RESULTS

Over 3 886 274 person-months of follow-up, 31 815 COVID-19 cases were documented. Compared with individuals in the lowest quartile of the diet score, high diet quality was associated with lower risk of COVID-19 (HR 0.91; 95% CI 0.88 to 0.94) and severe COVID-19 (HR 0.59; 95% CI 0.47 to 0.74). The joint association of low diet quality and increased deprivation on COVID-19 risk was higher than the sum of the risk associated with each factor alone (Pinteraction=0.005). The corresponding absolute excess rate per 10 000 person/months for lowest vs highest quartile of diet score was 22.5 (95% CI 18.8 to 26.3) among persons living in areas with low deprivation and 40.8 (95% CI 31.7 to 49.8) among persons living in areas with high deprivation.

CONCLUSIONS

A diet characterised by healthy plant-based foods was associated with lower risk and severity of COVID-19. This association may be particularly evident among individuals living in areas with higher socioeconomic deprivation.

Differential associations between a priori diet quality scores and markers of cardiovascular health in women: cross-sectional analyses from TwinsUK

CVD is the leading cause of death worldwide and, after dementia, is the second biggest cause of death for women. In England, it accounts for one in four of all deaths. Lifestyle modifications represent the primary route both to reduce CVD risk factors and prevent CVD outcomes. Diet constitutes one of the key modifiable risk factors in the aetiology of CVD. We investigated the relationship between nine main dietary indices and a comprehensive range of CVD risk factors in 2590 women from TwinsUK. After adjustment for multiple testing, we found that the Dietary Approaches to Stop Hypertension (DASH) diet was inversely correlated with some of the most common CVD risk factors (BMI, visceral fat (VF), TAG, insulin, homoeostasis model assessment of insulin resistance (HOMA2-IR) and atherosclerotic CVD (ASCVD) risk) with PFDR ranging from 6·28 × 10-7 to 5·63 × 10-4. Similar association patterns were detected across most of the dietary indices analysed. In our post hoc investigation, to determine if any specific food groups were driving associations between the DASH score and markers of cardiometabolic risk, we found that increased BMI, VF, HOMA2-IR, ASCVD risk, insulin and TAG levels were directly correlated with red meat consumption (PFDR ranging from 4·65 × 10-9 to 7·98 × 10-3) and inversely correlated with whole-grain cereal consumption (PFDR ranging from 1·26 × 10-6 to 8·28 × 10-3). Our findings revealed that the DASH diet is associated with a more favourable CVD risk profile, suggesting that this diet may be a candidate dietary pattern to supplement current UK dietary recommendations for CVD prevention.

Associations Among Plant-Based Dietary Indexes, the Dietary Inflammatory Index, and Inflammatory Potential in Female College Students In Saudi Arabia: A Cross-Sectional Study

BACKGROUND

Saudi Arabian diets are transitioning to more Western dietary patterns that have been associated with higher levels of inflammation. Emerging evidence suggests plant-based diets are related to lower levels of inflammation; however, the definition of plant-based diets varies.

OBJECTIVE

The purpose of this study was to identify the extent to which an overall Plant-Based Diet Index (PDI), Healthy-PDI (hPDI), and Unhealthy-PDI (uPDI) vs Energy-Adjusted Dietary Inflammatory Index correlate with high-sensitivity C-reactive protein (hs-CRP) level.

DESIGN

This was a cross-sectional study carried out at King Saud University. Data on dietary intake, anthropometrics, and hs-CRP were collected.

PARTICIPANTS/SETTING

Female students aged 19 to 35 years (n = 401) were recruited from King Saud University, Riyadh, Saudi Arabia, between February and May 2019.

MAIN OUTCOME MEASURES

The main outcome was hs-CRP level.

STATISTICAL ANALYSES PERFORMED

Pearson correlation and multivariate linear regression analyses were used to examine the associations between hs-CRP, each PDI, and Energy-Adjusted Dietary Inflammatory Index (E-DII).

RESULTS

E-DII and uPDI scores had a moderate and a small positive correlation with hs-CRP levels (r = 0.46 and 0.22, respectively), whereas PDI and hPDI scores had a small and a moderate inverse correlation with hs-CRP levels (r = -0.13 and -0.31, respectively). A 1-standard deviation higher E-DII score was directly associated with a 1.05 mg/L higher hs-CRP level (95% confidence interval 0.72 to 1.38; P < 0.0001) after adjusting for body mass index. Overall PDI score was not associated with hs-CRP levels. A 6-point higher hPDI and uPDI score were associated with a 0.13 mg/L lower hs-CRP (95% confidence interval -0.08 to -0.28) and a 0.15 mg/L higher hs-CRP (95% confidence interval 0.03 to 0.31), respectively, after adjusting for lifestyle and dietary factors; however, results attenuated and were no longer statistically significant after body mass index adjustment.

CONCLUSIONS

Although all indexes had a small or moderate correlation with hs-CRP, only E-DII score was positively associated with hs-CRP level. Future research can examine PDI-based interventions for lowering inflammation.

Blue poo: impact of gut transit time on the gut microbiome using a novel marker

BACKGROUND AND AIMS

Gut transit time is a key modulator of host-microbiome interactions, yet this is often overlooked, partly because reliable methods are typically expensive or burdensome. The aim of this single-arm, single-blinded intervention study is to assess (1) the relationship between gut transit time and the human gut microbiome, and (2) the utility of the 'blue dye' method as an inexpensive and scalable technique to measure transit time.

METHODS

We assessed interactions between the taxonomic and functional potential profiles of the gut microbiome (profiled via shotgun metagenomic sequencing), gut transit time (measured via the blue dye method), cardiometabolic health and diet in 863 healthy individuals from the PREDICT 1 study.

RESULTS

We found that gut microbiome taxonomic composition can accurately discriminate between gut transit time classes (0.82 area under the receiver operating characteristic curve) and longer gut transit time is linked with specific microbial species such as Akkermansia muciniphila, Bacteroides spp and Alistipes spp (false discovery rate-adjusted p values <0.01). The blue dye measure of gut transit time had the strongest association with the gut microbiome over typical transit time proxies such as stool consistency and frequency.

CONCLUSIONS

Gut transit time, measured via the blue dye method, is a more informative marker of gut microbiome function than traditional measures of stool consistency and frequency. The blue dye method can be applied in large-scale epidemiological studies to advance diet-microbiome-health research. Clinical trial registry website https://clinicaltrials.gov/ct2/show/NCT03479866 and trial number NCT03479866.

The Parkinson's Real-World Impact Assessment (PRISM) Study: A European Survey of the Burden of Parkinson's Disease in Patients and their Carers

Background:

A greater understanding of the everyday experiences of people with Parkinson’s disease (PD) and their carers may help improve clinical practice.

Objective:

The Parkinson’s Real-world Impact assesSMent (PRISM) study evaluated medication use, health-related quality of life (HRQoL) and the use of healthcare resources by people with PD and their carers.

Methods:

PRISM is an observational cross-sectional study, in which people with PD and their carers completed an online survey using structured questionnaires, including the Parkinson’s Disease Quality of Life Questionnaire (PDQ-39), Non-Motor Symptoms Questionnaire (NMSQuest) and Zarit Burden Interview (ZBI).

Results:

Data were collected from 861 people with PD (mean age, 65.0 years; mean disease duration, 7.7 years) and 256 carers from six European countries. People with PD reported a large number of different co-morbidities, non-motor symptoms (mean NMSQuest score, 12.8), and impaired HRQoL (median PDQ-39 summary score, 29.1). Forty-five percent of people with PD reported at least one impulse control behaviour. Treatment patterns varied considerably between different European countries. Levodopa was taken in the last 12 months by 85.9% of participants, and as monotherapy by 21.8%. Carers, who were mostly female (64.8%) and the partner/spouse of the person with PD (82.1%), reported mild to moderate burden (mean ZBI total score, 26.6).

Conclusions:

The PRISM study sheds light on the lives of people with PD and those who care for them, re-emphasising the many challenges they face in everyday life. The study also provides insights into the current treatment of PD in Europe.

Exenatide once weekly over 2 years as a potential disease-modifying treatment for Parkinson's disease: protocol for a multicentre, randomised, double blind, parallel group, placebo controlled, phase 3 trial: The 'Exenatide-PD3' study

INTRODUCTION

Parkinson's disease (PD) is a common neurodegenerative disorder with substantial morbidity. No disease-modifying treatments currently exist. The glucagon like peptide-1 receptor agonist exenatide has been associated in single-centre studies with reduced motor deterioration over 1 year. The aim of this multicentre UK trial is to confirm whether these previous positive results are maintained in a larger number of participants over 2 years and if effects accumulate with prolonged drug exposure.

METHODS AND ANALYSIS

This is a phase 3, multicentre, double-blind, randomised, placebo-controlled trial of exenatide at a dose of 2 mg weekly in 200 participants with mild to moderate PD. Treatment duration is 96 weeks. Randomisation is 1:1, drug to placebo. Assessments are performed at baseline, week 12, 24, 36, 48, 60, 72, 84 and 96 weeks.The primary outcome is the comparison of Movement Disorders Society Unified Parkinson's Disease Rating Scale part 3 motor subscore in the practically defined OFF medication state at 96 weeks between participants according to treatment allocation. Secondary outcomes will compare the change between groups among other motor, non-motor and cognitive scores. The primary outcome will be reported using descriptive statistics and comparisons between treatment groups using a mixed model, adjusting for baseline scores. Secondary outcomes will be summarised between treatment groups using summary statistics and appropriate statistical tests to assess for significant differences.

ETHICS AND DISSEMINATION

This trial has been approved by the South Central-Berkshire Research Ethics Committee and the Health Research Authority. Results will be disseminated in peer-reviewed journals, presented at scientific meetings and to patients in lay-summary format.

TRIAL REGISTRATION NUMBERS

NCT04232969, ISRCTN14552789.

Modest effects of dietary supplements during the COVID-19 pandemic: insights from 445 850 users of the COVID-19 Symptom Study app

OBJECTIVES

Dietary supplements may ameliorate SARS-CoV-2 infection, although scientific evidence to support such a role is lacking. We investigated whether users of the COVID-19 Symptom Study app who regularly took dietary supplements were less likely to test positive for SARS-CoV-2 infection.

DESIGN

App-based community survey.

SETTING

445 850 subscribers of an app that was launched to enable self-reported information related to SARS-CoV-2 infection for use in the general population in the UK (n=372 720), the USA (n=45 757) and Sweden (n=27 373).

MAIN EXPOSURE

Self-reported regular dietary supplement usage (constant use during previous 3 months) in the first waves of the pandemic up to 31 July 2020.

MAIN OUTCOME MEASURES

SARS-CoV-2 infection confirmed by viral RNA reverse transcriptase PCR test or serology test before 31 July 2020.

RESULTS

In 372 720 UK participants (175 652 supplement users and 197 068 non-users), those taking probiotics, omega-3 fatty acids, multivitamins or vitamin D had a lower risk of SARS-CoV-2 infection by 14% (95% CI (8% to 19%)), 12% (95% CI (8% to 16%)), 13% (95% CI (10% to 16%)) and 9% (95% CI (6% to 12%)), respectively, after adjusting for potential confounders. No effect was observed for those taking vitamin C, zinc or garlic supplements. On stratification by sex, age and body mass index (BMI), the protective associations in individuals taking probiotics, omega-3 fatty acids, multivitamins and vitamin D were observed in females across all ages and BMI groups, but were not seen in men. The same overall pattern of association was observed in both the US and Swedish cohorts.

CONCLUSION

In women, we observed a modest but significant association between use of probiotics, omega-3 fatty acid, multivitamin or vitamin D supplements and lower risk of testing positive for SARS-CoV-2. We found no clear benefits for men nor any effect of vitamin C, garlic or zinc. Randomised controlled trials are required to confirm these observational findings before any therapeutic recommendations can be made.

A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales

Introduction

There is a paucity of knowledge and understanding of medical error in opioid substitution treatment programmes.

Objectives

To characterise patient safety incidents involving opioid-substitution treatment with methadone or buprenorphine in community-based care to identify the sources and nature of harm, describe and interpret themes and use this qualitative analysis to identify priorities to focus future improvement work.

Methods

We undertook a mixed-methods study examining incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care submitted between 2005 and 2015 from the National Reporting and Learning System, a repository of incident reports from England and Wales. We analysed each report using four frameworks to identify incident type, contributory factors, incident outcome and severity of harm. Analysis involved detailed data coding and iterative generation of data summaries using descriptive statistical and thematic analysis.

Results

2,284 reports were identified. We found that most risks of harm came from failure in one of four processes of care delivery: prescribing opiate-substitution (n=151); supervised dispensing errors (n=248); non-supervised dispensing errors (n=318); and monitoring and communication activities (n=1544). Most incidents resulting in harm involved supervised or non-supervised dispensing (n=91/127, 72%). Staff- (e.g. mistakes, not following protocols) and organisation-related (e.g. poor working conditions or poor continuity of care between services) contributory factors were present for over half of incidents.

Conclusions

We have identified four processes of care delivery and associated contributory factors, which represent potential target areas for healthcare systems worldwide to develop interventions to improve the safe delivery of opioid substitution treatment.

Dietary Assessment Methods to Estimate (Poly)phenol Intake in Epidemiological Studies: A Systematic Review

Nutritional epidemiological studies have frequently reported associations between higher (poly)phenol intake and a decrease in the risk or incidence of noncommunicable diseases. However, the assessment methods that have been used to quantify the intakes of these compounds in large-population samples are highly variable. This systematic review aims to characterize the methods used to assess dietary (poly)phenol intake in observational studies, report the validation status of the methods, and give recommendations on method selection and data reporting. Three databases were searched for publications that have used dietary assessment methods to measure (poly)phenol intake and 549 eligible full texts were identified. Food-frequency questionnaires were found to be the most commonly used tool to assess dietary (poly)phenol intake (73%). Published data from peer-reviewed journals were the major source of (poly)phenol content data (25%). An increasing number of studies used open-access databases such as Phenol-Explorer and USDA databases on flavonoid content since their inception, which accounted for 11% and 23% of the data sources, respectively. Only 16% of the studies reported a method that had been validated for measuring the target (poly)phenols. For future research we recommend: 1) selecting a validated dietary assessment tool according to the target compounds and target period of measurement; 2) applying and combining comprehensive (poly)phenol content databases such as USDA and Phenol-Explorer; 3) detailing the methods used to assess (poly)phenol intake, including dietary assessment method, (poly)phenol content data source; 4) follow the Strengthening the Reporting of Observational Studies in Epidemiology-Nutritional Epidemiology (STROBE-nut) framework; and 5) complementing dietary intake assessment based on questionnaires with measurement of (poly)phenols in biofluids using appropriate and validated analytical methods.