4938Left ventricular global longitudinal strain recovery predicts scar size reduction and systolic remodelling post ST-elevation myocardial infarction

Background

Left ventricular (LV) strain has prognostic utility following ST-elevation myocardial infarction (STEMI); however, serial changes in LV strain has not been evaluated post-infarct. We sought to determine the relationship between post-STEMI transthoracic echocardiographic (TTE) LV global longitudinal strain (GLS) and cardiac magnetic resonance (CMR) imaging derived scar size and LV systolic remodelling.

Methods

Following revascularisation, 172 first STEMI patients (85% male, 56.9±10.7 years) had paired TTE for GLS, and CMR to evaluate scar size and LV systolic function at baseline (2–7 days) and follow-up (8–10 weeks). Patients were divided into 3 groups according to absolute baseline GLS: group 1 (GLS ≥16%), group 2 (12%< GLS <16%), group 3 (GLS ≤12%). GLS recovery was defined as ≥10% increase in GLS at follow-up, excluding patients with normal baseline GLS. LV systolic adverse remodelling was defined as ≥15% increase in LVESV. LV systolic reverse remodelling was defined as ≥15% decrease in LVESV. Scar reduction was defined as ≥30% decrease in scar size.

Results

Group 1 and 2 had smaller follow-up scar size and higher LVEF compared to group 3 (p<0.0001 for both, see table). There was no difference in scar size reduction or systolic reverse remodeling among the baseline GLS groups (p>0.05 for both). Importantly, no patients from group 1 demonstrated systolic adverse remodelling. Relative change in GLS is significantly correlated with changes in LVEF (r=0.354, p<0.0001) and scar size (r=−0.262, p<0.0001), see figure. On multivariate binary logistic analysis, patients who demonstrated GLS recovery had greater reduction in scar size (OR=2.77 (1.09–7.01), p=0.032) and LV systolic reverse remodelling (OR=9.63 (1.21–76.41), p=0.032).

Follow-up parameters within GLS groups All patients (n=172) Group 1 (n=47) Group 2 (n=72) Group 3 (n=53) Follow-up GLS, % 16.02±3.44 19.38±1.90 16.36±2.09 12.57±2.69 GLS recovery, n 110 (64%) 19 (40%) 53 (74%) 38 (72%) Follow-up scar size, % 7.67±5.40 5.01±3.38 6.27±3.73 12.02±6.24 Follow-up LVEF, % 51.80±10.20 57.83±6.95 54.14±8.02 43.26±9.83 Data presented as mean ± SD or n (%).

Correlation graphs for change in GLS

Conclusion

Stratification of STEMI patients by baseline GLS was a determinant of CMR scar size as well as LV systolic function. However, the evaluation of GLS recovery could provide additional insights into reduction in scar size and LV systolic remodelling, both important prognostic markers. Thus, echocardiographic serial GLS evaluation may be a relevant non-invasive parameter, that is cheaper and more widely available for monitoring STEMI patients and guiding therapy.

P1483Serial changes in peak left atrial strain predicts diastolic remodelling following percutaneous revascularisation for ST-segment elevation myocardial infarction

Background

Echocardiographic 2D speckle tracking peak left atrial (LA) strain reflects LA reservoir function. Limited studies have reported the relationship between peak LA strain and diastolic dysfunction. In addition, adverse diastolic remodeling (ADR) has been reported, to have better prognostic value than single diastolic function assessment following ST-elevation myocardial infarction (STEMI).

Purpose

We examined the relationship between serial changes in echocardiographic peak LA strain and diastolic function in STEMI patients.

Methods

186 percutaneously revascularized first presentation STEMI patients (87% male, 56.9±10.6 years) underwent serial TTE at baseline (2–7 days) and at follow-up (8–10 weeks) post-STEMI. Peak LA reservoir strain measurements were analysed from apical 2-, 3- and 4- chamber views. Diastolic function was graded as per 2016 guidelines: normal, grade 1, grade 2 and grade 3. ADR was defined as worsening of diastolic function grade (≥1) from baseline to follow-up, or persistent grade 3.

Results

Lower baseline peak LA strain was associated with grade 2 and grade 3 diastolic dysfunction compared to normal and grade 1 function at follow-up (p<0.05, see figure and table). Change in LA strain was less with worsening grades of diastolic function (see table). ADR was seen in 33 patients. Lower baseline peak LA strain predicted ADR (B=0.86 (0.80–0.92), p<0.0001). In addition, a reduction in peak LA strain at follow up was independently associated with ADR (B=0.91 (0.84–0.97), p=0.007) (see figure).

Diastolic function grades with LA strain Follow-up diastolic function Baseline peak LA strain (%) Follow-up peak LA strain (%) Change in peak LA strain (%) Normal (n=91) 35.70±6.38 40.97±8.10 5.26±6.07 Grade 1 (n=61) 30.70±6.97 34.54±8.77 3.84±6.32 Grade 2 (n=17) 23.95±6.11 25.49±5.93 1.54±4.70 Grade 3 (n=17) 23.66±8.07 23.49±10.64 −0.17±7.44 Data presented as mean ± SD.

Peak LA strain vs diastolic function

Conclusion

Peak LA strain is associated with diastolic function following STEMI and differentiates normal diastolic function from diastolic dysfunction. Serial changes in peak LA strain correlated with diastolic remodelling. Longer-term follow-up is required to determine the prognostic value of changes in peak LA strain, and diastolic remodelling.

Anisotropic Plasmonic CuS Nanocrystals as a Natural Electronic Material with Hyperbolic Optical Dispersion

Copper sulfide nanocrystals have recently been studied due to their metal-like behavior and strong plasmonic response, which make them an attractive material for nanophotonic applications in the near-infrared spectral range; however, the nature of the plasmonic response remains unclear. We have performed a combined experimental and theoretical study of the optical properties of copper sulfide colloidal nanocrystals and show that bulk CuS resembles a heavily doped p-type semiconductor with a very anisotropic energy band structure. As a consequence, CuS nanoparticles possess key properties of relevance to nanophotonics applications: they exhibit anisotropic plasmonic behavior in the infrared and support optical modes with hyperbolic dispersion in the 670-1050 nm spectral range. We also predict that the ohmic loss is low compared to conventional plasmonic materials such as noble metals in the NIR. The plasmonic resonances can be tuned by controlling the size and shape of the nanocrystals, providing a playground for future nanophotonic applications in the near-infrared.

Assessing the efficacy and acceptability of an internet-delivered intervention for resilience among college students: A pilot randomised control trial protocol

BACKGROUND

Exposure to new stressors places college students at increased risk for developing mental health problems. Preventive interventions aimed at enhancing resilience have the potential to improve mental health and well-being in college students and internet-delivery may improve access to these interventions. However, few studies have evaluated the efficacy of online interventions for resilience in college students. The present study seeks to assess the feasibility [initial efficacy and acceptability] of a newly developed internet-delivered intervention for resilience provided with human or automated support, in a sample of college students.

METHOD

A pilot randomised controlled trial including three groups: 1) an intervention group with human support; 2) an intervention group with automated support; and 3) a waiting list control group. The intervention, Space for Resilience, is based on positive psychology and consists of seven modules, delivered over a period of eight weeks. Primary outcomes measures will include the Connor-Davidson Resilience Scale (CD-RISC) and the Pemberton Happiness Index (PHI). Secondary outcomes measures will include the Brief Resilience Scale (BRS), the Patient Health Questionnaire - 4 items (PHQ-4), the Rosenberg Self-Esteem Scale (RSES), and the Perceived Stress Scale - 4 items (PSS-4). Acceptability will be examined using the Satisfaction with Treatment (SAT) questionnaire. Analysis will be conducted on an intention-to-treat basis.

DISCUSSION

The study seeks to establish the initial efficacy and acceptability of an internet-delivered intervention for resilience with human support and automated support. Apart from determining the impact of the intervention on acceptability and effectiveness, this study will be a first to explore more clearly the relative benefits of different support modes.

Inhibitors of DAG metabolism suppress CCR2 signalling in human monocytes

BACKGROUND AND PURPOSE

CCL2 is an inflammatory chemokine that stimulates the recruitment of monocytes into tissue via activation of the GPCR CCR2.

EXPERIMENTAL APPROACH

Freshly isolated human monocytes and THP-1 cells were used. Fura-2 loaded cells were used to measure intracellular Ca²⁺ responses. Transwell migration to measure chemotaxis. siRNA-mediated gene knock-down was used to support pharmacological approaches.

KEY RESULTS

CCL2 evoked intracellular Ca²⁺ signals and stimulated migration in THP-1 monocytic cells and human CD14⁺ monocytes in a CCR2-dependent fashion. Attenuation of DAG catabolism in monocytes by inhibiting DAG kinase (R59949) or DAG lipase (RHC80267) activity suppressed CCL2-evoked Ca²⁺ signalling and transwell migration in monocytes. These effects were not due to a reduction in the number of cell surface CCR2. The effect of inhibiting DAG kinase or DAG lipase could be mimicked by addition of the DAG analogue 1-oleoyl-2-acetyl-sn-glycerol (OAG) but was not rescued by application of exogenous phosphatidylinositol 4,5-bisphosphate. Suppressive effects of R59949, RHC80267, and OAG were partially or fully reversed by Gö6983 (pan PKC isoenzyme inhibitor) but not by Gö6976 (PKCα and PKCβ inhibitor). RNAi-mediated knock-down of DAG kinase α isoenzyme modulated CCL2-evoked Ca²⁺ responses in THP-1 cells.

CONCLUSIONS AND IMPLICATIONS

Taken together, these data suggest that DAG production resulting from CCR2 activation is metabolised by both DAG kinase and DAG lipase pathways in monocytes and that pharmacological inhibition of DAG catabolism or application suppresses signalling on the CCL2-CCR2 axis via a mechanism dependent upon a PKC isoenzyme that is sensitive to Gö6983 but not Gö6976.

Action of MK-7264 (gefapixant) at human P2X3 and P2X2/3 receptors and in vivo efficacy in models of sensitisation

BACKGROUND AND PURPOSE

The P2X3 receptor is an ATP-gated ion channel expressed by sensory afferent neurons and is used as a target to treat chronic sensitisation conditions. The first-in-class, selective P2X3 and P2X2/3 receptor antagonist, the diaminopyrimidine MK-7264 (gefapixant), has progressed to Phase III trials for refractory or unexplained chronic cough. We used patch clamp to elucidate the pharmacology and kinetics of MK-7264 and rat models of hypersensitivity and hyperalgesia to test its efficacy on these conditions.

EXPERIMENTAL APPROACH

Whole-cell patch clamp of 1321N1 cells expressing human P2X3 and P2X2/3 receptors was used to determine mode of MK-7264 action, potency, and kinetics. The analgesic efficacy was assessed using paw withdrawal threshold and limb weight distribution in rat models of inflammatory, osteoarthritic, and neuropathic sensitisation.

KEY RESULTS

MK-7264 is a reversible allosteric antagonist at human P2X3 and P2X2/3 receptors. Experiments with the slowly desensitising P2X2/3 heteromer revealed concentration- and state-dependency to wash-on, with faster rates and greater inhibition when applied before agonist compared to during agonist application. The wash-on rate (τ value) for MK-7264 at maximal concentrations was much lower when applied before compared to during agonist application. In vivo, MK-7264 displayed efficacy comparable to naproxen in inflammatory and osteoarthritic sensitisation models and gabapentin in neuropathic sensitisation models, increasing paw withdrawal threshold and decreasing weight-bearing discomfort.

CONCLUSIONS AND IMPLICATIONS

MK-7264 is a reversible and selective P2X3 and P2X2/3 antagonist, exerting allosteric antagonism via preferential activity at closed channels. Its efficacy in rat models supports its clinical investigation for chronic sensitisation conditions.

Evaluating Augmented Depression Therapy (ADepT): study protocol for a pilot randomised controlled trial

BACKGROUND

While existing psychological treatments for depression are effective for many, a significant proportion of depressed individuals do not respond to current approaches and few remain well over the long-term. Anhedonia (a loss of interest or pleasure) is a core symptom of depression which predicts a poor prognosis but has been neglected by existing treatments. Augmented Depression Therapy (ADepT) has been co-designed with service users to better target anhedonia alongside other features of depression. This mixed methods pilot trial aims to establish proof of concept for ADepT and to examine the feasibility and acceptability of a future definitive trial evaluating the clinical and cost-effectiveness of ADepT, compared to an evidence-based mainstream therapy (Cognitive Behavioural Therapy; CBT) in the acute treatment of depression, the prevention of subsequent depressive relapse, and the enhancement of wellbeing.

METHODS

We aim to recruit 80 depressed participants and randomise them 1:1 to receive ADepT (15 weekly acute and 5 booster sessions in following year) or CBT (20 weekly acute sessions). Clinical and health economic assessments will take place at intake and at 6-, 12-, and 18-month follow-up. Reductions in PHQ-9 depression severity and increases in WEMWBS wellbeing at 6-month assessment (when acute treatment should be completed) are the co-primary outcomes. Quantitative and qualitative process evaluation will assess mechanism of action, implementation issues, and contextual moderating factors. To evaluate proof of concept, intake-post effect sizes and the proportion of individuals showing reliable and clinically significant change on outcome measures in each arm at each follow-up will be reported. To evaluate feasibility and acceptability, we will examine recruitment, retention, treatment completion, and data completeness rates and feedback from patients and therapists about their experience of study participation and therapy. Additionally, we will establish the cost of delivery of ADepT.

DISCUSSION

We will proceed to definitive trial if any concerns about the safety, acceptability, feasibility, and proof of concept of ADepT and trial procedures can be rectified, and we recruit, retain, and collect follow-up data on at least 60% of the target sample.

TRIAL REGISTRATION

ISCRTN85278228, registered 27/03/2017.

Electronic capturing of patient-reported outcome measures on a touchscreen computer in clinical diabetes practice (the DiaPROM trial): a feasibility study

BACKGROUND

Living with type 1 diabetes (T1D) is demanding, and emotional problems may impair ability for diabetes self-management. Thus, diabetes guidelines recommend regular assessment of such problems. Using patient-reported outcome measures (PROMs) to assess diabetes-related distress and psychological well-being is considered useful. It has been proposed that future work should examine the use of PROMs to support the care of individual patients and improve the quality of health services. To our knowledge, the use of PROMs has not been systematically evaluated in diabetes care services in Norway. Electronically captured PROMs can be directly incorporated into electronic patient records. Thus, the study's overall aim was to examine the feasibility and acceptability of capturing PROMs electronically on a touchscreen computer in clinical diabetes practice.

METHODS

Adults with T1D age ≥ 40 years completed PROMs on a touchscreen computer at Haukeland University Hospital's diabetes outpatient clinic. We included 46 items related to diabetes-related distress, self-perceived diabetes competence, awareness of hypoglycaemia, occurrence of hyperglycaemia, hypoglycaemia and fluctuating glucose levels, routines for glucose monitoring, general well-being and health-related quality of life. Participants subsequently completed a paper-based questionnaire regarding comprehension and relevance of the PROMs, acceptance of the number of items and willingness to complete electronic PROMs annually. We wrote field notes in the outpatient clinic based on observations and comments from the invited participants.

RESULTS

During spring 2017, 69 participants (50.7% men), age 40 to 74 years, were recruited. Generally, the touchscreen computer functioned well technically. Median time spent completing the PROMs was 8 min 19 s. Twenty-nine (42.0%) participants completed the PROMs without missing items, with an 81.4% average instrument completion rate. Participants reported that the PROMs were comprehensible (n = 62) and relevant (n = 46) to a large or very large degree, with an acceptable number of items (n = 51). Moreover, 54 were willing to complete PROMs annually. Participants commented that the focus on living with diabetes was valued.

CONCLUSIONS

Capturing PROMs on a touchscreen computer in an outpatient clinic was technically and practically feasible. The participants found the PROMs to be relevant and acceptable with a manageable number of items, and reported willingness to complete PROMs annually.

Endoscopic and Histologic Features of Immune Checkpoint Inhibitor-Related Colitis

BACKGROUND

Diarrhea and colitis are the second most common immune checkpoint inhibitor (ICPI)-induced adverse events. However, a comprehensive characterization of the endoscopic and histologic features of ICPI-induced diarrhea and colitis is lacking. Therefore, we aimed to describe endoscopic and histologic features of ICPI-induced gastrointestinal toxicities and to assess their association with patients' clinical characteristics and outcomes.

METHODS

We retrospectively reviewed records of 53 patients with ICPI-related diarrhea/colitis between 2011 and 2017. We collected data on demographics, diarrhea/colitis grade, treatment, and endoscopic and histologic findings. Long-term follow-up included repeat endoscopy findings, diarrhea recurrence, and overall survival. We compared groups by treatment, endoscopic and histologic findings, and constructed Kaplan-Meier survival curves.

RESULTS

Most patients had grade 2 or higher diarrhea (87%) and colitis (60%). Thirty-one patients were successfully treated with corticosteroids, and 22 additionally required infliximab. On endoscopy, 21 (40%) patients had ulcerations and 22 (42%) had nonulcerative inflammation. Patients with ulcerations had more steroid-refractory disease (P = 0.044) and high-grade diarrhea (P = 0.033). Histology showed mostly acute (23%) or chronic (60%) inflammation. During mean follow-up duration of 18.9 months, 19 (36%) developed recurrent diarrhea. Most patients had persistent endoscopic (8/13, 62%) and histologic (9/11, 82%) inflammation. Patients with higher-grade adverse events had improved survival. Higher-grade colitis was associated with endoscopic inflammation (P = 0.039), but grade of diarrhea was not associated with endoscopic inflammation or grade of colitis.

CONCLUSION

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Community-based nutrition intervention to promote oral health and restore healthy body weight in refugee children: a scoping review

OBJECTIVE

To determine the scope and quality of evidence on the effectiveness of community-based nutrition interventions to promote oral health and restore healthy body weight in school-aged refugee children.

BASIC RESEARCH DESIGN

Scoping review using a systematic approach.

MAIN OUTCOME MEASURES

Oral health and body weight.

RESULTS

Four primary studies, two evaluation studies and one systematic review met the inclusion criteria. No nutrition interventions or reviews to promote oral health in school-aged refugee children were found. There is limited weak evidence for the effectiveness of community-based nutrition interventions to restore healthy body weight in refugee settings. A systematic review also reported weak evidence of correction of child body weight as a result of community-based nutrition interventions in refugee camps.

CONCLUSION

This scoping review found no community-based nutrition interventions for school-aged refugee children to promote oral health and restore healthy body weight. There is limited and weak evidence for the effectiveness of community-based nutrition interventions to restore healthy body weight in refugee settings. There is a need to conduct an early phase study to develop and co-produce community-based nutrition interventions to promote oral health and healthy body weight for children residing in long-term refugee situations and to investigate the feasibility for their implementation.

Automated Method of Grading Vitreous Haze in Patients With Uveitis for Clinical Trials

Purpose

Uveitis is associated with accumulation of exudate in the vitreous, which reduces fundus visibility. The condition is assessed in patients by subjectively matching fundus photographs to a six-level (NIH) or nine-level (Miami) haze scale. This study aimed to develop an objective method of assessing vitreous haze.

Methods

An image-processing algorithm was designed that quantifies vitreous haze via high-pass filtering, entropy analysis, and power spectrum integration. The algorithm was refined using nine published photographs that represent incremental levels of fundus blur and applied without further refinement to 120 random fundus photographs from a uveitis image library. Computed scores were compared against the grades of two trained readers of vitreous haze and against acutance, a generic measure of image clarity, using Cohen's κ and Gwet's AC statistics.

Results

Exact agreement between algorithm scores and reader grades was substantial for both NIH and Miami scales (κ = 0.61 and 0.67, AC = 0.82 and 0.92). Within-one (κ = 0.78 and 0.82) and within-two (κ = 0.80 and 0.84) levels of agreement were almost perfect. The correspondence was comparable to that between readers. Whereas, exact (κ = 0.45 and 0.44, AC = 0.73 and 0.75), within-one (κ = 0.69 and 0.68), and within-two (κ = 0.73 and 0.72) levels of agreement for the two scales were moderate to substantial for acutance calculations.

Conclusions

The computer algorithm produces a quantitative measure of vitreous haze that correlates strongly with the perception of expert graders.

Translational Relevance

The work offers a rapid, unbiased, standardized means of assessing vitreous haze for clinical and telemedical monitoring of uveitis patients.

Photoresponsive Hydrogels with Photoswitchable Mechanical Properties Allow Time-Resolved Analysis of Cellular Responses to Matrix Stiffening

As cell function and phenotype can be directed by the mechanical characteristics of the surrounding matrix, hydrogels have become important platforms for cell culture systems, with properties that can be tuned by external stimuli, such as divalent cations, enzymatic treatment, and pH. However, many of these stimuli can directly affect cell behavior, making it difficult to distinguish purely mechanical signaling events. This study reports on the development of a hydrogel that incorporates photoswitchable cross-linkers, which can reversibly alter their stiffness upon irradiation with the appropriate wavelength of light. Furthermore, this study reports the response of bone-marrow-derived mesenchymal stem cells (MSCs) on these hydrogels that were stiffened systematically by irradiation with blue light. The substrates were shown to be noncytotoxic, and crucially MSCs were not affected by blue-light exposure. Time-resolved analysis of cell morphology showed characteristic cell spreading and increased aspect ratios in response to greater substrate stiffness. This hydrogel provides a platform to study mechanosignaling in cells responding to dynamic changes in stiffness, offering a new way to study mechanotransduction signaling pathways and biological processes, with implicit changes to tissue mechanics, such as development, ageing, and fibrosis.

CollAborative care and active surveillance for Screen-Positive EldeRs with subthreshold depression (CASPER): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness

BACKGROUND

Efforts to reduce the burden of illness and personal suffering associated with depression in older adults have focused on those with more severe depressive syndromes. Less attention has been paid to those with mild disorders/subthreshold depression, but these patients also suffer significant impairments in their quality of life and level of functioning. There is currently no clear evidence-based guidance regarding treatment for this patient group.

OBJECTIVES

To establish the clinical effectiveness and cost-effectiveness of a low-intensity intervention of collaborative care for primary care older adults who screened positive for subthreshold depression.

DESIGN

A pragmatic, multicentred, two-arm, parallel, individually randomised controlled trial with a qualitative study embedded within the pilot. Randomisation occurred after informed consent and baseline measures were collected.

SETTING

Thirty-two general practitioner (GP) practices in the north of England.

PARTICIPANTS

A total of 705 participants aged ≥ 75 years during the pilot phase and ≥ 65 years during the main trial with subthreshold depression.

INTERVENTIONS

Participants in the intervention group received a low-intensity intervention of collaborative care, which included behavioural activation delivered by a case manager for an average of six sessions over 7-8 weeks, alongside usual GP care. Control-arm participants received only usual GP care.

MAIN OUTCOME MEASURES

The primary outcome measure was a self-reported measure of depression severity, the Patient Health Questionnaire-9 items PHQ-9 score at 4 months post randomisation. Secondary outcome measures included the European Quality of Life-5 Dimensions, Short Form questionnaire-12 items, Patient Health Questionnaire-15 items, Generalised Anxiety Disorder seven-item scale, Connor-Davidson Resilience Scale two-item version, a medication questionnaire and objective data. Participants were followed up for 12 months.

RESULTS

In total, 705 participants were randomised (collaborative care n = 344, usual care n = 361), with 586 participants (83%; collaborative care 76%, usual care 90%) followed up at 4 months and 519 participants (74%; collaborative care 68%, usual care 79%) followed up at 12 months. Attrition was markedly greater in the collaborative care arm. Model estimates at the primary end point of 4 months revealed a statistically significant effect in favour of collaborative care compared with usual care [mean difference 1.31 score points, 95% confidence interval (CI) 0.67 to 1.95 score points; p < 0.001]. The difference equates to a standard effect size of 0.30, for which the trial was powered. Treatment differences measured by the PHQ-9 were maintained at 12 months' follow-up (mean difference 1.33 score points, 95% CI 0.55 to 2.10 score points; p = 0.001). Base-case cost-effectiveness analysis found that the incremental cost-effectiveness ratio was £9633 per quality-adjusted life-year (QALY). On average, participants allocated to collaborative care displayed significantly higher QALYs than those allocated to the control group (annual difference in adjusted QALYs of 0.044, 95% bias-corrected CI 0.015 to 0.072; p = 0.003).

CONCLUSIONS

Collaborative care has been shown to be clinically effective and cost-effective for older adults with subthreshold depression and to reduce the proportion of people who go on to develop case-level depression at 12 months. This intervention could feasibly be delivered in the NHS at an acceptable cost-benefit ratio. Important future work would include investigating the longer-term effect of collaborative care on the CASPER population, which could be conducted by introducing an extension to follow-up, and investigating the impact of collaborative care on managing multimorbidities in people with subthreshold depression.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN02202951.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 8. See the NIHR Journals Library website for further project information.

Abstract PD5-08: Not presented

This abstract was not presented at the symposium.