P5308Mediterranean-style diet for the primary and secondary prevention of cardiovascular disease: Cochrane systematic review and meta-analysis of randomised clinical trials

Background

Observational studies have confirmed the benefits of adherence to a Mediterranean dietary pattern on cardiovascular disease (CVD) but the randomised controlled trial (RCT) evidence is limited.

Objective

To determine the effectiveness of a Mediterranean-style diet for the primary and secondary prevention of CVD.

Methods

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Web of Science, DARE, HTA, NHS EED and trial registers (September 2018). We selected RCTs in healthy adults and adults at high risk of CVD (primary prevention) and those with established CVD (secondary prevention). Both of the following key components were required for our definition of a Mediterranean-style diet: high monounsaturated/saturated fat ratio and a high intake of plant based foods, including fruits, vegetables, and legumes. The intervention could be dietary advice, provision of relevant foods or both. The comparison group received either no intervention, minimal intervention, usual care or another dietary intervention. Outcomes included clinical events and CVD risk factors. We included only studies with follow-up periods of 3 months or more.

Results

Overall, 30 RCTs (12,461 participants randomised) and 7 ongoing trials met our inclusion criteria, whereas 22 primary prevention trials and 6 secondary prevention trials were analysed. Low quality evidence shows little or no effect of the PREDIMED (7747 randomised) intervention (advice to follow a Mediterranean diet plus supplemental extra virgin olive oil or tree nuts) compared to a low fat diet on CVD mortality (HR 0.81 (95% CI 0.5, 1.32)) or total mortality (HR 1.0 (95% CI 0.81, 1.24)) over 4.8 years. There was however a reduction in the number of strokes with the PREDIMED intervention (HR 0.6 (95% CI 0.45, 0.8), moderate quality evidence). For secondary prevention, in the Lyon Diet Heart Study (605 CVD patients), there was moderate quality evidence of a reduction in CVD mortality (HR 0.35 (95% CI 0.15, 0.82)) and total mortality (HR 0.44 (95% CI 0.21, 0.92)) with the intervention, over 46 months. For CVD risk factors, in primary prevention trials, there was low quality evidence for a possible small reduction in total cholesterol (−0.16 mmol/L (95% CI −0.32, 0.00), and moderate quality evidence for a reduction in SBP (−2.99 mmHg (95% CI −3.45, −2.53)) and DBP (−2.0 mmHg (95% CI −2.29, −1.71)). In secondary prevention trials, there was moderate quality evidence of no effect of a Mediterranean-style diet on lipid levels and low or very low quality evidence for blood pressure.

Conclusions

Despite the relatively large number of studies included in this review, there is still some uncertainty regarding the effects of a Mediterranean-style diet on clinical endpoints and CVD risk factors for both primary and secondary prevention. The ongoing studies may provide more certainty in the future.

Honeybee caste lipidomics in relation to life-history stages and the long life of the queen

Honey bees have evolved a system in which fertilised eggs transit through the same developmental stages but can become either workers or queens. This difference is determined by their diet through development. Whereas workers live for weeks (normally 2-6 weeks), queens can live for years. Unfertilised eggs also develop through the same stages but result in a short living male caste (drones). Workers and drones are fed pollen throughout their late larval and adult life stages, while queens are fed exclusively on royal jelly and do not eat pollen. Pollen has high content of polyunsaturated fatty acids (PUFA) while royal jelly has a negligible amount of PUFA. To investigate the role of dietary PUFA lipids, and their oxidation in the longevity difference of honey bees, membrane fatty acid composition of the three castes was characterised at six different life-history stages (larvae, pupa, emergent, and different adult stages) through mass spectrometry. All castes were found to share a similar membrane phospholipid composition during early larval development. However, at pupation, drones and workers increased their level of PUFA, whilst queens increased their level of monounsaturated fatty acids. After emergence, worker bees further increased their level of PUFA by 5-fold across most phospholipid classes. In contrast, the membrane phospholipids of adult queens remained highly monounsaturated throughout their adult life. We postulate that this diet-induced increase in membrane PUFA results in more oxidative damage and is potentially responsible for the much shorter lifespans of worker bees compared to long-living queens.

Acinetobacter - the trojan horse of infection control?

BACKGROUND

Five cases of multi-resistant Acinetobacter baumanii (MRA) producing OXA-23 and OXA-51 occurred in a regional burn intensive care unit (BICU). Three were repatriated from other parts of the world (Dubai and Mumbai) and colonized on admission. Despite optimal precautions, two patients acquired MRA. Both had been nursed in the same room.

METHODS

Multi-disciplinary outbreak investigation of MRA in a regional BICU.

FINDINGS

The mechanism of transfer for the first case is thought to have been contaminated air from theatre activity releasing MRA bacteria into the communal corridor. No MRA patients went to theatre between the first and second acquired cases. The mechanism of transfer for the second case is thought to have been via a shower unit that was decontaminated inadequately between patients.

CONCLUSION

In an outbreak where contact precautions and environmental cleaning are optimal, it is important to give careful consideration to other mechanisms of spread. If there is a failure to do this, it is likely that the true causes of transmission will not be addressed and the problem will recur. It is recommended that burn theatres within burn facilities should be designed to operate at negative pressure; this is the opposite of normal operating theatre ventilation. Where showers are used, both the shower head and the hose should be changed after a patient with a resistant organism. The role of non-contact disinfection (e.g. hydrogen peroxide dispersal) should be reconsidered, and constant vigilance should be given to any 'trojan horse' item in the room.

Comparative Effectiveness of Enoxaparin vs Dalteparin for Thromboprophylaxis After Traumatic Injury

BACKGROUND

Enoxaparin 30 mg twice daily and dalteparin 5,000 units once daily are two common low-molecular-weight heparin (LMWH) thromboprophylaxis regimens used in the trauma population. Pharmacodynamic studies suggest that enoxaparin provides more potent anticoagulation than does dalteparin.

METHODS

In 2009, our institution switched its formulary LMWH from enoxaparin to dalteparin followed by a switch back to enoxaparin in 2013. Using a difference in differences design, we contrasted the change in the VTE rate accompanying the LMWH switch with the change in a control group of trauma patients given unfractionated heparin (UFH) during the same period.

RESULTS

The study included 5,880 patients: enoxaparin period (enoxaparin, n = 2,371; UFH, n = 1,539) vs the dalteparin period (dalteparin, n = 1,046; UFH, n = 924). The VTE rate was unchanged in the LMWH group: 3.3/1000 days in the enoxaparin period vs 3.8/1000 days in the dalteparin period: rate ratio (RR), 1.16; 95% CI 0.74-1.81. The rate was also unchanged in the UFH control subjects: 5.7/1,000 days in the enoxaparin period vs 5.2/1,000 days in the dalteparin period: RR, 0.92; 95% CI, 0.61-1.38. After confounding adjustment, the ratio of the change in VTE rate between the LMWH and UFH groups was similar: RR, 1.06; 95% CI 0.71-2.00. A secondary analysis excluding patients with delayed or interrupted prophylaxis (or both) altered this estimate nonsignificantly in favor of enoxaparin: RR, 2.39; 95% CI, 0.80-7.09.

CONCLUSIONS

Our results suggest that dalteparin has an effectiveness similar to that of enoxaparin in real-world trauma patients. Future research should investigate how the timing and consistency of prophylaxis affects LMWH effectiveness.

MRI assessment and outcomes in patients receiving neoadjuvant chemotherapy only for primary rectal cancer: long-term results from the GEMCAD 0801 trial

Background

Primary chemotherapy has been tested as a possible approach for patients with high risk features but predicted clear mesorectal margins on preoperative MRI assessment. This study investigates the prognostic relevance of baseline and post-treatment MRI and pathology staging in rectal cancer patients undergoing primary chemotherapy.

Patients and methods

Forty-six patients with T3 tumour > =2 mm from the mesorectal fascia were prospectively treated with Neoadjuvant Capecitabine, Oxaliplatin and Bevacizumab prior to surgery between 2009 and 2011. The baseline and post-treatment MRI: T, Nodal and Extra-mural venous invasion (EMVI) status were recorded as well as post-treatment MRI Tumour regression grade (TRG) and modified-RECIST assessment of tumour length. The post-treatment pathology (yp) assessments of T3 substage, N, EMVI and TRG status were also recorded. Three-year disease-free survival (DFS) and cumulative incidence of recurrence were estimated by using the Kaplan-Meier product-limit method, and Cox proportional hazards models were used to determine associations between staging and response on MRI and pathology with survival outcomes.

Results

About 46 patients underwent neoadjuvant chemotherapy alone for high risk margin safe primary rectal cancer. The median follow-up was 41 months, 5 patients died and 11 patients experienced relapse (2 local, 8 distant and 1 both). In total 23/46 patients were identified with MRI features of EMVI at baseline. mrEMVI positive status carried independent prognostic significance for DFS (P = 0.0097) with a hazard ratio of 31.33 (95% CI: 2.3-425.4). The histopathologic factor that was of independent prognostic importance was a final ypT downstage of ypT3a or less, hazard ratio: 14.0 (95% CI: 1.5-132.5).

Conclusions

mrEMVI is an independent prognostic factor at baseline for poor outcomes in rectal cancer treated with neoadjuvant chemotherapy while ≤ypT3a is associated with an improvement in DFS. Future preoperative therapy evaluation in rectal cancer patients will need to stratify treatment according to baseline EMVI status as a crucial risk factor for recurrence in patients with predicted CRM clear rectal cancer.

Assessing the delivery of alcohol screening and brief intervention in sexual health clinics in the north east of England

Background

Risky drinking is associated with risky sexual experiences, however the relationship between alcohol and sex is complex. The aim of the study was to assess the feasibility of delivering alcohol screening and brief interventions in genitourinary medicine (GUM) clinics. The objectives were to; understand the levels of alcohol use amongst patients; report on the number of alcohol interventions delivered; and to analyse the relationship between alcohol use with demographic data as well as diagnosed sexually transmitted infections (STIs) to see if there were any associations.

Methods

All new patients attending GUM between April 2012 and March 2013 self-completed the Alcohol Use Disorder Identification Test (AUDIT) prior to their clinical consultation. Where appropriate (scoring 8+ on AUDIT) the clinician would deliver up to 2–3 min of alcohol brief intervention. Descriptive statistics, t-tests, ANOVA and logistic regression were carried out as appropriate.

Results

AUDIT scores were available for 90% of all new patients (3058/3390) with an average mean score of 7.75. Of those who drank alcohol, 44% were categorised as being AUDIT positive, including 2% who had a score indicative of probable alcohol dependence (20+). 55 % (n = 638) of patients who screened positive on the AUDIT received a brief intervention whilst 24% (n = 674) of drinkers were diagnosed with a STI. Logistic regression modelling revealed that males, younger age groups and those of ‘white’ ethnicity were more likely to score positive on AUDIT. Patients classified as non-students, living in deprivation quintiles one to four and categorised as probable alcohol dependence on the AUDIT were more likely to be diagnosed with an STI.

Conclusion

It is possible to embed alcohol screening into routine practice within sexual health services however further work is required to embed brief interventions particularly amongst increasing risk drinkers. If resources are limited, services may consider more targeted rather than universal alcohol screening to specific population groups. The study was undertaken in one GUM service in the North East of England and therefore findings may not be generalizable. The study did not assess efficacy of alcohol brief intervention in this setting.

Developing an emergency department crowding dashboard: A design science approach

BACKGROUND

As an emergency department (ED) is a complex adaptive system, the analysis of continuously gathered data is valuable to gain insight in the real-time patient flow. To support the analysis and management of ED operations, relevant data should be provided in an intuitive way.

AIM

Within this context, this paper outlines the development of a dashboard which provides real-time information regarding ED crowding.

METHODS

The research project underlying this paper follows the principles of design science research, which involves the development and study of artifacts which aim to solve a generic problem. To determine the crowding indicators that are desired in the dashboard, a modified Delphi study is used. The dashboard is implemented using the open source Shinydashboard package in R.

RESULTS

A dashboard is developed containing the desired crowding indicators, together with general patient flow characteristics. It is demonstrated using a dataset of a Flemish ED and fulfills the requirements which are defined a priori.

CONCLUSIONS

The developed dashboard provides real-time information on ED crowding. This information enables ED staff to judge whether corrective actions are required in an effort to avoid the adverse effects of ED crowding.

The role of oral methotrexate as a steroid sparing agent in refractory eosinophilic asthma

The use of oral methotrexate for refractory eosinophilic asthma in a tertiary asthma referral centre, Glenfield Hospital, Leicester, was evaluated between January 2006 and December 2014. The patients (n = 61) were carefully phenotyped at baseline with markers of airway inflammation. In addition, a structured oral methotrexate proforma was utilized to evaluate response to therapy and adverse events. Oral steroid withdrawal was attempted 3 months after commencing treatment. Several outcomes were evaluated at 12 months, including both efficacy and adverse effects; 15% (n = 9/61) responded by achieving a decrease in daily oral corticosteroid dose (mean 8.43 (±8.76) mg), although we were unable to identify factors that predicted a treatment response. There were no other significant changes in any other clinical outcome measures. There was a high rate of adverse events (19/61 (31%)), primarily gastrointestinal/hepatitis. Our findings support the use of biological agents in preference to using oral methotrexate as a steroid sparing agent at the first instance. In the event of failure of these agents, oral methotrexate remains a therapeutic option, which can be considered in highly specialist severe asthma centres.