Squaring the circle: health as a bridge to global solidarity in the Sustainable Development Goals

The Sustainable Development Goals (SDGs), launched in September 2015 to follow on from the Millennium Development Goals, require action by all countries. The new goals range from traditional areas of health and education to a newer focus on global trade and environmental protection. We discuss how all countries can be incentivised to engage and commit and argue that thoughtful target-setting and benchmarking, a more aggressive focus on equity and an emphasis on the interdependence of health and non-health development goals are key to meaningful progress. Fundamental shared values and aspirations around health, and in particular child health, within SDG3 may, we argue, offer a platform on which to build genuine global solidarity.

Thrombospondin-1 and microRNA-1 expression in response to multiwalled carbon nanotubes in alveolar epithelial cells

Thrombospondin-1 (TSP-1) is a glycoprotein that plays a role in extracellular matrix (ECM) remodeling. Previously, we have shown that multiwalled carbon nanotubes (MWCNT) regulate ECM components TGFβ and its target Col3A1 in alveolar epithelial cells. In this study, we investigated the effect of MWCNT on TSP-1 and microRNA-1 (miR-1) in the regulation of TGFβ in ECM remodeling using alveolar epithelial A549 cells. A549 cells were treated with MWCNT (20 or 50 µg/mL) for 6 or 24 h and the expression of TSP-1 and miR-1, and the exogenous miR-1 effect on cell morphology were analyzed. MWCNT induced in a time- and dose-dependent manner the expression of TSP-1. miR-1 was suppressed by MWCNT after 6 or 24 h of treatment regardless of the dose. TSP-1 and miR-1 negatively correlated with each other, r = -0.58. Exogenous administration of miR-1 induced alveolar epithelial cell morphology changes including cell clustering, whereas inhibition of miR-1 induced less cell to cell contact, cell rounding, and cellular projections. IntAct molecular network interactions analysis revealed that TSP-1 interacts with 21 molecular factors including ECM genes, and molecules. These results indicate a relationship between that TSP-1, MWCNT, and TGFβ, and suggest TSP-1 may play a role in MWCNT-induced TGFβ and ECM remodeling. Moreover, these data also suggest an inverse relationship between TSP-1 and miR-1 and a potential role of miR-1 in MWCNT-induced fibrotic signaling. © 2016 Wiley Periodicals, Inc. Environ Toxicol 32: 1596-1606, 2017.

Protein arginine deiminase 4 inhibition is sufficient for the amelioration of collagen-induced arthritis

Citrullination of joint proteins by the protein arginine deiminase (PAD) family of enzymes is recognized increasingly as a key process in the pathogenesis of rheumatoid arthritis. This present study was undertaken to explore the efficacy of a novel PAD4-selective inhibitor, GSK199, in the murine collagen-induced arthritis model of rheumatoid arthritis. Mice were dosed daily from the time of collagen immunization with GSK199. Efficacy was assessed against a wide range of end-points, including clinical disease scores, joint histology and immunohistochemistry, serum and joint citrulline levels and quantification of synovial autoantibodies using a proteomic array containing joint peptides. Administration of GSK199 at 30 mg/kg led to significant effects on arthritis, assessed both by global clinical disease activity and by histological analyses of synovial inflammation, pannus formation and damage to cartilage and bone. In addition, significant decreases in complement C3 deposition in both synovium and cartilage were observed robustly with GSK199 at 10 mg/kg. Neither the total levels of citrulline measurable in joint and serum, nor levels of circulating collagen antibodies, were affected significantly by treatment with GSK199 at any dose level. In contrast, a subset of serum antibodies reactive against citrullinated and non-citrullinated joint peptides were reduced with GSK199 treatment. These data extend our previous demonstration of efficacy with the pan-PAD inhibitor Cl-amidine and demonstrate robustly that PAD4 inhibition alone is sufficient to block murine arthritis clinical and histopathological end-points.

Cohort profile: Pacific Islands Families (PIF) growth study, Auckland, New Zealand

PURPOSE

This article profiles a birth cohort of Pacific children participating in an observational prospective study and describes the study protocol used at ages 14-15 years to investigate how food and activity patterns, metabolic risk and family and built environment are related to rates of physical growth of Pacific children.

PARTICIPANTS

From 2000 to 2015, the Pacific Islands Families Study has followed, from birth, the growth and development of over 1000 Pacific children born in Auckland, New Zealand. In 2014, 931 (66%) of the original cohort had field measures of body composition, blood pressure and glycated haemoglobin. A nested subsample (n=204) was drawn by randomly selecting 10 males and 10 females from each decile of body weight. These participants had measurement of body composition by dual-energy X-ray absorptiometry, food frequency, 6 min walk test and accelerometer-determined physical activity and sedentary behaviours, and blood biomarkers for metabolic disease such as diabetes. Built environment variables were generated from individual addresses.

FINDINGS TO DATE

Compared to the Centres for Disease Control and Prevention (CDC) reference population with mean SD scores (SDS) of 0, this cohort of 931 14-year-olds was taller, weighed more and had a higher body mass index (BMI) (mean SDS height >0.6, weight >1.6 and BMI >1.4). 7 of 10 youth were overweight or obese. The nested-sampling frame achieved an even distribution by body weight.

FUTURE PLANS

Cross-sectional relationships between body size, fatness and growth rate, food patterns, activity patterns, pubertal development, risks for diabetes and hypertension and the family and wider environment will be examined. In addition, analyses will investigate relationships with data collected earlier in the life course and measures of the cohort in the future. Understanding past and present influences on child growth and health will inform timely interventions to optimise future health and reduce inequalities for Pacific people.

Does somatosensation change with age in children and adolescents? A systematic review

BACKGROUND

Somatosensory modalities, such as touch, proprioception and haptic ability, greatly influence the achievement of developmental milestones for children. Describing somatosensory impairment, natural variability and typical or expected developmental changes across age groups will help establish frameworks for intervention in clinical populations. This systematic review aimed to determine how different somatosensory modalities develop across childhood into adolescence to use as a point of reference for children at risk of somatosensory impairment.

METHODS

Searches of five electronic databases were undertaken through EBSCO-host (MEDLINE, CINAHL, PsycINFO, SPORTDiscus and ERIC) for studies measuring at least one somatosensory modality in typically developing individuals between birth and 18 years and analysed by age. Characteristics of studies were collected including country of origin, sample size, demographics and outcome measure used. Quality assessment and data extraction were performed by two independent reviewers.

RESULTS

Twenty three cross-sectional studies were included from a total of 188 articles retrieved: 8 examined aspects of touch, 5 proprioception and 10 haptic ability. Variability of study designs and variation in assessment tools precluded any formal meta-analysis.

CONCLUSIONS

Somatosensation matures through childhood into adolescence; however, the present review found the pattern of somatosensory development varied depending on the assessment tool used and the aspect of somatosensation being measured, making it difficult to describe typical performance. There is a need for comprehensive assessment batteries to measure the somatosensation, including touch, proprioception and haptic ability, of children at risk of somatosensory impairment to aid in the development of effective interventions.

Relationship between physical function and biomechanical gait patterns in boys with haemophilia

INTRODUCTION

The World Federation of Haemophilia recommends joint and muscle health is evaluated using X-ray and magnetic resonance imaging, together with clinical examination scores. To date, inclusion of performance-based functional activities to monitor children with the condition has received little attention.

AIM

To evaluate test-retest repeatability of physical function tests and quantify relationships between physical function, lower limb muscle strength and gait patterns in young boys with haemophilia.

METHODS

Timed 6-minute walk, timed up and down stairs, timed single leg stance, muscle strength of the knee extensors, ankle dorsi and plantar flexors, together with joint biomechanics during level walking were collected from 21 boys aged 6-12 years with severe haemophilia.

RESULTS

Measures of physical function and recording of muscle strength with a hand-held myometer were repeatable (ICC > 0.78). Distances walked in six minutes, time taken to go up and down a flight of stairs and lower limb muscle strength correlated closely with ankle range of motion, together with peak knee flexion and ankle dorsi and plantarflexion moments during walking (P < 0.05).

CONCLUSION

Alterations in gait patterns of boys with haemophilia appear to be associated with changes in performance of physical function and performance seems to depend on their muscle strength. Timed 6-minute walk test, timed up and down steps test and muscle strength of the knee extensors showed the strongest correlation with biomechanical joint function, and hence might serve as a basis for the clinical monitoring of physical function outcomes in children with haemophilia.

Gamification for health promotion: systematic review of behaviour change techniques in smartphone apps

OBJECTIVE

Smartphone games that aim to alter health behaviours are common, but there is uncertainty about how to achieve this. We systematically reviewed health apps containing gaming elements analysing their embedded behaviour change techniques.

METHODS

Two trained researchers independently coded apps for behaviour change techniques using a standard taxonomy. We explored associations with user ratings and price.

DATA SOURCES

We screened the National Health Service (NHS) Health Apps Library and all top-rated medical, health and wellness and health and fitness apps (defined by Apple and Google Play stores based on revenue and downloads). We included free and paid English language apps using 'gamification' (rewards, prizes, avatars, badges, leaderboards, competitions, levelling-up or health-related challenges). We excluded apps targeting health professionals.

RESULTS

64 of 1680 (4%) health apps included gamification and met inclusion criteria; only 3 of these were in the NHS Library. Behaviour change categories used were: feedback and monitoring (n=60, 94% of apps), reward and threat (n=52, 81%), and goals and planning (n=52, 81%). Individual techniques were: self-monitoring of behaviour (n=55, 86%), non-specific reward (n=49, 82%), social support unspecified (n=48, 75%), non-specific incentive (n=49, 82%) and focus on past success (n=47, 73%). Median number of techniques per app was 14 (range: 5-22). Common combinations were: goal setting, self-monitoring, non-specific reward and non-specific incentive (n=35, 55%); goal setting, self-monitoring and focus on past success (n=33, 52%). There was no correlation between number of techniques and user ratings (p=0.07; r_s=0.23) or price (p=0.45; r_s=0.10).

CONCLUSIONS

Few health apps currently employ gamification and there is a wide variation in the use of behaviour change techniques, which may limit potential to improve health outcomes. We found no correlation between user rating (a possible proxy for health benefits) and game content or price. Further research is required to evaluate effective behaviour change techniques and to assess clinical outcomes.

TRIAL REGISTRATION NUMBER

CRD42015029841.

The Three-item ALERT-B Questionnaire Provides a Validated Screening Tool to Detect Chronic Gastrointestinal Symptoms after Pelvic Radiotherapy in Cancer Survivors

AIMS

Although pelvic radiotherapy is an effective treatment for various malignancies, around half of patients develop significant gastrointestinal problems. These symptoms often remain undetected, despite the existence of effective treatments. This study developed and refined a simple screening tool to detect common gastrointestinal symptoms in outpatient clinics. These symptoms have a significant effect on quality of life. This tool will increase detection rates and so enable access to specialist gastroenterologists, which will in turn lead to improved symptom control and quality of life after treatment.

MATERIALS AND METHODS

A literature review and expert consensus meeting identified four items for the ALERT-B (Assessment of Late Effects of RadioTherapy - Bowel) screening tool. ALERT-B was face tested for its usability and acceptability using cognitive interviews with 12 patients experiencing late gastrointestinal symptoms after pelvic radiotherapy. Thematic analysis and probe category were used to analyse interview transcripts. Interview data were presented to a group of experts to agree on the final content and format of the tool. ALERT-B was assessed for reliability and tested for validity against the Gastrointestinal Symptom Rating Scale in a clinical study (EAGLE).

RESULTS

Overall, the tool was found to be acceptable in terms of wording, response format and completion time. Participant-reported experiences, including lifestyle modifications and the psychological effect of the symptoms, led to further modifications of the tool. The refined tool includes three questions covering rectal bleeding, incontinence, nocturnal bowel movements and impact on quality of life, including mood, relationships and socialising. ALERT-B was successfully validated against the Gastrointestinal Symptom Rating Scale in the EAGLE study with the tool shown broadly to be internally consistent (Cronbach's α = 0.61 and all item-subscale correlation [Spearman] coefficients are > 0.6).

CONCLUSION

The ALERT-B screening tool can be used in clinical practice to improve post-treatment supportive care by triggering the clinical assessment of patients suitable for referral to a gastroenterologist.

Evaluating hospital at home and early discharge schemes for patients with an acute exacerbation of COPD

Hospital at home and early discharge schemes for patients experiencing an acute exacerbation of their chronic obstructive pulmonary disease, appear to be an effective and safe option for selected patients and these services have become increasingly common. Here we discuss the evaluation of such schemes including: the rationale for evaluation; aspects of quality which might be considered for evaluation; the role of evaluation frameworks, quantitative and qualitative evaluation and steps in planning an evaluation.

Colonic response to laxative ingestion as assessed by MRI differs in constipated irritable bowel syndrome compared to functional constipation

BACKGROUND

Functional constipation (FC) and irritable bowel syndrome with constipation (IBS-C) share many symptoms but underlying mechanisms may be different. We have developed a magnetic resonance imaging (MRI) technique to measure intestinal volumes, transit, and motility in response to a laxative, Moviprep(®) . We aim to use these biomarkers to study the pathophysiology in IBS-C and FC.

METHODS

Twenty-four FC and 24 IBS-C were studied. Transit was assessed using the weighted average position score (WAPS) of five MRI marker pills, taken 24 h before MRI scanning. Following baseline scan, participants ingested 1 L of Moviprep(®) followed by hourly scans. Magnetic resonance imaging parameters and bowel symptoms were scored from 0 to 4 h.

KEY RESULTS

Weighted average position score for FC was 3.6 (2.5-4.2), significantly greater than IBS-C at 2.0 (1.5-3.2), p = 0.01, indicating slower transit for FC. Functional constipation showed greater fasting small bowel water content, 83 (63-142) mL vs 39 (15-70) mL in IBS-C, p < 0.01 and greater ascending colon volume (AC), 314 (101) mL vs 226 (71) mL in IBS-C, p < 0.01. FC motility index was lower at 0.055 (0.044) compared to IBS-C, 0.107 (0.070), p < 0.01. Time to first bowel movement following ingestion of Moviprep(®) was greater for FC, being 295 (116-526) min, compared to IBS-C at 84 (49-111) min, p < 0.01, and correlated with AC volume 2 h after Moviprep(®) , r = 0.44, p < 0.01. Using a cut-off >230 min distinguishes FC from IBS-C with low sensitivity of 55% but high specificity of 95%.

CONCLUSION & INFERENCES

Our objective MRI biomarkers allow a distinction between FC and IBS-C.

A global survey of HIV-positive people's attitudes towards cure research

OBJECTIVES

Involvement of people living with HIV (PLHIV) in the design of HIV cure studies is important, given the potential risks to participants. We present results of an international survey of PLHIV to define these issues and inform cure research.

METHODS

PLHIV were recruited in June-November 2014 through HIV websites, advocacy forums, social media and 12 UK HIV clinics. The survey included questions concerning demographics, HIV disease history, the desirability of types of cure and the patient's willingness to accept potential toxicity and treatment interruption (TI). We examined factors associated with TI and willingness to accept substantial risks.

RESULTS

A total of 982 PLHIV completed the survey; 87% were male, 79% white and 81% men who have sex with men (MSM). Fifty-one per cent were aged 25-44 years and 69% were UK residents. The median time since diagnosis was 7 years [interquartile range (IQR) 2-17 years]. Eighty-eight per cent were receiving antiretrovirals (91% reported undetectable viral load). Health/wellbeing improvements (96%) and an inability to transmit HIV (90%) were more desirable cure characteristics than testing HIV-negative (69%). Ninety-five per cent were interested in participating in cure studies, and 59% were willing to accept substantial risks. PLHIV with a low CD4 count [201-350 cells/μL vs. ≥ 350 cells/μL; odds ratio (OR) 2.11; 95% confidence interval (CI) 1.11-4.00] were more likely to accept risks, whereas those with limited knowledge of HIV treatments vs. excellent/good knowledge and those aged ≥ 65 years vs. 45-64 years were less likely to accept risks [OR 0.58 (95% CI 0.37-0.90) and OR 0.18 (95% CI 0.07-0.45), respectively]. TI was acceptable for 62% of participants, with the main concerns being becoming unwell (82%), becoming infectious (76%) and HIV spreading through the body (76%).

CONCLUSIONS

Cure research was highly acceptable to the PLHIV surveyed. Most individuals would accept risks, including TI, even in the absence of personal benefit. An optimal cure would improve health and minimize onward transmission risk.

Integrating smoking cessation into routine care in hospitals--a randomized controlled trial

AIMS

To evaluate the effectiveness of a pharmacist-led multi-component smoking cessation programme (GIVE UP FOR GOOD) compared with usual care in hospitalized smokers.

DESIGN

Randomized, assessor-blinded, parallel-group trial.

SETTING

Three tertiary public hospitals in Australia.

PARTICIPANTS

A total of 600 adult in-patient smokers [mean ± standard deviation (SD), age 51 ± 14 years; 64% male] available for 12 months follow-up.

INTERVENTIONS

Multi-component hospital pharmacist-led behavioural counselling and/or pharmacotherapy provided during hospital stay, on discharge and 1 month post-discharge, with further support involving community health professionals (n = 300). Usual care comprised routine care provided by hospitals (n = 300).

MEASUREMENTS

Two primary end-points were tested using intention-to-treat analysis: carbon monoxide (CO)-validated 1-month sustained abstinence at 6-month follow-up and verified 6-month sustained abstinence at 12-month follow-up. Smoking status and pharmacotherapy usage were assessed at baseline, discharge, 1, 6 and 12 months.

FINDINGS

Sustained abstinence rates for intervention and control groups were not significantly different at both 6 months [11.6% (34 of 294) versus 12.6% (37 of 294); odds ratio (OR) = 0.91, 95% confidence interval (CI) = 0.55-1.50] and 12 months [11.6% (34 of 292) versus 11.2% (33 of 294); OR = 1.04, 95% CI = 0.63-1.73]. Secondary end-points, self-reported continuous abstinence at 6 and 12 months, also agreed with the primary end-points. Use of pharmacotherapy was higher in the intervention group, both during hospital stay [52.3% (157 of 300) versus 42.7% (128 of 300); P = 0.016] and after discharge [59.6% (174 of 292) versus 43.5% (128 of 294); P < 0.001].

CONCLUSIONS

A pharmacist-led multi-component smoking cessation intervention provided during hospital stay did not improve sustained abstinence rates at either 6 or 12 months compared with routine hospital care.

[Bilateral adrenal hemorrhage (BAH): cannabis and vascular involvement]

We report the case of a 39-year-old man with bilateral adrenal haemorrhage. The diagnosis is rarely primarily made with imaging alone. Our patient had a previous history of a stroke six years prior to this episode. We evoke the possibility that long-term daily cannabis use could be the underlying cause of the patient's vascular pathologies. After thorough review of existing literature, this link was found to be probable. Cannabis is the most consumed recreational drug in the world, and this tendency is ever-increasing. Serious complications other than psychiatric resulting from consumption are reported with increasing frequency. Neurological, cerebrovascular, cardiovascular and respiratory complications have been observed. It is thus important to remain vigilant when patients are hospitalised notably through the emergency department, in order to obtain a complete anamnesis, optimise screening, and to adapt the treatment of these patients.

Occurrence and origin of methane in groundwater in Alberta (Canada): Gas geochemical and isotopic approaches

To assess potential future impacts on shallow aquifers by leakage of natural gas from unconventional energy resource development it is essential to establish a reliable baseline. Occurrence of methane in shallow groundwater in Alberta between 2006 and 2014 was assessed and was ubiquitous in 186 sampled monitoring wells. Free and dissolved gas sampling and measurement approaches yielded comparable results with low methane concentrations in shallow groundwater, but in 28 samples from 21 wells methane exceeded 10mg/L in dissolved gas and 300,000 ppmv in free gas. Methane concentrations in free and dissolved gas samples were found to increase with well depth and were especially elevated in groundwater obtained from aquifers containing coal seams and shale units. Carbon isotope ratios of methane averaged -69.7 ± 11.1‰ (n=63) in free gas and -65.6 ± 8.9‰ (n=26) in dissolved gas. δ(13)C values were not found to vary with well depth or lithology indicating that methane in Alberta groundwater was derived from a similar source. The low δ(13)C values in concert with average δ(2)HCH4 values of -289 ± 44‰ (n=45) suggest that most methane was of biogenic origin predominantly generated via CO2 reduction. This interpretation is confirmed by dryness parameters typically >500 due to only small amounts of ethane and a lack of propane in most samples. Comparison with mud gas profile carbon isotope data revealed that methane in the investigated shallow groundwater in Alberta is isotopically similar to hydrocarbon gases found in 100-250 meter depths in the WCSB and is currently not sourced from thermogenic hydrocarbon occurrences in deeper portions of the basin. The chemical and isotopic data for methane gas samples obtained from Alberta groundwater provide an excellent baseline against which potential future impact of deeper stray gases on shallow aquifers can be assessed.

Evolution of multi-parametric MRI quantitative parameters following transrectal ultrasound-guided biopsy of the prostate

BACKGROUND

To determine the evolution of prostatic multi-parametric magnetic resonance imaging (mp-MRI) signal following transrectal ultrasound (TRUS)-guided biopsy.

METHODS

Local ethical permission and informed written consent was obtained from all the participants (n=14, aged 43-69, mean 64 years). Patients with a clinical suspicion of prostate cancer (PSA range 2.2-11.7, mean 6.2) and a negative (PIRAD 1-2/5) pre-biopsy mp-MRI (pre-contrast T1, T2, diffusion-weighted and dynamic-contrast-enhanced MRI) who underwent 10-core TRUS-guided biopsy were recruited for additional mp-MRI examinations performed at 1, 2 and 6 months post biopsy. We quantified mp-MRI peripheral zone (PZ) and transition zone (TZ) normalized T2 signal intensity (nT2-SI); T1 relaxation time (T10); diffusion-weighted MRI, apparent diffusion coefficient (ADC); dynamic contrast-enhanced MRI, maximum enhancement (ME); slope of enhancement (SoE) and area-under-the-contrast-enhancement-curve at 120 s (AUC120). Significant changes in mp-MRI parameters were identified by analysis of variance with Dunnett's post testing.

RESULTS

Diffuse signal changes were observed post-biopsy throughout the PZ. No significant signal change occurred following biopsy within the TZ. Left and right PZ mean nT2-SI (left PZ: 5.73, 5.16, 4.90 and 5.12; right PZ: 5.80, 5.10, 4.84 and 5.05 at pre-biopsy, 1, 2 and 6 months post biopsy, respectively) and mean T10 (left PZ: 1.02, 0.67, 0.78, 0.85; right PZ: 1.29, 0.64, 0.78, 0.87 at pre-biopsy, 1, 2 and 6 months post biopsy, respectively) were reduced significantly (P<0.05) from pre-biopsy values for up to 6 months post biopsy. Significant changes (P<0.05) of PZ-ME and AUC120 were observed at 1 month but resolved by 2 months post biopsy. PZ ADC did not change significantly following biopsy (P=0.23-1.0). There was no significant change of any TZ mp-MRI parameter at any time point following biopsy (P=0.1-1.0).

CONCLUSIONS

Significant PZ (but not TZ) T2 signal changes persist up to 6 months post biopsy, whereas PZ and TZ ADC is not significantly altered as early as 1 month post biopsy. Caution must be exercised when interpreting T1- and T2-weighted imaging early post biopsy, whereas ADC images are more likely to maintain clinical efficacy.

Multiparametric MRI for detection of radiorecurrent prostate cancer: added value of apparent diffusion coefficient maps and dynamic contrast-enhanced images

BACKGROUND

Multiparametric magnetic resonance imaging (mp-MRI) is increasingly advocated for prostate cancer detection. There are limited reports of its use in the setting of radiorecurrent disease. Our aim was to assess mp-MRI for detection of radiorecurrent prostate cancer and examine the added value of its functional sequences.

METHODS

Thirty-seven men with mean age of 69.7 (interquartile range, 66-74) with biochemical failure after external beam radiotherapy underwent mp-MRI (T2-weighted, high b-value, multi-b-value apparent diffusion coefficient (ADC) and dynamic contrast-enhanced (DCE) imaging); then transperineal systematic template prostate mapping (TPM) biopsy. Using a locked sequential read paradigm (with the sequence order above), two experienced radiologists independently reported mp-MRI studies using score 1-5. Radiologist scores were matched with TPM histopathology at the hemigland level (n=74). Accuracy statistics were derived for each reader. Interobserver agreement was evaluated using kappa statistics.

RESULTS

Receiver-operator characteristic area under curve (AUC) for readers 1 and 2 increased from 0.67 (95% confidence interval (CI), 0.55-0.80) to 0.80 (95% CI, 0.69-0.91) and from 0.67 (95% CI, 0.55-0.80) to 0.84 (95% CI, 0.76-0.93), respectively, between T2-weighted imaging alone and full mp-MRI reads. Addition of ADC maps and DCE imaging to the examination did not significantly improve AUC for either reader (P=0.08 and 0.47 after adding ADC, P=0.90 and 0.27 after adding DCE imaging) compared with T2+high b-value review. Inter-reader agreement increased from k=0.39 to k=0.65 between T2 and full mp-MRI review.

CONCLUSIONS

mp-MRI can detect radiorecurrent prostate cancer. The optimal examination included T2-weighted imaging and high b-value DWI; adding ADC maps and DCE imaging did not significantly improve the diagnostic accuracy.

The effect of buffering dairy cow diets with limestone, calcareous marine algae, or sodium bicarbonate on ruminal pH profiles, production responses, and rumen fermentation

Six ruminally cannulated Holstein cows were used to evaluate the effect of 2 dietary buffers on rumen pH, milk production, milk composition, and rumen fermentation parameters. A high concentrate total mixed ration [35.2% forage dry matter (DM)], formulated to be potentially acidotic, was used to construct 3 dietary treatments in which calcareous marine algae (calcified remains of the seaweed Lithothamnium calcareum) was compared with limestone (control) and sodium bicarbonate plus limestone. One basal diet was formulated and the treatment diets contained either 0.4% of dietary DM as Acid Buf, a calcified marine algae product (AB treatment), or 0.8% of dietary DM as sodium bicarbonate and 0.37% as limestone (BC treatment), or 0.35% of dietary DM as limestone [control (CON) treatment]. Cows were randomly allocated to treatments according to a double 3×3 Latin square design, with 3 treatments and 3 periods. The total experimental period was 66 d during which each cow received each treatment for a period of 15 d before the data collection period of 7 d. Rumen fluid was collected to determine volatile fatty acids, lactic acid, and ammonia concentrations. Rumen pH was monitored every 10min for 2 consecutive days using a portable data logging system fitted with in-dwelling electrodes. Milk samples were analyzed for solid and mineral contents. The effect of treatment on acidity was clearly visible, especially from the period from midday to midnight when rumen pH dropped below 5.5 for a longer period of time (13 h) in the CON treatment than in the BC (8.7 h) and AB (4 h) treatments. Daily milk, 4% fat-corrected milk, and energy-corrected milk yields differed among treatments, with AB being the highest, followed by BC and CON. Both buffers increased milk fat content. Treatment had no effect on milk protein content, but protein yield was increased in the AB treatment. Total rumen volatile fatty acids and acetate concentrations were higher and propionate was lower in the AB treatment than in CON. The molar proportion of acetate was higher in AB than in CON, but that of propionate was lower in both buffer treatments than in CON. The acetate:propionate ratio was increased in the AB and BC treatments compared with CON. Lactic acid concentration was higher in the CON treatment than in the buffer treatments. Treatment had no effect on rumen ammonia concentrations. Results indicated that buffer inclusion in high concentrate diets for lactating dairy cows had a positive effect on milk production and milk composition. Calcareous marine algae, at a level of 90 g/cow per day, had a greater effect on rumen pH, milk production and milk composition, and efficiency of feed conversion into milk than sodium bicarbonate at a level of 180 g/cow per day.

Diagnosis of Helicobacter pylori by carbon-13 urea breath test using a portable mass spectrometer

Context:

In the non-invasive detection of markers of disease, mass spectrometry is able to detect small quantities of volatile markers in exhaled air. However, the problem of size, expense and immobility of conventional mass spectrometry equipment has restricted its use. Now, a smaller, less expensive, portable quadrupole mass spectrometer system has been developed. Helicobacter pylori has been implicated in the development of chronic gastritis, gastric and duodenal ulcers and gastric cancer.

Objectives:

To compare the results obtained from the presence of H. pylori by a carbon-13 urea test using a portable quadrupole mass spectrometer system with those from a fixed mass spectrometer in a hospital-based clinical trial.

Methods:

Following ethical approval, 45 patients attending a gastroenterology clinic at the Royal Liverpool University Hospital exhaled a breath sample into a Tedlar gas sampling bag. They then drank an orange juice containing urea radiolabelled with carbon and 30 min later gave a second breath sample. The carbon-13 content of both samples was measured using both quadrupole mass spectrometer systems. If the post-drink level exceeded the pre-drink level by 3% or more, a positive diagnosis for the presence of H. pylori was made.

Results:

The findings were compared to the results using conventional isotope ratio mass spectrometry using a laboratory-based magnetic sector instrument off-site. The results showed agreement in 39 of the 45 patients.

Conclusions:

This study suggests that a portable quadrupole mass spectrometer is a potential alternative to the conventional centralised testing equipment. Future development of the portable quadrupole mass spectrometer to reduce further its size and cost is indicated, together with further work to validate this new equipment and to enhance its use in mass spectrometry diagnosis of other medical conditions.

A review of equine sepsis

Sepsis is defined as an exaggerated, systemic inflammatory response to infection and is a common condition in horses. Systemic inflammatory response syndrome (SIRS) associated with bacterial infection is a hallmark of sepsis. Sepsis in neonatal foals is a common sequela of failure of passive transfer and, in addition to development of SIRS, may be characterised by bacteraemia, pneumonia, enterocolitis, omphalophlebitis, meningoencephalitis or arthritis. Sepsis in mature horses is most commonly observed secondary to gastrointestinal lesions that result in disrupted mucosa and bacterial translocation into circulation (endotoxaemia). Pleuropneumonia and metritis may also cause sepsis in mature horses. Diagnosis of sepsis is based on SIRS criteria as well as suspected or confirmed infection. Due to the relatively low sensitivity of microbial culture and the subjectivity of sepsis scoring, many sepsis biomarkers are being studied for their usefulness in diagnosis and prognostication of sepsis in horses. Treatment of sepsis requires an intensive care approach that includes antimicrobial drug administration, fluid resuscitation and pressure support, and treatment for inflammation, endotoxaemia and coagulopathy. Early recognition of sepsis and prompt antimicrobial drug treatment are critical for a successful outcome. Multiple organ dysfunction syndrome may occur in severe cases of sepsis, with common manifestations including laminitis and coagulopathies. Although prognosis for septic mature horses depends highly on the primary disease process, the overall survival rate in septic neonatal foals ranges from 26 to 86%, with most studies indicating a survival rate of 45-60%.

Search for superconductivity in micrometeorites

We have developed a very sensitive, highly selective, non-destructive technique for screening inhomogeneous materials for the presence of superconductivity. This technique, based on phase sensitive detection of microwave absorption is capable of detecting 10⁻¹² cc of a superconductor embedded in a non-superconducting, non-magnetic matrix. For the first time, we apply this technique to the search for superconductivity in extraterrestrial samples. We tested approximately 65 micrometeorites collected from the water well at the Amundsen-Scott South pole station and compared their spectra with those of eight reference materials. None of these micrometeorites contained superconducting compounds, but we saw the Verwey transition of magnetite in our microwave system. This demonstrates that we are able to detect electro-magnetic phase transitions in extraterrestrial materials at cryogenic temperatures.

Economic modelling of diagnostic and treatment pathways in National Institute for Health and Care Excellence clinical guidelines: the Modelling Algorithm Pathways in Guidelines (MAPGuide) project

BACKGROUND

National Institute for Health and Care Excellence (NICE) clinical guidelines (CGs) make recommendations across large, complex care pathways for broad groups of patients. They rely on cost-effectiveness evidence from the literature and from new analyses for selected high-priority topics. An alternative approach would be to build a model of the full care pathway and to use this as a platform to evaluate the cost-effectiveness of multiple topics across the guideline recommendations.

OBJECTIVES

In this project we aimed to test the feasibility of building full guideline models for NICE guidelines and to assess if, and how, such models can be used as a basis for cost-effectiveness analysis (CEA).

DATA SOURCES

A 'best evidence' approach was used to inform the model parameters. Data were drawn from the guideline documentation, advice from clinical experts and rapid literature reviews on selected topics. Where possible we relied on good-quality, recent UK systematic reviews and meta-analyses.

REVIEW METHODS

Two published NICE guidelines were used as case studies: prostate cancer and atrial fibrillation (AF). Discrete event simulation (DES) was used to model the recommended care pathways and to estimate consequent costs and outcomes. For each guideline, researchers not involved in model development collated a shortlist of topics suggested for updating. The modelling teams then attempted to evaluate options related to these topics. Cost-effectiveness results were compared with opinions about the importance of the topics elicited in a survey of stakeholders.

RESULTS

The modelling teams developed simulations of the guideline pathways and disease processes. Development took longer and required more analytical time than anticipated. Estimates of cost-effectiveness were produced for six of the nine prostate cancer topics considered, and for five of eight AF topics. The other topics were not evaluated owing to lack of data or time constraints. The modelled results suggested 'economic priorities' for an update that differed from priorities expressed in the stakeholder survey.

LIMITATIONS

We did not conduct systematic reviews to inform the model parameters, and so the results might not reflect all current evidence. Data limitations and time constraints restricted the number of analyses that we could conduct. We were also unable to obtain feedback from guideline stakeholders about the usefulness of the models within project time scales.

CONCLUSIONS

Discrete event simulation can be used to model full guideline pathways for CEA, although this requires a substantial investment of clinical and analytic time and expertise. For some topics lack of data may limit the potential for modelling. There are also uncertainties over the accessibility and adaptability of full guideline models. However, full guideline modelling offers the potential to strengthen and extend the analytical basis of NICE's CGs. Further work is needed to extend the analysis of our case study models to estimate population-level budget and health impacts. The practical usefulness of our models to guideline developers and users should also be investigated, as should the feasibility and usefulness of whole guideline modelling alongside development of a new CG.

FUNDING

This project was funded by the Medical Research Council and the National Institute for Health Research through the Methodology Research Programme [grant number G0901504] and will be published in full in Health Technology Assessment; Vol. 17, No. 58. See the NIHR Journals Library website for further project information.

The impact of brief tobacco treatment training on practice behaviours, self-efficacy and attitudes among healthcare providers

INTRODUCTION AND PURPOSE

The need for aggressive efforts to help tobacco users quit remains a healthcare priority. Brief interventions delivered in the healthcare environment continue to be a valuable component of a comprehensive tobacco control policy. Unfortunately, such treatments are offered less often than desired, and quality is variable. Previous research has demonstrated the value of training experiences in increasing treatment availability, quality, as well as improving clinical outcomes. Less is known about how specific clinical activities and other features are impacted as a function of training. These issues were explored within the context of a standardised 5A's (ASK, ADVISE, ASSESS, ASSIST, ARRANGE) brief intervention training program.

METHODS

A variety of healthcare providers participated in this study. Survey methodology was employed to collect Practice Behaviour, Self-Efficacy and Attitude ratings at pretraining, post training and 6-month follow-up. Linear mixed effects models were used to evaluate primary outcomes, and linear regression to explore the relationships among clinical variables.

RESULTS

Pretraining data suggested overall modest levels of tobacco treatment activity, with limited direct intervention (ASSIST) or follow-up (ARRANGE) efforts. The training experience was shown to have a substantial and sustained impact on 5A's Practice Behaviour ratings, and other clinical indicators (all Pre vs. Post and Pre vs. Follow-up comparisons p < 0.001). Self-Efficacy at post training predicted practice behaviours at follow-up (for ADVISE, ASSESS, ASSIST and ARRANGE: all p's < 0.05).

CONCLUSIONS

The value of a structured training experience was confirmed, and findings served to clarify the specific nature of training program impact.

MGMT promoter hypermethylation and K-RAS, PTEN and TP53 mutations in tamoxifen-exposed and non-exposed endometrial cancer cases

BACKGROUND

Tamoxifen has anti-oestrogenic and anti-tumour activity in the breast, but is oestrogenic and carcinogenic in the endometrium. It can induce experimental tumours by both hormonal and DNA-damaging mechanisms, but its carcinogenic mode of action in human endometrium remains unclear.

METHODS

We investigated whether an epigenetic mechanism, involving promoter hypermethylation of the gene for the DNA repair enzyme MGMT (O6-methylguanine DNA methyltransferase), was associated with K-RAS, TP53 and PTEN mutations in endometrial tumours from women treated with tamoxifen (TAM, n=30) or unexposed to the drug (EC, n=38).

RESULTS

There were significant (P<0.05) differences in tumour grade between the TAM and EC groups, with more favourable morphology in the latter. K-RAS mutations, predominantly G>A, occurred in small numbers in both groups. TP53 mutations were of mainly A>G, C>T and indel modifications in both groups, but more frequent in TAM cases. PTEN mutations dominated in EC tumours and were of the type that has large impact on protein function, such as indel or nonsense mutations. These observations alongside the mutational spectrum in PTEN suggest that the malignancies arise from different backgrounds, hence pointing to an effect of tamoxifen. Both groups displayed MGMT promoter hypermethylation. This coincided with mutations more frequently in the TAM (78%) than in the EC (50%) group, even though there were significantly (P<0.05) fewer mutations and methylations in TAM cases.

CONCLUSIONS

Although the difference in coincidence did not reach significance with the current sample size, the findings suggest that epigenetic processes may play a role in the way tamoxifen induces endometrial cancer.