UK health performance: findings of the Global Burden of Disease Study 2010

Elective alcohol detoxification - a resource and efficacy evaluation

An evaluation was performed to assess efficacy and resource utilisation of an elective inpatient alcohol detoxification service at a large inner-city teaching hospital. Abstinence rates at 3, 6 and 12 months post-detoxification were 68.1, 44.7 and 36.2%, respectively. Relapse was associated with referrals from acute hospital services, previous detoxifications, longer time between referral and admission for detoxification, presence of alcohol in the blood on the day of admission and requirement for benzodiazepines during withdrawal. The service operates within the national 18-week referral target and runs at a cost substantially lower than that of residential alcohol detoxification facilities but with similar sobriety rates. We demonstrate that elective detoxification with specialist follow-up provides an effective service both in terms of patient outcomes and resource use. Further investment in these services at both local and national level should be considered.

Peak Pruritus Numerical Rating Scale: psychometric validation and responder definition for assessing itch in moderate-to-severe atopic dermatitis

BACKGROUND

Moderate-to-severe atopic dermatitis (AD) is a chronic disease characterized by intense, persistent and debilitating itch, resulting in sleep deprivation, signs of anxiety and depression, impaired quality of life and reduced productivity. The Peak Pruritus Numerical Rating Scale (NRS) was developed and validated as a single-item, patient-reported outcome (PRO) of itch severity.

OBJECTIVES

To describe the content validity and psychometric assessment (test-retest reliability, construct validity, known-groups validity, sensitivity to change) of the Peak Pruritus NRS, and to derive empirically a responder definition to identify adults with a meaningful change in itch.

METHODS

Content validity was assessed through in-depth patient interviews. Psychometric assessments used data from phase IIb and phase III dupilumab clinical trials and included test-retest reliability, construct validity, known-groups validity and sensitivity to change in patients with moderate-to-severe AD.

RESULTS

Interview participants indicated that the Peak Pruritus NRS was a relevant, clear and comprehensive assessment of itch severity. Peak Pruritus NRS scores showed large, positive correlations with existing PRO measures of itch, and weak or moderate correlations with clinician-reported measures assessing objective signs of AD. Peak Pruritus NRS score improvements were highly correlated with improvements in other itch PROs, and moderately correlated with improvements in clinician-reported measures assessing objective signs of AD. The most appropriate threshold for defining a clinically relevant, within-person response was ≥ 2-4-point change in the Peak Pruritus NRS.

CONCLUSIONS

The Peak Pruritus NRS is a well-defined, reliable, sensitive and valid scale for evaluating worst itch intensity in adults with moderate-to-severe AD.

Comparative trends in coronary heart disease subgroup hospitalisation rates in England and Australia

Background

Population-based coronary heart disease (CHD) studies have focused on myocardial infarction (MI) with limited data on trends across the spectrum of CHD. We investigated trends in hospitalisation rates for acute and chronic CHD subgroups in England and Australia from 1996 to 2013.

Methods

CHD hospitalisations for individuals aged 35–84 years were identified from electronic hospital data from 1996 to 2013 for England and Australia and from the Oxford Region and Western Australia. CHD subgroups identified were acute coronary syndromes (ACS) (MI and unstable angina) and chronic CHD (stable angina and ‘other CHD’). We calculated age-standardised and age-specific rates and estimated annual changes (95% CI) from age-adjusted Poisson regression.

Results

From 1996 to 2013, there were 4.9 million CHD hospitalisations in England and 2.6 million in Australia (67% men). From 1996 to 2003, there was between-country variation in the direction of trends in ACS and chronic CHD hospitalisation rates (p<0.001). During 2004–2013, reductions in ACS hospitalisation rates were greater than for chronic CHD hospitalisation rates in both countries, with the largest subgroup declines in unstable angina (England: men: −7.1 %/year, 95% CI −7.2 to –7.0; women: −7.5 %/year, 95% CI −7.7 to –7.3; Australia: men: −8.5 %/year, 95% CI −8.6 to –8.4; women: −8.6 %/year, 95% CI −8.8 to –8.4). Other CHD rates increased in individuals aged 75–84 years in both countries. Chronic CHD comprised half of all CHD admissions, with the majority involving angiography or percutaneous coronary intervention.

Conclusions

Since 2004, rates of all CHD subgroups have fallen, with greater declines in acute than chronic presentations. The slower declines and high proportion of chronic CHD admissions undergoing coronary procedures requires greater focus.

Supporting informed choice in acupuncture: effects of a new person-, evidence- and theory-based website for patients with back pain

OBJECTIVES

To test whether a newly developed person-, theory- and evidence-based website about acupuncture helps patients make informed decisions about whether or not to use acupuncture for back pain.

METHODS

A randomised online study compared a newly developed 'enhanced website' to a 'standard website'. The enhanced website provided evidence-based information in a person-based manner and targeted psychological constructs. The standard website was based on a widely used patient information leaflet. In total, 350 adults with recent self-reported back pain were recruited from general practices in South West England. The two primary outcomes were knowledge change and making an informed choice about using acupuncture. Secondary outcomes were beliefs about and willingness to have acupuncture.

RESULTS

Participants who viewed the enhanced acupuncture website had a significantly greater increase in knowledge about acupuncture (M = 1.1, standard deviation (SD) = 1.7) than participants who viewed the standard website (M = 0.2, SD = 1.1; F(1, 315) = 37.93, p < 0.001, η² = .107). Participants who viewed the enhanced acupuncture website were also 3.3 times more likely to make an informed choice about using acupuncture than those who viewed the standard website (χ²(1) = 23.46, p < 0.001). There were no significant effects on treatment beliefs or willingness to have acupuncture.

CONCLUSION

The enhanced website improved patients' knowledge and ability to make an informed choice about acupuncture, but did not optimise treatment beliefs or change willingness to have acupuncture. The enhanced website could be used to support informed decision-making among primary care patients and members of the general public considering using acupuncture for back pain.

Hospital Care and Surgical Treatment of Children With Congenital Upper Limb Defects

BACKGROUND AND AIMS

To evaluate hospital care of children with congenital upper limb defects.

MATERIALS AND METHODS

Three hundred and sixty-two children with an upper limb defect, born 1993-2005, and alive after birth admission were identified in the Finnish Register of Congenital Malformations. The data on hospital care, with focus on operative treatment, were collected from the National Hospital Discharge Register, until 31 December 2009. Mean follow-up was 10.2 years (range: 4-17 years). The results were compared with data on the whole children population (1.1 million) in Finland.

RESULTS

Most children (321, 87%) with upper limb defects had hospital admissions: on average, one admission/year (range: 0-36), and they were treated in hospital 5 days/year (range: 0-150), which is 11-fold compared with an average child in Finland. Four surgical procedures/child were done (range: 0-45), including one hand surgical procedure. The most common procedures were orthopedic (513); gastrointestinal (263); ear, nose, and throat (143); dental (118); thoracic (48); and urologic (44). Of the 513 orthopedic procedures, 326 were directed to upper limbs, 107 to the lower limbs, and 10 to the spine. Median operation age was 2 years 7 months. Altogether, 60% of hospital admissions were non-surgical. Leading causes of non-operative hospital admissions were congenital anomalies (32%), gastroenterological problems (20%), respiratory tract conditions (13%), neurological problems (7%), perinatal conditions (5%), and infectious diseases (5%).

CONCLUSION

Treatment of children with upper limb defects is teamwork between pediatric and surgical subspecialties. Burden of hospital care is 11-fold as compared with an average child.

The commercial pig as a model of spontaneously-occurring osteoarthritis

BACKGROUND

Preclinical osteoarthritis models where damage occurs spontaneously may better reflect the initiation and development of human osteoarthritis. The aim was to assess the commercial pig as a model of spontaneous osteoarthritis development by examining pain-associated behaviour, joint cartilage integrity, as well as the use of porcine cartilage explants and isolated chondrocytes and osteoblasts for ex vivo and in vitro studies.

METHODS

Female pigs (Large white x Landrace x Duroc) were examined at different ages from 6 weeks to 3-4 years old. Lameness was assessed as a marker of pain-associated behaviour. Femorotibial joint cartilage integrity was determined by chondropathy scoring and histological staining of proteoglycan. IL-6 production and proteoglycan degradation was assessed in cartilage explants and primary porcine chondrocytes by ELISA and DMMB assay. Primary porcine osteoblasts from damaged and non-damaged joints, as determined by chondropathy scoring, were assessed for mineralisation, proliferative and mitochondrial function as a marker of metabolic capacity.

RESULTS

Pigs aged 80 weeks and older exhibited lameness. Osteoarthritic lesions in femoral condyle and tibial plateau cartilage were apparent from 40 weeks and increased in severity with age up to 3-4 years old. Cartilage from damaged joints exhibited proteoglycan loss, which positively correlated with chondropathy score. Stimulation of porcine cartilage explants and primary chondrocytes with either IL-1β or visfatin induced IL-6 production and proteoglycan degradation. Primary porcine osteoblasts from damaged joints exhibited reduced proliferative, mineralisation, and metabolic capacity.

CONCLUSION

In conclusion, the commercial pig represents an alternative model of spontaneous osteoarthritis and an excellent source of tissue for in vitro and ex vivo studies.

Treating alcohol-related liver disease from a public health perspective

Herein, we describe the evolving landscape of alcohol-related liver disease (ALD) including the current global burden of disease and cost to working-aged people in terms of death and disability, in addition to the larger spectrum of alcohol-related heath complications and its wider impact on society. We further review the most effective and cost-effective public health policies at both a population and individual level. Currently, abstinence is the only effective treatment for ALD, and yet because the majority of ALD remains undetected in the community abstinence is initiated too late to prevent premature death in the majority of cases. We therefore hope that this review will help inform clinicians of the "public health treatment options" for ALD to encourage engagement with policy makers and promote community-based hepatology as a speciality, expanding our patient cohort to allow early detection, and thereby a reduction in the enormous morbidity and mortality associated with this disease.

American Heart Association's Cholesterol CarePlan as a Smartphone-Delivered Web App for Patients Prescribed Cholesterol-Lowering Medication: Protocol for an Observational Feasibility Study

Background

Adoption of healthy lifestyle and compliance with cholesterol-lowering medication reduces the risk of cardiovascular disease (CVD). The use of digital tools and mobile technology may be important for sustaining positive behavioral change.

Objective

The primary objective of this study is to evaluate the feasibility and acceptability of administering the Cholesterol CarePlan Web app developed by the American Heart Association aimed at improving lifestyle and medication adherence among patients prescribed cholesterol-lowering medication. The secondary objective is to assess the Web app’s efficacy.

Methods

A prospective, observational feasibility study will be conducted to demonstrate whether the Web app may be successfully taken up by patients and will be associated with improved clinical and behavioral outcomes. The study will aim to recruit 180 study participants being prescribed cholesterol-lowering medication for at least 30 days across 14 general practices in London, England. Potentially eligible patients will be invited to use the Web app on a smartphone and visit general practice for three 20-minute clinical assessments of blood pressure, height, weight, smoking, and nonfasting cholesterol over 24 weeks. The feasibility of administering the Web app will be judged by recruitment and dropout statistics and the sociodemographic and comorbidity profile of consenting study participants, consenting nonparticipants, and all potentially eligible patients. Acceptability will be assessed using patients’ readiness to embrace new technologies, the usability of the Web app, and patient satisfaction. The efficacy of the Web app will be assessed by changes in medication adherence and clinical risk factors by levels of the Web app compliance.

Results

This study is currently funded by the American Heart Association. Initial study recruitment will take place between February and July 2018 followed by patient follow-up. Patient level data will be obtained in January 2019. Data analysis will be completed by February 2019. Results will be submitted for publication in March 2019.

Conclusions

The potential of an app to improve patients’ lifestyle and management of cholesterol may inform the design of a randomized controlled trial and the delivery of more effective CVD prevention programs.

International Registered Report Identifier (IRRID)

PRR1-10.2196/9017

Detergent-based decellularization strategy preserves macro- and microstructure of heart valves

OBJECTIVES

Biological tissue has great potential to function as bioprostheses in patients for heart valve replacement. As these matrices are mainly xenogenic, the immunogenicity needs to be reduced by decellularization steps. Reseeding of bioscaffolds has tremendous potential to prevent calcification upon implantation, so intact microstructure of the material is mandatory. An optimal decellularization protocol of heart valves resulting in adequate preservation of the extracellular architecture has still not been developed. Biological scaffolds must be decellularized to remove the antigenic potential while preserving the complex mixture of structural and functional proteins that constitute the extracellular matrix.

METHODS

Here, we compared 3 different decellularization strategies for their efficiency to remove cells completely while preserving the porcine heart valve ultrastructure. Porcine pulmonary heart valves were treated either with trypsin-ethylenediaminetetraacetic acid (TRP), a protocol using detergents in combination with nucleases (DET + ENZ), or with Accutase® solution followed by nuclease treatment (ACC + ENZ). The treated heart valves then were subjected to histological, DNA and scanning electron microscopic analyses.

RESULTS

All DNA fragments were removed after ACC + ENZ treatment, whereas cellular removal was incomplete in the TRP group. TRP and ACC + ENZ-treated valves were enlarged and showed a disrupted architecture and degraded ultrastructure. In contrast, fully acellular heart valves with intact architecture, layer composition and surface topography were achieved with DET + ENZ treatment. DET + ENZ treatment yielded excellent results in terms of preservation of material architecture and removal of DNA content.

CONCLUSIONS

Compared to TRP and ACC + ENZ procedures, DET + ENZ-treated porcine pulmonary heart valves demonstrated well-preserved macroscopic structures and microscopic matrix components and represent an excellent scaffold for further application in tissue engineering.

Assessment of the burden of diseases and injuries attributable to risk factors in Canada from 1990 to 2016: an analysis of the Global Burden of Disease Study

BACKGROUND

An understanding of the risk factors contributing to disease burden is critical for determining research priorities and informing national health policy. We aimed to identify the risk factor trends in Canada.

METHODS

As part of the Global Burden of Disease (GBD) study (1990-2016), we conducted an analysis of country-level estimates for Canada to assess the burden of diseases and injuries attributable to risk factors. For both 1990 and 2016, metabolic, environmental and behavioural risk factors were ranked according to their contribution to disability-adjusted life years (healthy years of life lost), total deaths and years lived with disability.

RESULTS

In 2016, the risk factors accounting for the largest percentage of disability-adjusted life years in Canada were (1) tobacco, (2) diet, (3) high body mass index, (4) high fasting plasma glucose, (5) high systolic blood pressure, (6) alcohol and drug use, (7) occupational risks, (8) high total cholesterol, (9) impaired kidney function and (10) air pollution. Risk factor rankings remained similar from 1990 to 2016 despite some substantial declines in burden, including a 47% (± 3%) decline in the age-standardized disability-adjusted life years rate attributable to tobacco since 1990. Risk factors with an increasing contribution to disability-adjusted life years rates from 1990 to 2016 included high body mass index, high fasting plasma glucose and alcohol and drug use.

INTERPRETATION

Metabolic and behavioural risk factors, including modifiable factors such as tobacco use and diet, remain the leading risk factors contributing to the burden of diseases and injuries in Canada. This work identifies priorities and targets for reducing premature death and disability burden in Canada.

Inaccurate diagnosis of COPD: the Welsh National COPD Audit

BACKGROUND

The diagnosis of chronic obstructive pulmonary disease (COPD) is confirmed with spirometry demonstrating persistent airflow obstruction.

AIM

To evaluate the clinical characteristics and management of patients in primary care on COPD registers with spirometry incompatible with COPD.

DESIGN AND SETTING

A primary care audit of Welsh COPD Read-Coded patient data from the Quality and Outcomes Framework (QOF) COPD register in Wales.

METHOD

Patients on the QOF COPD register with incompatible spirometry (post-bronchodilator forced expiratory lung volume in 1 second/forced vital capacity [FEV1/FVC] ratio ≥0.70) were compared with those with compatible spirometry (FEV1/FVC <0.70).

RESULTS

This audit included 63% of Welsh practices contributing 48 105 patients. Only 19% (n = 8957) of patients were post-bronchodilator FEV1/FVC Read-Coded and were included in this study. Of these, 75% (n = 6702) had compatible spirometry and 25% (n = 2255) did not. Patients with incompatible spirometry were more likely female (P = 0.009), never-smokers (P<0.001), had higher body mass index (P<0.001), and better mean FEV1 (P<0.001). Medical Research Council (MRC) breathlessness scores, exacerbation frequency, and asthma co-diagnosis were similar between groups. Patients in both groups were just as likely to receive inhaled corticosteroid (ICS) and long-acting beta-agonists (LABAs), but patients with incompatible spirometry were less likely to receive long-acting muscarinic antagonists (LAMAs) (P<0.001) or LABA/ICS (P = 0.002) combinations.

CONCLUSION

Patients on the COPD QOF register with spirometry incompatible with COPD are symptomatic and managed using significant resources. If quality of care and effective resource use are to be improved, focus must be given to correct diagnosis in this group.

The impact of health on economic and social outcomes in the United Kingdom: A scoping literature review

This is the first review of the evidence, based on longitudinal studies in the United Kingdom, on the association of ill health at any life stage and later social and economic outcomes. The review included a wide range of physical and mental health exposures, both self-reported and objectively measured, as well as social (e.g. life satisfaction) and economic (e.g. employment) outcomes. We searched the Web of Science, key longitudinal datasets based in the UK, major economic journals, Google Scholar and reference lists of relevant publications. The review includes 80 studies. There was strong evidence for the association between early mental health, mainly attention deficit hyperactivity disorder, and lifetime educational, occupational and various social outcomes. Also, both poor physical and mental health in early and middle adulthood, tended to be associated with unemployment and lower socioeconomic status. Among older adults, the evidence quite consistently indicated an association between mental health, chronic conditions, disability/functional limitations, self-rated general health and quality of life, life satisfaction and early retirement. Overall, mental health was consistently found to be associated with a range of social and economic outcomes throughout the lifespan. The evidence for the association between physical health and later outcomes is more inconsistent. A number of methodological challenges need to be addressed, particularly related to causal inference, to produce robust evidence with potential to inform public health policy.

A model for spatiotemporal injury surveillance: implications for the evolution of a trauma system

BACKGROUND

Geographic variations in case volume have important implications for trauma system configuration and have been recognized for some time. However, temporal trends in these distributions have received relatively little attention. The aim of this study was to propose a model to facilitate the spatiotemporal surveillance of injuries, using Scotland as a case study.

METHODS

Retrospective analysis of 5 years (2009-2013) of trauma incident location data. We analyzed the study population as a whole, as well as predefined subgroups, such as those with abnormal physiologic signs. To leverage sufficient statistical power to detect temporal trends in rare events over short time periods and small spatial units, we used a geographically weighted regression model.

RESULTS

There were 509,725 incidents. There were increases in case volume in Glasgow, the central southern part of the country, the northern parts of the Highlands, the Northeast, and the Orkney and Shetland Islands. Statistically significant changes were mostly restricted to major cities. Decreases in the number of incidents were seen in the Hebrides, Western Scotland, Fife and Lothian, and the Borders. Statistically significant changes were seen mostly in Fife and Lothian, the West, some areas of the Borders, and in the Peterhead area. Subgroup analyses showed markedly different spatiotemporal patterns.

CONCLUSIONS

This project has demonstrated the feasibility of population-based spatiotemporal injury surveillance. Even over a relatively short period, the geographic distribution of where injuries occur may change, and different injuries present different spatiotemporal patterns. These findings have implications for health policy and service delivery.

LEVEL OF EVIDENCE

Epidemiologic study, level V.

Do care plans and annual reviews of physical health influence unplanned hospital utilisation for people with serious mental illness? Analysis of linked longitudinal primary and secondary healthcare records in England

OBJECTIVE

To investigate whether two primary care activities that are framed as indicators of primary care quality (comprehensive care plans and annual reviews of physical health) influence unplanned utilisation of hospital services for people with serious mental illness (SMI).

DESIGN, SETTING, PARTICIPANTS

Retrospective observational cohort study using linked primary care and hospital records (Hospital Episode Statistics) for 5158 patients diagnosed with SMI between April 2006 and March 2014, who attended 213 primary care practices in England that contribute to the Clinical Practice Research Datalink GOLD database.

OUTCOMES AND ANALYSIS

Cox survival models were used to estimate the associations between two primary care quality indicators (care plans and annual reviews of physical health) and the hazards of three types of unplanned hospital utilisation: presentation to accident and emergency departments (A&E), admission for SMI and admission for ambulatory care sensitive conditions (ACSC).

RESULTS

Risk of A&E presentation was 13% lower (HR 0.87, 95% CI 0.77 to 0.98) and risk of admission to hospital for ACSC was 23% lower (HR 0.77, 95% CI 0.60 to 0.99) for patients with a care plan documented in the previous year compared with those without a care plan. Risk of A&E presentation was 19% lower for those who had a care plan documented earlier but not updated in the previous year (HR: 0.81, 95% CI 0.67 to 0.97) compared with those without a care plan. Risks of hospital admission for SMI were not associated with care plans, and none of the outcomes were associated with annual reviews.

CONCLUSIONS

Care plans documented in primary care for people with SMI are associated with reduced risk of A&E attendance and reduced risk of unplanned admission to hospital for physical health problems, but not with risk of admission for mental health problems. Annual reviews of physical health are not associated with risk of unplanned hospital utilisation.

Respiratory disease mortality in the United Kingdom compared with EU15+ countries in 1985-2015: observational study

OBJECTIVE

To compare age standardised death rates for respiratory disease mortality between the United Kingdom and other countries with similar health system performance.

DESIGN

Observational study.

SETTING

World Health Organization Mortality Database, 1985-2015.

PARTICIPANTS

Residents of the UK, Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain, Sweden, Australia, Canada, the United States, and Norway (also known as EU15+ countries).

MAIN OUTCOME MEASURES

Mortality from all respiratory disease and infectious, neoplastic, interstitial, obstructive, and other respiratory disease. Differences between countries were tested over time by mixed effect regression models, and trends in subcategories of respiratory related diseases assessed by a locally weighted scatter plot smoother.

RESULTS

Between 1985 and 2015, overall mortality from respiratory disease in the UK and EU15+ countries decreased for men and remained static for women. In the UK, the age standardised death rate (deaths per 100 000 people) for respiratory disease mortality in the UK fell from 151 to 89 for men and changed from 67 to 68 for women. In EU15+ countries, the corresponding changes were from 108 to 69 for men and from 35 to 37 in women. The UK had higher mortality than most EU15+ countries for obstructive, interstitial, and infectious subcategories of respiratory disease in both men and women.

CONCLUSION

Mortality from overall respiratory disease was higher in the UK than in EU15+ countries between 1985 and 2015. Mortality was reduced in men, but remained the same in women. Mortality from obstructive, interstitial, and infectious respiratory disease was higher in the UK than in EU15+ countries.

Use of Dental Practices for the Identification of Adults With Undiagnosed Type 2 Diabetes Mellitus or Nondiabetic Hyperglycemia: Protocol for a Systematic Review

Background

Type 2 diabetes mellitus (T2DM) is a growing global health burden and is expected to affect more than 590 million people by the year 2035. Evidence exists to demonstrate that dental settings have been used for risk assessment and identification of individuals who may be at high risk for T2DM or who may already unknowingly have the condition.

Objective

This protocol aims to outline the methodology that will be undertaken to synthesize the literature relating to the use of primary care (nonhospital-based) dental services for the identification of undiagnosed T2DM or prediabetes—often termed nondiabetic hyperglycemia—in adult patients.

Methods

This paper outlines the protocol that will be followed to conduct a systematic review and meta-analysis of the available literature. The protocol outlines the aims, objectives, search strategy, data extraction and data management methods, as well as the statistical analysis plan. The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines were followed in developing the protocol as were elements of the Cochrane handbook.

Results

We expect the systematic review to be completed within 18 months of publication of this protocol and expect to see a high degree of heterogeneity in the existing literature.

Conclusions

This review is of importance as it will synthesize the existing evidence base and inform future studies in the field. Following the publication of the protocol, the review will be registered on Prospective Register of Systematic Reviews. Following the completion of the review, results will be published in a suitable peer-reviewed journal.

International Registered Report Identifier (IRRID)

PRR1-10.2196/11843

Exploring the impact of public health teams on alcohol premises licensing in England and Scotland (ExILEnS): procotol for a mixed methods natural experiment evaluation

BACKGROUND

Recent regulatory changes in the system by which premises are licensed to sell alcohol, have given health representatives a formal role in the process in England and Scotland. The degree to which local public health teams engage with this process varies by locality in both nations, which have different licensing regimes. This study aims to critically assess the impact on alcohol-related harms - and mechanisms - of public health stakeholders' engagement in alcohol premises licensing from 2012 to 2018, comparing local areas with differing types and intensities of engagement, and examining practice in Scotland and England.

METHODS

The study will recruit 20 local authority areas where public health stakeholders have actively engaged with the alcohol premises licensing system (the 'intervention') and match them to a group of 20 lower activity areas using genetic matching. Four work packages are included: (1) Structured interviews and documentary analysis will examine the type and level of intervention activity from 2012 to 2018, creating a novel composite measure of the intensity of such activity and will assess the local licensing system and potential confounding activities over the same period. In-depth interviews with public health, licensing, police and others will explore perceived mechanisms of change, acceptability, and impact. (2) Using longitudinal growth models and time series analyses, the study will evaluate the impact of high and low levels of activity on alcohol-related harms using routine data from baseline 2009 to 2018. (3) Intervention costs, estimated National Health Service cost savings and health gains will be evaluated using the Sheffield Alcohol Policy Model to estimate impact on alcohol consumption and health inequalities. (4) The study will engage public health teams to create a new theory of change for public health involvement in the licensing process using our data. We will share findings with local, national and international stakeholders.

DISCUSSION

This interdisciplinary study examines, for the first time, whether and how public health stakeholders' involvement in alcohol licensing impacts on alcohol harms. Using mixed methods and drawing on complex systems thinking, it will make an important contribution to an expanding literature evaluating interventions not suited to traditional epidemiological research.

Changes in health in the countries of the UK and 150 English Local Authority areas 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

Previous studies have reported national and regional Global Burden of Disease (GBD) estimates for the UK. Because of substantial variation in health within the UK, action to improve it requires comparable estimates of disease burden and risks at country and local levels. The slowdown in the rate of improvement in life expectancy requires further investigation. We use GBD 2016 data on mortality, causes of death, and disability to analyse the burden of disease in the countries of the UK and within local authorities in England by deprivation quintile.

METHODS

We extracted data from the GBD 2016 to estimate years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and attributable risks from 1990 to 2016 for England, Scotland, Wales, Northern Ireland, the UK, and 150 English Upper-Tier Local Authorities. We estimated the burden of disease by cause of death, condition, year, and sex. We analysed the association between burden of disease and socioeconomic deprivation using the Index of Multiple Deprivation. We present results for all 264 GBD causes of death combined and the leading 20 specific causes, and all 84 GBD risks or risk clusters combined and 17 specific risks or risk clusters.

FINDINGS

The leading causes of age-adjusted YLLs in all UK countries in 2016 were ischaemic heart disease, lung cancers, cerebrovascular disease, and chronic obstructive pulmonary disease. Age-standardised rates of YLLs for all causes varied by two times between local areas in England according to levels of socioeconomic deprivation (from 14 274 per 100 000 population [95% uncertainty interval 12 791-15 875] in Blackpool to 6888 [6145-7739] in Wokingham). Some Upper-Tier Local Authorities, particularly those in London, did better than expected for their level of deprivation. Allowing for differences in age structure, more deprived Upper-Tier Local Authorities had higher attributable YLLs for most major risk factors in the GBD. The population attributable fractions for all-cause YLLs for individual major risk factors varied across Upper-Tier Local Authorities. Life expectancy and YLLs have improved more slowly since 2010 in all UK countries compared with 1990-2010. In nine of 150 Upper-Tier Local Authorities, YLLs increased after 2010. For attributable YLLs, the rate of improvement slowed most substantially for cardiovascular disease and breast, colorectal, and lung cancers, and showed little change for Alzheimer's disease and other dementias. Morbidity makes an increasing contribution to overall burden in the UK compared with mortality. The age-standardised UK DALY rate for low back and neck pain (1795 [1258-2356]) was higher than for ischaemic heart disease (1200 [1155-1246]) or lung cancer (660 [642-679]). The leading causes of ill health (measured through YLDs) in the UK in 2016 were low back and neck pain, skin and subcutaneous diseases, migraine, depressive disorders, and sense organ disease. Age-standardised YLD rates varied much less than equivalent YLL rates across the UK, which reflects the relative scarcity of local data on causes of ill health.

INTERPRETATION

These estimates at local, regional, and national level will allow policy makers to match resources and priorities to levels of burden and risk factors. Improvement in YLLs and life expectancy slowed notably after 2010, particularly in cardiovascular disease and cancer, and targeted actions are needed if the rate of improvement is to recover. A targeted policy response is also required to address the increasing proportion of burden due to morbidity, such as musculoskeletal problems and depression. Improving the quality and completeness of available data on these causes is an essential component of this response.

FUNDING

Bill & Melinda Gates Foundation and Public Health England.

Therapeutic effectiveness of neuromuscular electrical stimulation for treating patients with chronic low back pain

This retrospective study investigated the effectiveness and safety of neuromuscular electrical stimulation (NMES) for patients with chronic low back pain (CLBP).A total of 72 patients with CLBP were included in this retrospective study. All patients received usual care, and were assigned to a NMES group (n = 36) and a control group (n = 36). In addition, patients in the NMES group also received NMES for a total of 4 weeks. The primary outcome was pain intensity, measured by numerical rating scale (NRS). The secondary outcome was disability, assessed by the Roland-Morris Disability Questionnaire (RMDQ), and the Quebec Back Pain Disability Scale (QBPDS). The outcomes were evaluated before and after 4-week treatment.After 4-week treatment, the patients in the NMES group did not show better effectiveness in pain intensity relief, as measured by NRS (P = .11); and disability improvement, as evaluated by the RMDQ (P = .14), and QBPDS (P = .33), when compared with the patients in the control group. Additionally, no adverse events related to the NNES were recorded.The results of this study did not show promising effectiveness of NMES for patients with CLBP after 4-week treatment.

Effects of dietary interventions on DNA methylation in adult humans: systematic review and meta-analysis

DNA methylation is a key component of the epigenetic machinery that is responsible for regulating gene expression and, therefore, cell function. Patterns of DNA methylation change during development and ageing, differ between cell types, are altered in multiple diseases and can be modulated by dietary factors. However, evidence about the effects of dietary factors on DNA methylation patterns in humans is fragmentary. This study was initiated to collate evidence for causal links between dietary factors and changes in DNA methylation patterns. We carried out a systematic review of dietary intervention studies in adult humans using Medline, EMBASE and Scopus. Out of 22 149 screened titles, sixty intervention studies were included, of which 65% were randomised (n 39). Most studies (53%) reported data from blood analyses, whereas 27% studied DNA methylation in colorectal mucosal biopsies. Folic acid was the most common intervention agent (33%). There was great heterogeneity in the methods used for assessing DNA methylation and in the genomic loci investigated. Meta-analysis of the effect of folic acid on global DNA methylation revealed strong evidence that supplementation caused hypermethylation in colorectal mucosa (P=0·009). Meta-regression analysis showed that the dose of supplementary folic acid was the only identified factor (P<0·001) showing a positive relationship. In summary, there is limited evidence from intervention studies of effects of dietary factors, other than folic acid, on DNA methylation patterns in humans. In addition, the application of multiple different assays and investigations of different genomic loci makes it difficult to compare, or to combine, data across studies.

The burden of hepatitis C infection in a Southern Brazilian State

INTRODUCTION

The study aimed to estimate the burden of hepatitis C in Santa Catarina, Brazil.

METHODS

An ecologic study was carried out to estimate the disability-adjusted life years (DALY) by summing the number of years of life lost and the number of years lived with disability.

RESULTS

A rate of 1,075.9 DALY/100,000 population was estimated, and was similar by sex. The highest burden was between the ages of 45 to 59 years and in the Grande Oeste region.

CONCLUSIONS

The burden of hepatitis C was high and concentrated in adult age groups with variations among regions.

Scoping review of systematic reviews of complementary medicine for musculoskeletal and mental health conditions

OBJECTIVE

To identify potentially effective complementary approaches for musculoskeletal (MSK)-mental health (MH) comorbidity, by synthesising evidence on effectiveness, cost-effectiveness and safety from systematic reviews (SRs).

DESIGN

Scoping review of SRs.

METHODS

We searched literature databases, registries and reference lists, and contacted key authors and professional organisations to identify SRs of randomised controlled trials for complementary medicine for MSK or MH. Inclusion criteria were: published after 2004, studying adults, in English and scoring >50% on Assessing the Methodological Quality of Systematic Reviews (AMSTAR); quality appraisal checklist). SRs were synthesised to identify research priorities, based on moderate/good quality evidence, sample size and indication of cost-effectiveness and safety.

RESULTS

We included 84 MSK SRs and 27 MH SRs. Only one focused on MSK-MH comorbidity. Meditative approaches and yoga may improve MH outcomes in MSK populations. Yoga and tai chi had moderate/good evidence for MSK and MH conditions. SRs reported moderate/good quality evidence (any comparator) in a moderate/large population for: low back pain (LBP) (yoga, acupuncture, spinal manipulation/mobilisation, osteopathy), osteoarthritis (OA) (acupuncture, tai chi), neck pain (acupuncture, manipulation/manual therapy), myofascial trigger point pain (acupuncture), depression (mindfulness-based stress reduction (MBSR), meditation, tai chi, relaxation), anxiety (meditation/MBSR, moving meditation, yoga), sleep disorders (meditative/mind-body movement) and stress/distress (mindfulness). The majority of these complementary approaches had some evidence of safety-only three had evidence of harm. There was some evidence of cost-effectiveness for spinal manipulation/mobilisation and acupuncture for LBP, and manual therapy/manipulation for neck pain, but few SRs reviewed cost-effectiveness and many found no data.

CONCLUSIONS

Only one SR studied MSK-MH comorbidity. Research priorities for complementary medicine for both MSK and MH (LBP, OA, depression, anxiety and sleep problems) are yoga, mindfulness and tai chi. Despite the large number of SRs and the prevalence of comorbidity, more high-quality, large randomised controlled trials in comorbid populations are needed.

Occupational therapy delivered by specialists versus non-specialists for people with schizophrenia

BACKGROUND

Schizophrenia is a severe mental health condition that is characterised by positive symptoms, such as hallucinations and delusions; negative symptoms, such as flattened affect, thought disorder (disrupted speech), and lack of motivation; and cognitive symptoms, such as problems with memory and attention. Schizophrenia can occur as an isolated episode, or as a recurring cycle of remission and relapse, and is associated with impairment in psychosocial and occupational functioning.Although antipsychotic drugs are the main treatment for people with schizophrenia, in most countries mental health services usually provide a range of add-on interventions, including occupational therapy. This is a complex intervention designed to support and enable continued participation in daily life through engagement in activities and occupations meaningful to the individual. Occupational therapists are professionals trained to deliver therapy where the emphasis is on improving occupational function and participation rather than treating symptoms, and uses a wide range of methods based on the needs of individuals. However, similar interventions may also be delivered by staff not trained as occupational therapists.

OBJECTIVES

To examine the effects of occupational therapy delivered by occupational therapists compared to occupational therapy delivered by any other person for people with schizophrenia.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (including trial registers) on 4 November 2016 and 26 July 2018.

SELECTION CRITERIA

All randomised controlled trials evaluating the functional or clinical outcomes of occupational therapy, or both, for people with schizophrenia delivered by occupational therapists compared with occupational therapy for people with schizophrenia delivered by anyone other than occupational therapists.

DATA COLLECTION AND ANALYSIS

Review authors independently inspected citations, selected studies, extracted data, and appraised study quality.

MAIN RESULTS

The search yielded 1633 records. Of these, we retrieved 17 full-text reports (14 studies) for further scrutiny, which we subsequently excluded as they did not meet our inclusion criteria.

AUTHORS' CONCLUSIONS

Currently there are no randomised controlled trials comparing delivery of occupational therapy for people diagnosed with schizophrenia by occupational therapists with delivery of similar interventions by anyone other than occupational therapists. Research studies employing methodologically robust trial designs are needed to establish whether or not there are better outcomes for people with a diagnosis of schizophrenia with occupational therapy that is delivered by trained occupational therapists.

Identification of target gene and prognostic evaluation for lung adenocarcinoma using gene expression meta-analysis, network analysis and neural network algorithms

BACKGROUND

Lung adenocarcinoma (LUAD) is a heterogeneous disease with poor survival in the advanced stage and a high incidence rate in the world. Novel drug targets are urgently required to improve patient treatment. Therefore, we aimed to identify therapeutic targets for LUAD based on protein-protein and protein-drug interaction network analysis with neural network algorithms using mRNA expression profiles.

RESULTS

A comprehensive meta-analysis of selective non-small cell lung cancer (NSCLC) mRNA expression profile datasets from Gene Expression Omnibus were used to identify potential biomarkers and the molecular mechanisms related to the prognosis of NSCLC patients. Using the Network Analyst tool, based on combined effect size (ES) methods, we recognized 6566 differentially expressed genes (DEGs), which included 3036 downregulated and 3530 upregulated genes linked to NSCLC patient survival. ClueGO, a Cytoscape plugin, was exploited to complete the function and pathway enrichment analysis, which disclosed "regulated exocytosis", "purine nucleotide binding", "pathways in cancer", and "cell cycle" between exceptionally supplemented terms. Enrichr, a web tool examination, demonstrated "early growth response protein 1 (EGR-1)", "hepatocyte nuclear factor 4α (HNF4A)", "mitogen-activated protein kinase 14 (MAP3K14)", and "cyclin-dependent kinase 1 (CDK1)" to be among the most prevalent TFs and kinases associated with NSCLC. Our meta-analysis identified that MAPK1 and aurora kinase (AURKA) are the most obvious class of hub nodes. Furthermore, protein-drug interaction network and neural network algorithms identified candidate drugs such as phosphothreonine and 4-(4-methylpiperazin-1-yl)-n-[5-(2-thienylacetyl)-1,5-dihydropyrrolo[3,4-c]pyrazol-3-yl] benzamide and for the targets MAPK1 and AURKA, respectively.

CONCLUSION

Our study has identified novel candidate biomarkers, pathways, transcription factors (TFs), and kinases associated with NSCLC prognosis, as well as drug candidates, which may assist treatment strategy for NSCLC patients.

Distinguishing normal brain aging from the development of Alzheimer's disease: inflammation, insulin signaling and cognition

As populations age, prevalence of Alzheimer's disease (AD) is rising. Over 100 years of research has provided valuable insights into the pathophysiology of the disease, for which age is the principal risk factor. However, in recent years, a multitude of clinical trial failures has led to pharmaceutical corporations becoming more and more unwilling to support drug development in AD. It is possible that dependence on the amyloid cascade hypothesis as a guide for preclinical research and drug discovery is part of the problem. Accumulating evidence suggests that amyloid plaques and tau tangles are evident in non-demented individuals and that reducing or clearing these lesions does not always result in clinical improvement. Normal aging is associated with pathologies and cognitive decline that are similar to those observed in AD, making differentiation of AD-related cognitive decline and neuropathology challenging. In this mini-review, we discuss the difficulties with discerning normal, age-related cognitive decline with that related to AD. We also discuss some neuropathological features of AD and aging, including amyloid and tau pathology, synapse loss, inflammation and insulin signaling in the brain, with a view to highlighting cognitive or neuropathological markers that distinguish AD from normal aging. It is hoped that this review will help to bolster future preclinical research and support the development of clinical tools and therapeutics for AD.

Transplanting Patients with Alcohol-related Liver Disease in the National Health System: New Rules and Decisions

Aims

The UK has a socialized healthcare system that provides treatment that is free at the point of care for acute and chronic health disorders (the National Health Service-NHS), which is currently experiencing a period of unprecedented challenge.

Methods

A narrative review that discusses present and future arrangements for transplantation of alcohol-related liver disease (ArLD) in the UK.

Results

Liver disease in the UK is reaching epidemic proportions due to obesity and metabolic disease compounding alcohol-mediated liver damage. Unfortunately, hepatology services in the UK are geographically disparate and subject to significant variations in liver morbidity and mortality, prompting concerns that this may negatively impair access to transplantation. In an attempt to improve referrals to tertiary liver services, the UK listing criteria for alcohol-associated liver disease were revised in 2016 by a working party under the aegis of the UK-Liver Advisory Group with the ambition of increasing opportunities for disease evaluation and improving the condition of candidates referred for assessment.

Conclusion

Liver transplantation for ArLD is well established in the UK. Recent organizational changes seek to reduce inequities in access to transplant services.

Short Summary

Liver disease in the UK is reaching epidemic proportions. Concerns over equity of access to liver transplantation prompted revision of the UK listing criteria for alcohol-associated liver disease in 2016, to improve to the availability of tertiary hepatology services. Transplanting patients with alcohol-related liver disease in the National Health System: New Rules and Decisions '…The second property of your excellent sherris is, the warming of the blood; which, before cold and settled, hath left the liver white and pale…'Falstaff; Henry IV Part 2: Act 4, Scene 3.

Pain Reconceptualisation after Pain Neurophysiology Education in Adults with Chronic Low Back Pain: A Qualitative Study

Pain neurophysiology education (PNE) is an educational intervention for patients with chronic pain. PNE purports to assist patients to reconceptualise their pain away from the biomedical model towards a more biopsychosocial understanding by explaining pain biology. This study aimed to explore the extent, and nature, of patients' reconceptualisation of their chronic low back pain (CLBP) following PNE. Eleven adults with CLBP underwent semistructured interviews before and three weeks after receiving PNE. Interviews were transcribed verbatim and thematically analysed in a framework approach using four a priori themes identified from our previous research: (1) degrees of reconceptualisation, (2) personal relevance, (3) importance of prior beliefs, and (4) perceived benefit of PNE. We observed varying degrees of reconceptualisation from zero to almost complete, with most participants showing partial reconceptualisation. Personal relevance of the information to participants and their prior beliefs were associated with the degree of benefit they perceived from PNE. Where benefits were found, they manifested as improved understanding, coping, and function. Findings map closely to our previous studies in more disparate chronic pain groups. The phenomenon of reconceptualisation is applicable to CLBP and the sufficiency of the themes from our previous studies increases confidence in the certainty of the findings.

Intersectional identities and dilemmas in interactions with healthcare professionals: an interpretative phenomenological analysis of British Muslim gay men

Individual interviews were conducted with six self-identified Muslim gay men living in London focusing on their experience of health service use. Transcripts were analysed using interpretative phenomenological analysis. Analysis identified two major themes: the close(d) community and self-management with healthcare professionals, detailing participants' concerns regarding the risks of disclosing sexuality; and the authentic identity - 'you're either a Muslim or you're gay, you can't be both' - which delineated notions of incommensurate identity. Analysis highlights the need for health practitioners to have insight into the complexity of intersectional identities, identity disclosure dynamics and the negative consequences of assumptions made, be these heteronormative or faith-related.

The Global Spine Care Initiative: care pathway for people with spine-related concerns

PURPOSE

The purpose of this report is to describe the development of an evidence-based care pathway that can be implemented globally.

METHODS

The Global Spine Care Initiative (GSCI) care pathway development team extracted interventions recommended for the management of spinal disorders from six GSCI articles that synthesized the available evidence from guidelines and relevant literature. Sixty-eight international and interprofessional clinicians and scientists with expertise in spine-related conditions were invited to participate. An iterative consensus process was used.

RESULTS

After three rounds of review, 46 experts from 16 countries reached consensus for the care pathway that includes five decision steps: awareness, initial triage, provider assessment, interventions (e.g., non-invasive treatment; invasive treatment; psychological and social intervention; prevention and public health; specialty care and interprofessional management), and outcomes. The care pathway can be used to guide the management of patients with any spine-related concern (e.g., back and neck pain, deformity, spinal injury, neurological conditions, pathology, spinal diseases). The pathway is simple and can be incorporated into educational tools, decision-making trees, and electronic medical records.

CONCLUSION

A care pathway for the management of individuals presenting with spine-related concerns includes evidence-based recommendations to guide health care providers in the management of common spinal disorders. The proposed pathway is person-centered and evidence-based. The acceptability and utility of this care pathway will need to be evaluated in various communities, especially in low- and middle-income countries, with different cultural background and resources. These slides can be retrieved under Electronic Supplementary Material.

On the road to universal health care in Indonesia, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

As Indonesia moves to provide health coverage for all citizens, understanding patterns of morbidity and mortality is important to allocate resources and address inequality. The Global Burden of Disease 2016 study (GBD 2016) estimates sources of early death and disability, which can inform policies to improve health care.

METHODS

We used GBD 2016 results for cause-specific deaths, years of life lost, years lived with disability, disability-adjusted life-years (DALYs), life expectancy at birth, healthy life expectancy, and risk factors for 333 causes in Indonesia and in seven comparator countries. Estimates were produced by location, year, age, and sex using methods outlined in GBD 2016. Using the Socio-demographic Index, we generated expected values for each metric and compared these against observed results.

FINDINGS

In Indonesia between 1990 and 2016, life expectancy increased by 8·0 years (95% uncertainty interval [UI] 7·3-8·8) to 71·7 years (71·0-72·3): the increase was 7·4 years (6·4-8·6) for males and 8·7 years (7·8-9·5) for females. Total DALYs due to communicable, maternal, neonatal, and nutritional causes decreased by 58·6% (95% UI 55·6-61·6), from 43·8 million (95% UI 41·4-46·5) to 18·1 million (16·8-19·6), whereas total DALYs from non-communicable diseases rose. DALYs due to injuries decreased, both in crude rates and in age-standardised rates. The three leading causes of DALYs in 2016 were ischaemic heart disease, cerebrovascular disease, and diabetes. Dietary risks were a leading contributor to the DALY burden, accounting for 13·6% (11·8-15·4) of DALYs in 2016.

INTERPRETATION

Over the past 27 years, health across many indicators has improved in Indonesia. Improvements are partly offset by rising deaths and a growing burden of non-communicable diseases. To maintain and increase health gains, further work is needed to identify successful interventions and improve health equity.

FUNDING

The Bill & Melinda Gates Foundation.

The risk, burden, and management of non-communicable diseases in cerebral palsy: a scoping review

AIM

To examine the risk, burden, and management of non-communicable diseases (NCDs) among people with cerebral palsy (CP).

METHOD

Databases (Ovid MEDLINE, Embase Ovid, CINAHL Plus) were systematically searched up to August 2017. Data on the prevalence of risk factors for, and the burden and management of, cardiovascular diseases, diabetes, cancers, and respiratory diseases were extracted.

RESULTS

Thirty-six studies that examined the prevalence of risk factors among people with CP were identified. There was inconsistent evidence that people with CP had higher prevalence of metabolic risk factors such as hypertension, hyperlipidaemia, and obesity, but strong evidence that they participated in low levels of physical activity, compared with people without CP. Seven studies reported on the burden of NCDs. Adults with CP had a higher risk of NCDs, including stroke, chronic obstructive pulmonary disease, and other heart conditions, and death due to NCDs, including cancers, chronic obstructive pulmonary disease, stroke, and ischaemic heart disease, compared with the general population. Only one study reported on the management of NCD, specifically the uptake of breast cancer screening among females.

INTERPRETATION

The burden of NCDs is higher among adults with CP compared with the general population. Further research is required to determine the prevalence of metabolic risk factors and management of NCDs among people with CP.

WHAT THIS PAPER ADDS

Adults with cerebral palsy (CP) have an increased risk of non-communicable diseases (NCDs) and increased risk of death because of NCDs. Evidence is inconsistent about the elevated prevalence of metabolic risk factors for NCDs. Evidence is consistent that people with CP participate in reduced physical activity. Only one study reported on management of NCD among people with CP. Available evidence suggests people with CP are less likely to receive preventive medicine.

Associations among knee muscle strength, structural damage, and pain and mobility in individuals with osteoarthritis and symptomatic meniscal tear

Background

Sufficient lower extremity muscle strength is necessary for performing functional tasks, and individuals with knee osteoarthritis demonstrate thigh muscle weakness compared to controls. It has been suggested that lower muscle strength is associated with a variety of clinical features including pain, mobility, and functional performance, yet these relationships have not been fully explored in patients with symptomatic meniscal tear in addition to knee osteoarthritis. Our purpose was to evaluate the associations of quadriceps and hamstrings muscle strength with structural damage and clinical features in individuals with knee osteoarthritis and symptomatic meniscal tear.

Methods

We performed a cross-sectional study using baseline data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial. We assessed structural damage using Kellgren-Lawrence grade and the magnetic resonance imaging osteoarthritis knee score (MOAKS) for cartilage damage. We used the Knee Injury and Osteoarthritis Outcomes Score (KOOS) to evaluate pain, symptoms, and activities of daily living (ADL), and the Timed Up and Go (TUG) test to assess mobility. We assessed quadriceps and hamstrings strength using a hand-held dynamometer and classified each into quartiles (Q). We used Chi square tests to evaluate the association between strength and structural damage; and separate analysis of covariance models to establish the association between pain, symptoms, ADL and mobility with strength, after adjusting for demographic characteristics (age, sex and BMI) and structural damage.

Results

Two hundred fifty two participants were evaluated. For quadriceps strength, subjects in the strongest quartile scored 14 and 13 points higher on the KOOS Pain and ADL subscales, respectively, and completed the TUG two seconds faster than subjects in the weakest quartile. For hamstrings strength, subjects in the strongest quartile scored 13 and 14 points higher on the KOOS pain and ADL subscales, respectively, and completed the TUG two seconds faster than subjects in the weakest quartile. Strength was not associated with structural damage.

Conclusions

Greater quadriceps and hamstrings muscle strength was associated with less pain, less difficulty completing activities of daily living, and better mobility. These relationships should be evaluated longitudinally.

Cost-effectiveness of a model consultation to support self-management in patients with osteoarthritis

Objectives

The aim of this study was to estimate the cost-effectiveness of a model OA consultation for OA to support self-management compared with usual care.

Methods

An incremental cost-utility analysis using patient responses to the three-level EuroQoL-5D (EQ-5D) questionnaire was undertaken from a UK National Health Service perspective alongside a two-arm cluster-randomized controlled trial. Uncertainty was explored through the use of cost-effectiveness acceptability curves.

Results

Differences in health outcomes between the model OA consultation and usual care arms were not statistically significant. On average, visits to the orthopaedic surgeon were lower in the model OA consultation arm by -0.28 (95% CI: -0.55, -0.06). The cost-utility analysis indicated that the model OA consultation was associated with a non-significant incremental cost of £-13.11 (95% CI: -81.09 to 54.85) and an incremental quality adjusted life year (QALY) of -0.003 (95% CI: -0.03 to 0.02), with a 44% chance of being cost-effective at a threshold of £20 000 per QALY gained. The percentage of participants who took time off and the associated productivity cost were lower in the model OA consultation arm.

Conclusion

Implementing National Institute for Health and Care Excellence guidelines using a model OA consultation in primary care does not appear to lead to increased costs, but health outcomes remain very similar to usual care. Even though the intervention seems to reduce the demand for orthopaedic surgery, overall it is unlikely to be cost-effective.

Gastrointestinal endoscopy satisfaction questionnaire is a valid tool to measure patient satisfaction in Asian country

Patient satisfaction is a key quality indicator of gastrointestinal endoscopy (GIE). The gastrointestinal endoscopy satisfaction questionnaire (GESQ) was recently developed to assess patient satisfaction undergoing GIE in Europe; however, it was not validated in Asian countries. We aimed to translate and validate the GESQ in Korea and identify predictors for patient satisfaction during GIE.Translation of the original GESQ was performed according to accepted linguistic validation guidelines. Between March 2016 and July 2016, 350 consecutive patients were asked to complete a GESQ after GIE at Kyung Hee University Hospital. Total sum of scores was transformed from 0 to 100 by the formula: (Score-lowest possible/Score range) × 100.Exploratory and confirmatory factor analyses for construct validation reconfirmed that 4 factors were extracted from the Korean GESQ. Internal consistency reliability was acceptable with an overall Cronbach α score of 0.87. Female and nonsmoker were associated with less satisfaction with GIE (P = .021 and .006, respectively). Other factors, including age, alcohol, education or economic level, sedative endoscopy, gastroscopy with or without colonoscopy, experience of previous endoscopy, and additional examinations such as biopsy, were not associated with patient satisfaction during GIE.The Korean version of the GESQ was a valid and acceptable tool to measure satisfaction in patients who had undergone a GIE in Korea. Patient satisfaction measurement could contribute to systematic improvement of qualified GIE.

Changes in health in Belgium, 1990-2016: a benchmarking analysis based on the global burden of disease 2016 study

BACKGROUND

Despite increasing of the Belgian health expenditures, several indicators related to population health showed poor results. The objectives of this study were to perform an in-depth analysis of the secular trend of Belgian health status using the Global Burden of Disease (GBD) 2016 study results for Belgium, and to compare these results with other European countries.

METHODS

We collected results of the Global Burden of Disease 2016 study through the GBD results and visualization tools. We benchmarked Belgian GBD results with the other initial members of the European Union (EU15).

RESULTS

Belgium performed significantly better in 2016 than in 1990 in terms of age-standardized (AS) Year of Life Lost (YLL) rates but not significantly different in terms of AS Year Lived with Disability (YLD) and Disability-Adjusted Life Year (DALY) rates. The contribution of AS YLDs to total of AS DALYs increased from 1990 (42%) to 2016 (54%). Although AS YLD and DALY rates did not seem to differ between Belgium and the EU15 from 1990 to 2016, the ranking of Belgium among the EU15 in terms of AS DALY and YLL rates was worse in 2016 than in 1990. Belgium had significantly higher AS YLL rates for lower respiratory infections (B: 264 AS YLLs [95% uncertainty interval [UI] 231-301] per 100,000; EU15: 188 AS YLLs [95%UI 168-212] per 100,000), chronic obstructive pulmonary disease (B: 368 AS YLLs [95%UI 331-407] per 100,000; EU15: 285 AS YLLs [95%UI 258-316] per 100,000) and tracheal, bronchus, and lung cancer (B: 785 AS YLLs [95%UI 699-879] per 100,000; EU15: 613 AS YLLs [95%UI 556-674] per 100,000).

CONCLUSION

Belgium's ranking among the EU15 in terms of AS YLL and DALY rates decreased from 1990 to 2016. Significant health gains appear possible by acting on risk factors directly linked to a significant part of the Belgian burden of diseases, i.e., alcohol and tobacco consumption, and high body mass index. National burden of disease estimates can help defining Belgian health targets and are necessary as external validity of GBD results is not always guaranteed.

Opioid prescribing for chronic musculoskeletal pain in UK primary care: results from a cohort analysis of the COPERS trial

OBJECTIVE

To establish the level of opioid prescribing for patients with chronic musculoskeletal pain in a sample of patients from primary care and to estimate prescription costs.

DESIGN

Secondary data analyses from a two-arm pragmatic randomised controlled trial (COPERS) testing the effectiveness of group self-management course and usual care against relaxation and usual care for patients with chronic musculoskeletal pain (ISRCTN 24426731).

SETTING

25 general practices and two community musculoskeletal services in the UK (London and Midlands).

PARTICIPANTS

703 chronic pain participants; 81% white, 67% female, enrolled in the COPERS trial.

MAIN OUTCOME MEASURES

Anonymised prescribing data over 12 months extracted from GP electronic records.

RESULTS

Of the 703 trial participants with chronic musculoskeletal pain, 413 (59%) patients were prescribed opioids. Among those prescribed an opioid, the number of opioid prescriptions varied from 1 to 52 per year. A total of 3319 opioid prescriptions were issued over the study period, of which 53% (1768/3319) were for strong opioids (tramadol, buprenorphine, morphine, oxycodone, fentanyl and tapentadol). The mean number of opioid prescriptions per patient prescribed any opioid was 8.0 (SD=7.9). A third of patients on opioids were prescribed more than one type of opioid; the most frequent combinations were: codeine plus tramadol and codeine plus morphine. The cost of opioid prescriptions per patient per year varied from £3 to £4844. The average annual prescription cost was £24 (SD=29) for patients prescribed weak opioids and £174 (SD=421) for patients prescribed strong opioids. Approximately 40% of patients received >3 prescriptions of strong opioids per year, with an annual cost of £236 per person.

CONCLUSIONS

Long-term prescribing of opioids for chronic musculoskeletal pain is common in primary care. For over a quarter of patients receiving strong opioids, these drugs may have been overprescribed according to national guidelines.

TRIAL REGISTRATION NUMBER

ISRCTN24426731; Post-results.

A systematic review and meta-analysis of the reliability and validity of sensorimotor measurement instruments in people with chronic low back pain

BACKGROUND

Deficits in the sensorimotor system and its peripheral and central processing of the affected body part might be a contributing factor to chronic low back pain (CLBP). Hence, sensorimotor assessment is important. Valid and reliable sensorimotor measurement instruments are needed.

OBJECTIVE

To investigate the reliability and validity of sensorimotor measurement instruments for people with chronic low back pain (CLBP).

DESIGN

Systematic review and meta-analysis.

METHODS

The review was undertaken using the COSMIN guidelines. Databases were searched for studies investigating the clinimetric properties of sensorimotor tests in people with CLBP. The methodological study quality was rated by two independent reviewers using the COSMIN 4-point rating checklist.

RESULTS

Ten studies were included covering six sensorimotor measurement instruments with findings for reliability/measurement error, known-groups validity and convergent validity. The methodological quality ranged from poor to good, with only one study rated as good. There was insufficient evidence of enough quality to assess reliability/measurement error or convergent validity. Two-point discrimination, laterality judgement and movement control tests had moderate evidence supporting their ability to distinguish between healthy people and those with CLBP.

CONCLUSIONS

Two-point discrimination, laterality judgment and movement control tests demonstrate the greatest level of known-groups validity for people with CLBP. However, as the reliability of these measurement tools has yet to be established, this validity data should be interpreted cautiously. Further research is warranted to investigate the clinimetric properties of these sensorimotor techniques.

The effects of psychological distress and its interaction with socioeconomic position on risk of developing four chronic diseases

OBJECTIVE

To examine the relationship between psychological distress and risk of developing arthritis, cardiovascular disease, chronic obstructive pulmonary disease and diabetes across the range of distress severity, investigate the mediating roles of health behaviours and explore whether the associations vary with socioeconomic position.

METHODS

Participants were 16,485 adults from the UK Household Longitudinal Study We examined prospective relationships between psychological distress at baseline (measured using the 12-item General Health Questionnaire) and incidence of arthritis, cardiovascular disease, chronic obstructive pulmonary disease and diabetes (measured using self-report) over 3 years using logistic regression. We then examined the mediating effects of health behaviours and investigated whether the associations varied with socioeconomic position.

RESULTS

Distress significantly increased risk of incident arthritis, cardiovascular disease and chronic obstructive pulmonary disease in a dose-response pattern after controlling for age, sex, socioeconomic position, neighbourhood cohesion, marital status, BMI and baseline disease. High levels of distress (GHQ ≥ 7) increased risk of arthritis (OR 2.22; 1.58-2.13), cardiovascular disease (OR 3.06; 1.89-4.98) and chronic obstructive pulmonary disease (OR 3.25; 1.47-7.18). These associations were partially mediated by smoking status but remained significant after controlling for smoking status, diet and exercise. Distress significantly predicted incident diabetes in manual socioeconomic groups only. Effect sizes did not vary with socioeconomic position for arthritis, cardiovascular disease and chronic obstructive pulmonary disease.

CONCLUSION

Psychological distress increases risk of incident arthritis, cardiovascular disease and chronic obstructive pulmonary disease in a dose-response pattern, even at low and moderate distress levels. Future research should investigate the mediating role of inflammatory biomarkers.

Cost-effectiveness analysis of eliminating industrial and all trans fats in England and Wales: modelling study

Introduction

Coronary heart disease (CHD) remains a leading cause of UK mortality. Dietary trans fats (TFA) represent a powerful CHD risk factor. However, UK efforts to reduce intake have been less successful than other nations. We modelled the potential health and economic effects of eliminating industrial and all TFA up to 2020.

Methods

We extended the previously validated IMPACTsec model, to estimate the potential effects on health and economic outcomes of mandatory reformulation or a complete ban on dietary TFA in England and Wales from 2011 to 2020. We modelled two policy scenarios: 1) Elimination of industrial TFA consumption, from 0.8% to 0.4% daily energy 2) Elimination of all TFA consumption, from 0.8% to 0.

Results

Elimination of industrial TFA across the England and Wales population could result in approximately 1600 fewer deaths per year, with some 4000 fewer hospital admissions; gaining approximately 14 000 additional life years. Health inequalities would be substantially reduced in both scenarios. Elimination of industrial TFA would be cost saving. This would include approximately £100 m saved in direct healthcare costs. Elimination of all TFA would double the health and economic gains.

Conclusions

Eliminating industrial or all UK dietary intake of TFA could substantially reduce CHD mortality and inequalities, while resulting in substantial annual savings.

Does dietary nitrate say NO to cardiovascular ageing? Current evidence and implications for research

CVD are characterised by a multi-factorial pathogenesis. Key pathogenetic steps in the development of CVD are the occurrence of endothelial dysfunction and formation of atherosclerotic lesions. Reduced nitric oxide (NO) bioavailability is a primary event in the initiation of the atherosclerotic cascade. NO is a free radical with multiple physiological functions including the regulation of vascular resistance, coagulation, immunity and oxidative metabolism. The synthesis of NO proceeds via two distinct pathways identified as enzymatic and non-enzymatic. The former involves the conversion of arginine into NO by the NO synthases, whilst the latter comprises a two-step reducing process converting inorganic nitrate $({\rm NO}_3^ - )$ into nitrite and subsequently NO.

Inorganic ${\rm NO}_3^ - $ is present in water and food, particularly beetroot and green leafy vegetables. Several investigations have therefore used the non-enzymatic NO pathway as a target for nutritional supplementation (${\rm NO}_3^ - $ salts) or dietary interventions (high-${\rm NO}_3^ - $ foods) to increase NO bioavailability and impact on cardiovascular outcomes. Some studies have reported positive effects of dietary ${\rm NO}_3^ - $ on systolic blood pressure and endothelial function in patients with hypertension and chronic heart failure. Nevertheless, results have been inconsistent and the size of the effect appears to be declining in older individuals. Additionally, there is a paucity of studies for disorders such as diabetes, CHD and chronic kidney failure. Thus, whilst dietary ${\rm NO}_3^ - $ supplementation could represent an effective and viable strategy for the primary and secondary prevention of age-related cardiovascular and metabolic diseases, more large-scale, robust studies are awaited to confirm or refute this notion.

The future of UK healthcare: problems and potential solutions to a system in crisis

The UK's Health System is in crisis, central funding no longer keeping pace with demand. Traditional responses-spending more, seeking efficiency savings or invoking market forces-are not solutions. The health of our nation demands urgent delivery of a radical new model, negotiated openly between public, policymakers and healthcare professionals. Such a model could focus on disease prevention, modifying health behaviour and implementing change in public policy in fields traditionally considered unrelated to health such as transport, food and advertising. The true cost-effectiveness of healthcare interventions must be balanced against the opportunity cost of their implementation, bolstering the central role of NICE in such decisions. Without such action, the prognosis for our healthcare system-and for the health of the individuals it serves-may be poor. Here, we explore such a new prescription for our national health.

Countdown for UK Child Survival 2017: mortality progress and targets

BACKGROUND

The Countdown for UK Child Survival tracks recent UK child mortality trends and makes recommendations for improvement.

METHODS

We used data from the WHO World Mortality Database to calculate mortality from 1970 to 2014 for 0-19 year olds in the UK and a comparable group of wealthy countries (the EU15+). We used Poisson regression models to assess the significance of apparent differences. We extrapolated model coefficients to estimate future disparites between the UK and the EU15+ to 2030. We proposed goals and intermediate indicators to track UK mortality in keeping with the UN Sustainable Development Goals.

RESULTS

UK infant mortality continues to track in the worst decile of EU15+ mortality with 1-4 year mortality in the worst quartile. Annual reductions in total UK mortality have been significantly lower than the EU15+ since 1990 for infant, postneonatal and 1-4 year mortality. If current trends persist, by 2030 UK infant mortality and 1-4 year mortality could be respectively 180% and 145% of EU15+ median mortality. UK non-communicable disease (NCD) mortality among 1-4 years and 15-19 years persists in the worst quartile. UK injury mortality continues in the best quartile. A framework of goals and indicators for UK child survival and health is presented.

DISCUSSION

UK mortality among under 10 years of age continues to diverge from the EU15+ median, and UK NCD mortality remains persistently poor. We propose a set of goals to improve UK childhood survival by 2030 and an annual Countdown mechanism to monitor progress towards these targets.

Learning from good practice: a review of current oral health promotion materials for parents of young children

Objectives To examine the quality of UK-based oral health promotion materials (OHPM) for parents of young children aged 0-5 years old.Data sources OHPM were obtained via email request to dental public health consultants and oral health promotion teams in the UK, structured web-based searches or collected from oral health events.Data selection Materials were included if: they were freely available; they were in English; they were parent facing and included oral health advice aimed at children aged 0-5-years-old.Data extraction Quality assessment was based on: whether the oral health messages were consistent with Public Health England's Delivering better oral health guidance, and what barriers to good oral health were addressed by the OHPM using the Theoretical Domains Framework (TDF).Data synthesis A wide range of printed and digital OHPM were identified (n = 111). However, only one piece of material covered all 16 guidance points identified in Public Health England's Delivering better oral health (mean 6, SD 4), and one other material addressed all 12 domains of the TDF (mean 6, SD 2).Conclusions Although there were examples of high quality, further development is required to ensure OHPM are clear, consistent and address a wider range of barriers to good oral health behaviours.