A longitudinal qualitative study of women's experiences of postnatal care following hypertensive disorders of pregnancy

PROBLEM

There has been little focus on women's views of care and recovery following pregnancy complicated by hypertensive disorders of pregnancy [HDP] despite long-term implications for maternal health.

BACKGROUND

Increasingly in clinical research, areas of interest include the extent to which women are involved in postnatal care planning, perceived value of routine postnatal contacts, lifestyle behaviour advice, and extent to which ongoing concerns about HDP could be discussed with healthcare professionals.

AIM

This study explored women's experiences of birth-recovery up to 12 months following HDP.

METHODS

A longitudinal qualitative study using semi-structured interviews at four and 12 months postpartum. Twenty-four women who each had a form of HDP, were recruited using a maximum variation, purposive sampling strategy from four National Health Service maternity units in London, 21 of whom were interviewed at both time points. Data were collected and analysed by timepoint following a recurrent, cross-sectional cohort approach using template analysis methodology.

FINDINGS

Four main themes and ten sub-themes were identified. Main themes included: assumptions about blood pressure; perinatal experiences; postnatal care pathways; and managing complex health conditions.

DISCUSSION

Postnatal care needs to be tailored to women's individual needs following HDP, with ongoing review by relevant clinicians during and beyond the first six weeks. Many women with HDP have ongoing information needs about hypertensive status, treatment and prognoses, and future birth planning.

CONCLUSION

Policy makers, health providers and funders cannot continue to ignore the need to ensure postnatal services meet the needs of women who have experienced medically complex pregnancies.

Effect of maternal eating disorders on mother-infant quality of interaction, bonding and child temperament: A longitudinal study

AIMS

This study aims to investigate the effect of maternal eating disorders (ED) on mother-infant quality of interaction at 8 weeks and bonding and child temperament at 1 and 2 years postnatally. We also aimed to explore the relationship between maternal ED psychopathology, comorbid psychiatric difficulties, and both mother-infant quality of interaction and bonding in women with ED. Women were recruited to a prospective longitudinal study. By the time of giving birth, the sample consisted of 101 women of the initial 137 (73.7%). Overall, 62 women (ED = 36; HC = 26) participated in the 8-week assessment, 42 (ED = 20; HC = 22) at 1 year, and 78 (ED = 34; HC = 44) at 2 years. Mann-Whitney U Test was used to explore association between maternal ED and mother-infant quality of interaction and between maternal ED and bonding. Spearman correlations were used to explore associations between maternal ED psychopathology, comorbid psychiatric difficulties, and both mother-infant quality of interaction and bonding.

RESULTS

We found no differences between early mother-infant interaction and bonding in mothers with ED in comparison to HC. High levels of maternal ED psychopathology were correlated with high anxiety levels, higher negative affectivity, and lower extraversion in children of ED mothers both at 1 and 2 years. Furthermore, high levels of ED psychopathology were also associated with lower effortful control at 1 year.

CONCLUSIONS

Findings imply that maternal ED have an impact on child temperament. Future research should focus on resilience and on which protective factors might lead to positive outcomes. These factors can be then used as therapeutic and preventative targets.

Observational prospective study of social media, smartphone use and self-harm in a clinical sample of young people: study protocol

INTRODUCTION

Young people are the most frequent users of social media and smartphones and there has been an increasing speculation about the potential negative impacts of their use on mental health. This has coincided with a sharp increase in the levels of self-harm in young people. To date, studies researching this potential association are predominantly cross-sectional and reliant on self-report data, which precludes the ability to objectively analyse behaviour over time. This study is one of the first attempts to explore temporal patterns of real-world usage prior to self-harm, to identify whether there are usage patterns associated with an increased risk.

METHODS AND ANALYSIS

To study the mechanisms by which social media and smartphone use underpin self-harm in a clinical sample of young people, the Social media, Smartphone use and Self-harm in Young People (3S-YP) study uses a prospective, observational study design. Up to 600 young people aged 13-25 years old from secondary mental health services will be recruited and followed for up to 6 months. Primary analysis will compare real-world data in the 7 days leading up to a participant or clinician recorded self-harm episode, to categorise patterns of problematic usage. Secondary analyses will explore potential mediating effects of anxiety, depression, sleep disturbance, loneliness and bullying.

ETHICS AND DISSEMINATION

This study was approved by the National Research Ethics Service, London - Riverside, as well as by the Joint Research and Development Office of the Institute of Psychiatry, Psychology and Neuroscience and South London and Maudsley NHS Foundation Trust (SLaM), and the SLaM Clinical Research Interactive Search (CRIS) Oversight Committee. The findings from this study will be disseminated through peer-reviewed scientific journals, conferences, websites, social media and stakeholder engagement activities.

TRIAL REGISTRATION NUMBER

NCT04601220.

Cardiovascular disease-wide association study to investigate shared genetics with peak oxygen uptake

Introduction

Cardiorespiratory fitness, measured as peak oxygen uptake (VO2peak), is a strong predictor of cardiovascular disease (CVD) morbidity and mortality and is estimated to have a large genetic component (∼60%). However, the genetic determinants are yet to be established. Our research group recently identified novel genetic variants associated with directly measured VO2peak. Interestingly, most were specific to females. Looking into genetic pleiotropy between VO2peak and CVD can help elucidate the biological mechanisms explaining the link between this fitness related trait and disease, and potentially identify new therapeutic targets.

Purpose

The association study aims to investigate if genetic variants found to be associated with VO2peak in women is associated with any cardiovascular disease phenotypes.

Methods

34,188 female participants with genotype data from the Trøndelag Health Study (HUNT) were included in this study. ICD-coded hospital data related to cardiovascular disease was collected on each participant and the ICD codes were mapped to Phecodes, resulting in 100 disease-specific phenotypes. 26 single nucleotide polymorphisms (SNPs) previously found to be associated with directly measured VO2peak (p<5e-6) were included in the analyses, all common variants (minor allele frequency ≥1%). Each of the 26 genetic variants were tested for association with the 100 phenotypes using a logistic mixed model as implemented in SAIGE. The analysis was adjusted for birthyear and ten principal components of ancestry. The Benjamini-Hochberg false discovery rate (FDR) procedure controlling the FDR at 0.05 was used to correct for the number of tested SNPs and phenotypes.

Results

After testing each of the 26 SNPs for association with 100 cardiovascular disease phenotypes, 133 SNP-phenotype associations were nominally significant (p<0.05). The association between rs17066736 and myocarditis had the lowest p-value (1.7e-4). Among the other tested SNP-phenotype pairs were phenotypes related to ischemic heart disease, cardiac conduction disorders, heart failure, cerebrovascular disease, and diseases of arteries and veins. However, when adjusting for multiple testing, none reached overall statistical significance.

Conclusions

The findings showed no statistically significant associations between genetic variants associated with VO2peak and cardiovascular disease phenotypes in women. The role of inborn VO2peak in prediction of CVD (in women) needs further assessment.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): NTNU biotechnology

Improved cardiovascular disease risk prediction by implementing sex-specific cut-offs for intervention and new risk markers

Background

More than 17 million people die from cardiovascular disease (CVD) annually. CVDs are preventable and several risk prediction models are available for determining the 10-year risk of CVD, including the Norwegian NORRISK2 model. However, the available risk prediction models only explain a modest proportion of the incidence. For myocardial infarction (MI), it is estimated that 15–20% of the patients have none of the traditional risk factors and would be classified as “low risk”.

Purpose

Aim was to develop improved models for predicting the 10-year risk of MI.

Methods

We included 31.946 participants from the third wave of the Trøndelag Health Study (HUNT3) with no previous CVDs. HUNT data included 101 variables from interviews, clinical measurements, and biological samples on each participant. Totally, 11% of the men and 6% of the women experienced an MI between the HUNT3 and HUNT4 (10-year follow-up). The dataset was split 80/20 into a training set and a test set. XGBoost and logistic regression (LR) were used to fit two models for each sex predicting MI including variables from HUNT3. The models were evaluated by the area under the Receiver-Operating-Characteristic (ROC) curve and the Precision-Recall (PR) curve, both for the full test set and the test set divided into age groups. Thresholds for classification were suggested by maximizing different performance measures through 10-fold cross-validation on the training set. We then explored age- and sex-specific thresholds for intervention with a reasonable trade-off between sensitivity and specificity. All results were compared with NORRISK 2, which was implemented and applied to the same test set for exact comparison.

Results

For men, the XGBoost model improved risk prediction compared to NORRISK 2 for all age groups (AUC-ROC for XGBoost and NORRISK 2, respectively, 0.72 and 0.65 (age 45–54), 0.63 and 0.62 (age 55–64), 0.69 and 0.62 (age 65–74)). The liver-related enzyme alkaline phosphatase (ALP) was among the new predictors for MI in men. For women, NORRISK 2 performed best when evaluated by ROC curves, however, when evaluated by PR curves, the XGBoost models indicated improved prediction compared to NORRSIK 2 in the women 55–64 years (AUC-PR for XGBoost and NORRISK 2, respectively, 0.20 and 0.12). The thyroid stimulation hormone (TSH) was among the new predictors for MI in women. Regarding NORRISK 2, our results indicated that the thresholds for intervention should be increased for all age groups in men and decreased for all age groups in women for improved balance between sensitivity and specificity.

Conclusion

New risk factors should be considered implemented in CVD risk prediction algorithms, for improved identification of individuals at increased risk of MI. In addition, implementing sex-specific thresholds for intervention could be a useful step towards improved prevention of CVD for both men and women.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Regional Health Authorities

Screening instruments for eating disorders in pregnancy: Current evidence, challenges, and future directions

Pregnancy is a vulnerable period for eating disorder (ED) occurrence and maternal EDs are associated with heightened risk of adverse pregnancy and infant outcomes. This highlights the need to identify pregnant women with past or current EDs in order to offer appropriate support. However, there is a knowledge and practice gap on screening pregnant women for EDs. Clinical guidance is lacking in international treatment guidelines, which is unsurprising given that no validated ED screening tool specifically designed for use in antenatal populations exists. Moreover, data on the effectiveness of general population screening tools for identifying EDs in pregnant women are scarce. This article provides a synthesis of current evidence, treatment guidelines, and data on the diagnostic accuracy for screening for EDs in antenatal samples from three studies with different screening approaches. We outline recommendations for future steps to tackle the knowledge and practice gap on screening for EDs in pregnant women, including next steps for the development of a pregnancy-specific ED screener and the use of general mental health screeners to detect EDs during pregnancy. Up-to-date, the jury is still out as how to best identify current or past EDs in pregnancy. More research is needed to assess the efficacy of using general mental health screeners versus ED-specific screening instruments to detect ED in pregnancy. Additionally, clinicians have to be trained on how to assess and manage EDs during pregnancy. PUBLIC SIGNIFICANCE: Identifying pregnant women with eating disorders (EDs) is a public health concern which can be addressed using multiple approaches, including implementation of general and specific assessments within routine antenatal care, and training of healthcare professionals.

New genetic determinants of VO2max-level identified by GWAS: The HUNT Study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Central Norway Regional Health Authority

Norwegian Health Association

Introduction

Cardiovascular disease (CVD) is the leading cause of death worldwide. Several studies have shown that low cardiorespiratory fitness (CRF) is a major risk factor for CVD and is suggested to be a stronger predictor of CVD morbidity and mortality than established cardiovascular risk factors.

CRF quantified as maximal oxygen uptake (VO2max) has a strong genetic component, estimated to be ~50%. Unfortunately, current studies on genetic markers for CRF are limited by small sample sizes. In addition, there are few studies on directly measured VO2max, as most of the previous studies are based on estimated CRF. To overcome these limitations, we performed a large-scale systematic screening for genetic variants associated with VO2max aiming to provide awaited insight to this complex trait and discover possible links between VO2max and CVD.

Purpose

To identify and validate genetic factors associated with VO2max.

Methods

The genotypes of 70,000 participants from the Trøndelag Health study (HUNT) were imputed providing information on 25 million single-nucleotide polymorphisms (SNPs). We conducted a genome-wide association study (GWAS) including 4,525 participants with directly measured VO2max from the HUNT3 Fitness study. The GWAS was performed using BOLT-LMM, adjusted for age, gender, physical activity, principal components, and genotyping batch. In addition, we ran a GWAS with the same covariates except physical activity. Further, gender specific analyses were conducted. For validation, similar analyses were performed in the United Kingdom Biobank (UKBB). In the UKBB, CRF was assessed through a submaximal bicycle test. The analyses of UKBB included ~60,000 participants and over 90 million SNPs. Functional analyses of the GWAS results were examined by functional mapping and annotation (FUMA).

Results

Two GWAS-significant (p < 5×10-8) SNPs associated with VO2max were identified in the total population, two in the male population, and 24 in the female population in HUNT. Two of the 24 SNPs found in the female population were nominally significant in the UKBB. One of the validated SNPs in the female population is located inside PIK3R5, that is shown to be of importance in cardiac function and CVD. In addition, the functional analyses in the total- and male population revealed candidate SNPs in a gene previously found to be associated with endurance, PPP3CA.

Conclusions

We have identified 28 novel SNPs associated with VO2max in the HUNT cohort. Two of these SNPs were nominally validated in females in UKBB. One of the validated SNPs resides within a gene previously reported to be related to heart function and CVD. In addition, the functional analyses in the total- and male population revealed candidate SNPs in a gene previously found to be associated with endurance. Further functional analyses using bioinformatic approaches may provide more information on the physiological importance of these findings and their relation to CVD.

Perinatal mental health services in pregnancy and the year after birth: the ESMI research programme including RCT

Background

It is unclear how best to identify and treat women with mental disorders in pregnancy and the year after birth (i.e. the perinatal period).

Objectives

(1) To investigate how best to identify depression at antenatal booking [work package (WP) 1]. (2) To estimate the prevalence of mental disorders in early pregnancy (WP1). (3) To develop and examine the efficacy of a guided self-help intervention for mild to moderate antenatal depression delivered by psychological well-being practitioners (WP1). (4) To examine the psychometric properties of the perinatal VOICE (Views On Inpatient CarE) measure of service satisfaction (WP3). (5) To examine the clinical effectiveness and cost-effectiveness of services for women with acute severe postnatal mental disorders (WPs 1–3). (6) To investigate women’s and partners’/significant others’ experiences of different types of care (WP2).

Design

Objectives 1 and 2 – a cross-sectional survey stratified by response to Whooley depression screening questions. Objective 3 – an exploratory randomised controlled trial. Objective 4 – an exploratory factor analysis, including test–retest reliability and validity assessed by association with the Client Satisfaction Questionnaire contemporaneous satisfaction scores. Objective 5 – an observational cohort study using propensity scores for the main analysis and instrumental variable analysis using geographical distance to mother and baby unit. Objective 6 – a qualitative study.

Setting

English maternity services and generic and specialist mental health services for pregnant and postnatal women.

Participants

Staff and users of mental health and maternity services.

Interventions

Guided self-help, mother and baby units and generic care.

Main outcome measures

The following measures were evaluated in WP1(i) – specificity, sensitivity, positive predictive value, likelihood ratio, acceptability and population prevalence estimates. The following measures were evaluated in WP1(ii) – participant recruitment rate, attrition and adverse events. The following measure was evaluated in WP2 – experiences of care. The following measures were evaluated in WP3 – psychometric indices for perinatal VOICE and the proportion of participants readmitted to acute care in the year after discharge.

Results

WP1(i) – the population prevalence estimate was 11% (95% confidence interval 8% to 14%) for depression and 27% (95% confidence interval 22% to 32%) for any mental disorder in early pregnancy. The diagnostic accuracy of two depression screening questions was as follows: a weighted sensitivity of 0.41, a specificity of 0.95, a positive predictive value of 0.45, a negative predictive value of 0.93 and a likelihood ratio (positive) of 8.2. For the Edinburgh Postnatal Depression Scale, the diagnostic accuracy was as follows: a weighted sensitivity of 0.59, a specificity of 0.94, a positive predictive value of 0.52, a negative predictive value of 0.95 and a likelihood ratio (positive) of 9.8. Most women reported that asking about depression at the antenatal booking appointment was acceptable, although this was reported as being less acceptable for women with mental disorders and/or experiences of abuse. Cost-effectiveness analysis suggested that both the Whooley depression screening questions and the Edinburgh Postnatal Depression Scale were more cost-effective than with the Whooley depression screening questions followed by the Edinburgh Postnatal Depression Scale or no-screen option. WP1(ii) – 53 women with depression in pregnancy were randomised. Twenty-six women received modified guided self-help [with 18 (69%) women attending four or more sessions] and 27 women received usual care. Three women were lost to follow-up (follow-up for primary outcome: 92%). At 14 weeks post randomisation, women receiving guided self-help reported fewer depressive symptoms than women receiving usual care (adjusted effect size −0.64, 95% confidence interval −1.30 to 0.06). Costs and quality-adjusted life-years were similar, resulting in a 50% probability of guided self-help being cost-effective compared with usual care at National Institute for Health and Care Excellence cost per quality-adjusted life-year thresholds. The slow recruitment rate means that a future definitive larger trial is not feasible. WP2 – qualitative findings indicate that women valued clinicians with specialist perinatal expertise across all services, but for some women generic services were able to provide better continuity of care. Involvement of family members and care post discharge from acute services were perceived as poor across services, but there was also ambivalence among some women about increasing family involvement because of a complex range of factors. WP3(i) – for the perinatal VOICE, measures from exploratory factor analysis suggested that two factors gave an adequate fit (comparative fit index = 0.97). Items loading on these two dimensions were (1) those concerning aspects of the service relating to the care of the mother and (2) those relating to care of the baby. The factors were positively correlated (0.49; p < 0.0001). Total scores were strongly associated with service (with higher satisfaction for mother and baby units, 2 degrees of freedom; p < 0.0001) and with the ‘gold standard’ Client Service Questionnaire total score (test–retest intraclass correlation coefficient 0.784, 95% confidence interval 0.643 to 0.924; p < 0.0001). WP3(ii) – 263 of 279 women could be included in the primary analysis, which shows that the odds of being readmitted to acute care was 0.95 times higher for women who were admitted to a mother and baby unit than for those not admitted to a mother and baby unit (0.95, 95% confidence interval 0.86 to 1.04; p = 0.29). Sensitivity analysis using an instrumental variable found a markedly more significant effect of admission to mother and baby units (p < 0.001) than the primary analysis. Mother and baby units were not found to be cost-effective at 1 month post discharge because of the costs of care in a mother and baby unit. Cost-effectiveness advantages may exist if the cost of mother and baby units is offset by savings from reduced readmissions in the longer term.

Limitations

Policy and service changes had an impact on recruitment. In observational studies, residual confounding is likely.

Conclusions

Services adapted for the perinatal period are highly valued by women and may be more effective than generic services. Mother and baby units have a low probability of being cost-effective in the short term, although this may vary in the longer term.

Future work

Future work should include examination of how to reduce relapses, including in after-care following discharge, and how better to involve family members.

Trial registration

This trial is registered as ISRCTN83768230 and as study registration UKCRN ID 16403.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 5. See the NIHR Journals Library website for further project information.

Identifying new genetic markers for maximal oxygen uptake

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Central Norway Regional Health AuthorityNorwegian Health Association

Introduction

Cardiovascular disease (CVD) is the leading cause of death worldwide. Several studies have shown that low cardiorespiratory fitness (CRF) is a major risk factor for CVD. Low CRF is suggested to be a stronger predictor of CVD morbidity and mortality than established cardiovascular risk factors like obesity, diabetes, and cholesterol.

Several studies suggest that CRF quantified as maximal oxygen uptake (VO2max) has a strong genetic component, estimated to be ~50%. Unfortunately, current studies on genetic markers for CRF are limited by small sample sizes. In addition, there are few studies on directly measured VO2max, as most of the previous studies are based on estimated CRF. Directly measured VO2max is considered as the gold standard for measuring CRF. Thus, a large-scale systematic screening for genetic variants associated with VO2max may provide awaited insight to this complex trait and discover possible links between VO2max and CVD.

Purpose

To identify and validate genetic factors associated with VO2max.

Methods

The genotypes of 70.000 participants from the Trøndelag Health study (HUNT) were imputed providing information on 25 million SNPs. We conducted a genome-wide association study (GWAS) including 4525 participants with directly measured VO2max from the HUNT3 Fitness study. The GWAS was performed using BOLT-LMM, adjusted for age, gender, physical activity, principal components, and genotyping batch. In addition, we ran a GWAS with the same covariates except physical activity. Further, gender specific analyses were conducted. For validation, similar analyses were performed in the United Kingdom Biobank (UKBB). In the UKBB, CRF was assessed through a submaximal bicycle test. The analyses of UKBB included ~60.000 participants and over 90 million SNPs.

Results

Two GWAS-significant (p &lt; 5x10-8) SNPs associated with VO2max were identified in the total population in HUNT. Further, 24 GWAS-significant SNPs associated with VO2max in females, and two GWAS-significant SNPs associated with VO2max in males were discovered. Two of the 24 SNPs found in the female population were nominally significant in the UKBB. The validated SNPs are rs376927175, an intergenic SNP downstream of APBA1, and rs551942830 (proxy for rs190675254 with LD = 1.0), a 3 Prime UTR variant inside PIK3R5. PIK3R5 encodes the regulatory subunit of one class of PI3Ks, that is shown to be of importance in cardiac function and CVD. None of the SNPs found in the total population nor the male population were validated in UKBB.

Conclusions

We have identified 28 novel SNPs associated with VO2max in the HUNT cohort. Two of these SNPs were nominally validated in females in UKBB. One of the validated SNPs resides within a gene previously reported to be related to heart function and CVD. Further functional analyses using bioinformatic approaches may provide more information on the physiological importance of these findings and their relation to CVD.

Maximizing the positive and minimizing the negative: Social media data to study youth mental health with informed consent

Social media usage impacts upon the mental health and wellbeing of young people, yet there is not enough evidence to determine who is affected, how and to what extent. While it has widened and strengthened communication networks for many, the dangers posed to at-risk youth are serious. Social media data offers unique insights into the minute details of a user's online life. Timely consented access to data could offer many opportunities to transform understanding of its effects on mental wellbeing in different contexts. However, limited data access by researchers is preventing such advances from being made. Our multidisciplinary authorship includes a lived experience adviser, academic and practicing psychiatrists, and academic psychology, as well as computational, statistical, and qualitative researchers. In this Perspective article, we propose a framework to support secure and confidential access to social media platform data for research to make progress toward better public mental health.

Eating disorders, pregnancy and the postnatal period: a review of the recent literature

PURPOSE OF REVIEW

Eating disorders (ED) are severe psychiatric disorders that affect women in reproductive age. The purpose of this review is to provide an up-to-date overview of the impact of maternal ED on pregnancy and the postnatal period. The clinical implications for identification and management of maternal ED are also discussed.

RECENT FINDINGS

In the last 2 years, 15 articles focused on the impact of maternal ED in pregnancy and postpartum. Findings from this review indicate that around 15% of pregnant women are likely to have had an ED at some point in their lifetime, and about 5% have an ED in pregnancy. Although ED symptoms tend to decrease during pregnancy, remission is often only temporary with symptoms typically resurfacing in the postnatal period. Women with ED are prone to psychiatric comorbidities such as depression and anxiety during the perinatal period, with up to a third of women with ED reporting postnatal depression in clinical studies and prevalence ranging between 40% and 66% in general population samples. Furthermore, recent findings continue to highlight that current and prior history of maternal ED are associated with a heightened risk of adverse pregnancy and birth outcomes, most notably preterm birth and adverse birth weight outcomes.

SUMMARY

These findings continue to emphasise the clinical importance of early identification and response to maternal ED to mitigate potentially adverse maternal and infant outcomes.

Snap shot: Achieving better care through a one-page personal health profile

Children with intellectual disabilities (IDs) can have complex health conditions that require intense and ongoing care management by multiple healthcare professionals (HCPs). Families often experience frustrations and challenges sharing necessary information about their children's unique emotional and communicative needs with HCPs. In turn, these needs are often poorly documented and shared with other HCPs. This contributes to compromised care and frustrations for families and HCPs. We conducted a qualitative study using focus groups to examine how 10 parents and 3 HCPs experienced provision of care for children with ID, as well as their suggestions for developing a one-page personal health profile (PHP) to improve communication. Parents suggested including behavioural descriptors rather than diagnoses. All participants believed a one-page PHP that was child and parent led would be very helpful and would improve communication between HCPs, parents and children leading to effective and supportive care.

Lipoprotein subfraction LDL-5 and the presence of coronary atherosclerosis

Background

Coronary artery disease (CAD) has high mortality rates and is a frequent cause of death globally. Serum lipids play a pivotal role in the development of atherosclerosis, and elevated levels of total cholesterol, low density lipoprotein (LDL) cholesterol, and triglycerides are well known risk factors of cardiovascular disease (CVD). However, there are limitations in the ability to predict CVD risk, which has led to an increased clinical interest in identifying novel risk markers. With the advances in lipidomic technology, lipoprotein subfractions may provide additional information that is missing in today's evaluation of CVD risk. Lipoprotein subfractions differ in size and density, and recent studies suggest that high density of small LDL particles provide a greater risk for CVD.

Purpose

To investigate whether lipoprotein subfractions are associated with the presence and extent of coronary atherosclerosis.

Methods

Fasting serum samples from 60 participants with suspected stable CAD were collected before scheduled coronary angiography, and analysed by nuclear magnetic resonance (NMR). The presence and extent of atherosclerosis were quantified by the Gensini Score. Participants were classified into one of three Gensini groups based on severity (&lt;20.5, normal; 20.6–30, non-significant CAD; &gt;30.1, significant CAD).

Results

A three-way ANOVA, adjusted for statin-use and sex, revealed statistically significant differences (p&lt;0.005) in LDL-5 particle number, LDL-5 triglycerides, and LDL-5 phospholipids between the Gensini groups. In addition, significant differences (p&lt;0.005) were found in the ratios apolipoprotein A/apolipoprotein B and LDL cholesterol/HDL cholesterol between the Gensini groups. All significant variables, identified by the three-way ANOVA, displayed the highest levels in the Gensini group with significant CAD.

Conclusion

Despite no difference in the traditional clinical measurements (total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides), NMR-lipidomics revealed significant differences in LDL-5 between the Gensini groups. Interestingly, our results reveal that those with significant CAD have a higher density of small LDL subfractions.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Norwegian Health Association, The Liaison Committee for Education, Research and Innovation in Central Norway

Postnatal care following hypertensive disorders of pregnancy: a qualitative study of views and experiences of primary and secondary care clinicians

OBJECTIVES

To explore clinicians' views and experiences of caring for postnatal women who had hypertensive disorders of pregnancy (HDP), awareness of relevant National Institute for Health and Care Excellence (NICE) guidance to inform their postnatal management, the extent to which NICE guidance was implemented, barriers and facilitators to implementation and how care could be enhanced to support women's future health.

DESIGN

A qualitative study using semistructured interviews. Thematic analysis was used for coding and theme generation.

SETTING

Four National Health Service maternity units and three general practice clinics in South-East and South-West London.

PARTICIPANTS

A maximum variation, purposive sample of 20 clinicians with experience of providing postnatal care to women following HDP.

RESULTS

Four main themes were generated: variation in knowledge and clinical practice; communication and education; provision of care; locus of responsibility for care. Perceived barriers to implementation of NICE guidance included lack of postnatal care plans and pathways, poor continuity of care, poor antihypertensive medication management, uncertainty around responsibility for postnatal care and women's lack of awareness of the importance of postnatal follow-up for their future health. Some clinicians considered that women were discharged from inpatient care too soon, as primary care clinicians did not have specialist knowledge of HDP management. Most clinicians acknowledged the need for better planning, communication and coordination of care across health settings.

CONCLUSIONS

Evidence of longer term consequences for women's health following HDP is accumulating, with potential for NICE guidance to support better outcomes for women if implemented. Clinicians responsible for postnatal care following HDP should ensure that they are familiar with relevant NICE guidance, able to implement recommendations and involve women in decisions about ongoing care and why this is important. The continued low priority and resources allocated to postnatal services will continue to promote missed opportunities to improve outcomes for women, their infants and families.

P3528Circulating microRNA-210 concentrations are increased in patients with acute heart failure and provide prognostic information

Background

MicroRNA (miR)-210 is induced by cellular hypoxia and circulating miR-210 concentrations are associated with clinical outcome in patients with myocardial infarction and aortic stenosis. Whether circulating miR-210 concentrations provide diagnostic and prognostic information in unselected patients with dyspnea is not known.

Purpose

To assess the diagnostic and prognostic value of circulating miR-210 concentrations in patients hospitalised due to acute dyspnea.

Methods

We extracted microRNA from plasma samples obtained on admission from 314 patients hospitalised for acute dyspnea and 10 healthy control subjects. miR-210 concentrations were measured by quantitative polymerase chain reaction and we used miR-425 for normalisation. The merit of circulating miR-210 concentrations to diagnose and provide prognostic information in patients with acute heart failure (HF) was compared to the merit of N-terminal pro-B-type natriuretic peptide (NT-proBNP).

Results

In total, 143 patients (46%) were adjudicated as hospitalised due to acute heart failure (HF) and 84 patients (27%) due to acute exacerbation of chronic obstructive lung disease (AECOPD). All patients and control subjects had miR-210 concentrations within the range of detection (Cq 26–32) and analytical variation was low. miR-210 concentrations correlated with age, NT-proBNP and cardiac troponin T concentrations in the total cohort. Circulating miR-210 concentrations were increased in patients with HF (4.7±3.3 fold increase, p<0.0001) and AECOPD (3.4±1.7 fold increase, p<0.0001) compared to control subjects. Circulating miR-210 concentrations were not different between patient groups and receiver operating characteristics area under the curve (AUC) for miR-210 to diagnose acute HF was 0.50 (95% CI 0.43–0.57) compared to AUC 0.85 (0.81–0.89) for NT-proBNP. During a median 817 days of follow-up, 66 patients (46%) with acute HF died and 35 patients (42%) with AECOPD died. Circulating miR-210 concentrations separated acute HF patients with a poor and favourable outcome (Figure 1; p by the log rank test =0.017). Circulating miR-210 concentrations were also associated with mortality during follow-up in Cox regression model: hazard ratio (HR) for lnRQ of miR-210 was 2.11 (95% CI 1.27–2.50), p=0.004. The association between circulating miR-210 concentrations and outcome was attenuated and no longer significant after adjusting for NT-proBNP concentrations. Circulating miR-210 concentrations did not predict outcome in patients with AECOPD: HR 1.38 (0.65–2.93); p=0.4.

Figure 1

Conclusions

Circulating miR-210 concentrations are increased in patients with acute HF, and provide prognostic information during follow-up. Still, circulating miR-210 concentrations did not diagnose acute HF among unselected patients with dyspnea and the association with outcome was attenuated by NT-proBNP.

Acknowledgement/Funding

Nasjonalforeningen for Folkehelsen

4101Identification of genetic variants associated with the cardiovascular disease risk factor, low aerobic fitness - The HUNT study

Abstract

Background: Low maximal oxygen uptake (VO2max) is a strong and independent risk factor for all-cause and cardiovascular disease (CVD) mortality. Although physical activity is a major determinant of VO2maxlevel, genetics contribution is estimated to be ∼50%.

Methods

We performed a genetic association study on 123.545 single-nucleotide polymorphisms (SNPs) and directly measured VO2max in 3470 individuals (exploration cohort). The candidate SNPs were subsequently analyzed in a separate cohort of 718 individuals (validation cohort), in addition to 7 wild-card SNPs previously associated with VO2max, but not included on the chip used in the exploration cohort. Sub-analyses were performed for each gender. In silico analysis and genotype-phenotype databases were used to predict physiological function of the SNPs.

Results

In the exploration cohort, 42 SNPs were associated with VO2max (p<5.0×10–4). Six of the candidate SNPs were also found to be associated with VO2max in the validation cohort (p<0.05, either in men, women or both), in addition to three wild-card SNPs. By using these nine SNPs we created a genetic score for inborn VO2max-level. Together, these nine SNPs explained ∼8% of the variation in VO2max, and discriminate individuals with inborn high versus low VO2max based on simultaneous carriage of multiple favorable alleles. The cumulative number of favorable SNPs correlated negatively with the presence of several CVDrisk factors, e.g. waist-circumference, visceral fat, fat %, cholesterol levels and BMI. In silico analysis indicated that several of the SNPs influence gene expression across multiple organs, including adipose tissue, skeletal muscle and heart.

Conclusion

We identified six novel genetic variants associated with VO2max, and validated three SNPs previously associated with fitness related traits.

Acknowledgement/Funding

K.G. Jebsen Foundation, the Norwegian Health Association, the Liaison Committee between the Central Norway Regional Health Authority (RHA) and NTNU

P4154MicroRNA Signatures Predict Early Major Coronary Events in Middle Aged Men and Women

Background

The role of microRNA as biomarkers able to predict major coronary events (MACE) has not been fully elucidated, reproducibility being a critical issue.

Aim

To identify circulating microRNA signatures able to predict MACE.

Methods

We employed a PCR-based method to screen 754 microRNAs in a cohort of 60-year-olds (60YOs) from Stockholm, using a nested case-control design (100 cases vs 100 matched controls). The association of microRNAs and their interaction with the risk of MACE (myocardial infarction (MI), angina and sudden cardiac death) was estimated with random-effect logistic regression and expressed as OR with 95% CI. A bioinformatics approach identified microRNA clusters based on predicted targets. Main findings were tested in 58 MI and 60 age and sex matched referents from the the Nord-Trøndelag Health (HUNT) Study, a longitudinal population health study conducted in Norway.

Results

Fifty-five microRNAs were found to be associated with risk of MACE in the 60YO. MicroRNA-145-3p was associated with the largest estimated risk increase of MACE after adjustment for the common CV risk factors (OR: 2.18; 95% CI: 1.27–3.75). Interaction analysis revealed that increasing plasma levels of microRNA-320b modulated the association of 16 microRNAs with risk of MACE. As an example the estimated MACE risk associated with microRNA-145-3p was 1.47 (0.87–2.47) in the presence of low (<25th percentile) and 4.00 (1.79- 8.93) in the presence of high (>75th percentile) miRNA 320b expression levels. Sixteen microRNA pairs could be classified in 4 functional clusters with 492 predicted gene targets, mainly involved in the regulation of inflammation, thrombosis and lipid metabolism. Eight miRNAs interacting pairs belonging to cluster 2 and 4 showed a similar association trend with MI risk in the HUNT study.

Conclusions

We report the identification of microRNA signatures predicting risk of MACE in middle-aged Scandinavian men and women. These signatures could be a valuable tool to improve CV disease prediction in the aged.

P1547Circulating lipoprotein subfractions as new non-invasive biomarkers of coronary atherosclerosis

Objectives

Coronary artery disease (CAD) is the most common cause of death globally. In the next decade, the number of people at risk is expected to increase, due to obesity, inactivity and diabetes. Therefore, precise risk-prediction models will be increasingly important for the healthcare system, to be able to initiate cost-efficient prevention strategies. One of the first steps in CAD-development is sub-clinical atherosclerosis. Biomarkers that could reflect the presence of coronary atherosclerosis would be extremely valuable for risk prediction of myocardial infarction (MI). Serum cholesterol levels are key variables in risk prediction; however, there is growing interest for exploring the potential of other lipid subclasses. The aim of this study is to identify specific lipoprotein subfractions that are associated with the extent of coronary atherosclerosis.

Methods

60 patients with suspected CAD were enrolled. Blood samples were collected before the partiens underwent coronary angiography. The extent of coronary atherosclerosis were quantified using the Gensini score. The partients were classified into three groups based on their Gensini score (<20.5: normal, 20.6–30: non-significant CAD and >30.1: significant CAD). The blood samples were analyzed by nucelar magnetic resonance (NMR) lipidomics. Univariate and multivariate statistical tests were used to determine whether lipoprotein subfractions were associated with the extent of coronary atherosclerosis.

Results and discussion

Of the 117 lipoprotein subfractions quantified, 10 were different in patients with significant CAD compared to patients with normal vessels in non-statin users (p=0.005). Despite no difference in total cholesterol, LDL and HDL cholesterol between the three Gensini groups, NMR lipidomics revealed that patients with significant CAD had twice as many circulating LDL-5 and LDL-6 particles as patients with normal vessels. Furthermore, three types of small LDL-subfractions, called LDL-5-TG, LDL-5-ApoB and LDL-6-ApoB, were significantly increased in patients with significant CAD. Interestingly, previous studies have suggested that small LDL particles are more atherogenic than larger particles. In addition, patients with significant CAD had low levels of ApoA1 containing HDL particles, and high levels of two different small VLDL particles. Previous studies have indicated that small VLDLs are more atherogenic than larger VLDLs, and does to a greater extent penetrate the vessel intima.

Conclusions

This study reveals strong associations between serum lipoprotein subfractions and the degree of coronary atherosclerosis quantified by Gensini score. Especially, the high levels of certain types of small LDL-particles in patients with CAD, indicates that measuring lipoprotein subfractions may provide added value to risk prediction models for MI. However, these findings needs to be further explored and validated in large cohort studies.

Acknowledgement/Funding

Norwegian Health Association, the Liaison Committee between the Central Norway Regional Health Authority (RHA) and NTNU

Body weight, body composition and survival after 1 year: follow-up of a nutritional intervention trial in allo-HSCT recipients

The role of body weight change in survival among recipients of hematopoietic stem-cell transplantation is controversial. We assessed the effect of optimizing energy and protein intake on 1-year survival, body weight and body composition, and the effect of body weight and body composition on 1-year survival in 117 patients (57 intervention, 60 control) in a randomized controlled trial. Cox regression was used to study effects of the intervention, weight and body composition on death, relapse, and nonrelapse mortality (NRM). We found no significant effect of intervention versus control on death hazard ratio (HR) 1.05, 95% confidence interval (CI) 0.54-2.04, p = 0.88), relapse (HR 1.15, 95% CI 0.48-2.27, p = 0.75), and NRM (HR 0.95, 95% CI 0.39-2.28, p = 0.90). Body weight, fat-free mass index, body fat mass index and total body water changed over time (p < 0.001), similarly in both groups (0.17 ≤ p ≤ 0.98). In multivariable analyses adjusted for group, gender and age, HRs and 95% CIs per one kilo increase in weight were 1.03 (1.01-1.06) and 1.04 (1.01-1.08) for death and NRM after 1 year (p ≤ 0.02), respectively, and 1.08 (1.01-1.15) for relapse after 3 months (p = 0.02). In conclusion, weight gain is possibly due to fluid retention and is an indicator of a complication in HSCT, rather than a marker of improved nutritional status.

Accuracy of the Whooley questions and the Edinburgh Postnatal Depression Scale in identifying depression and other mental disorders in early pregnancy

BACKGROUND

There is limited evidence on the prevalence and identification of antenatal mental disorders. Aims To investigate the prevalence of mental disorders in early pregnancy and the diagnostic accuracy of depression-screening (Whooley) questions compared with the Edinburgh Postnatal Depression Scale (EPDS), against the Structured Clinical Interview DSM-IV-TR.

METHOD

Cross-sectional survey of women responding to Whooley questions asked at their first antenatal appointment. Women responding positively and a random sample of women responding negatively were invited to participate.

RESULTS

Population prevalence was 27% (95% CI 22-32): 11% (95% CI 8-14) depression; 15% (95% CI 11-19) anxiety disorders; 2% (95% CI 1-4) obsessive-compulsive disorder; 0.8% (95% CI 0-1) post-traumatic stress disorder; 2% (95% CI 0.4-3) eating disorders; 0.3% (95% CI 0.1-1) bipolar disorder I, 0.3% (95% CI 0.1-1%) bipolar disorder II; 0.7% (95% CI 0-1) borderline personality disorder. For identification of depression, likelihood ratios were 8.2 (Whooley) and 9.8 (EPDS). Diagnostic accuracy was similar in identifying any disorder (likelihood ratios 5.8 and 6).

CONCLUSIONS

Endorsement of Whooley questions in pregnancy indicates the need for a clinical assessment of diagnosis and could be implemented when maternity professionals have been appropriately trained on how to ask the questions sensitively, in settings where a clear referral and care pathway is available. Declaration of interest L.M.H. chaired the National Institute for Health and Care Excellence CG192 guidelines development group on antenatal and postnatal mental health in 2012-2014.

Perinatal hypothalamic-pituitary-adrenal axis regulation among women with eating disorders and their infants

BACKGROUND

Psychiatric illness is associated with heightened hypothalamic-pituitary-adrenal (HPA) axis activity during pregnancy which may have long term effects on infant stress regulation. HPA axis regulation has not previously been investigated in women with eating disorders (ED) or their infants during the perinatal period.

METHODS

Women were recruited to a prospective longitudinal study in three groups: 1) current or active ED (C-ED=31), 2) past ED (P-ED=29) and healthy control (HC=57). Maternal psychopathology, diurnal cortisol levels, corticotropin-releasing hormone (CRH) and CRH binding protein (CRH-BP) were measured during the third trimester of pregnancy. At eight weeks postpartum infant cortisol was obtained before and after routine immunisations to determine infant hormonal response to a stressful situation.

RESULTS

Women with current ED had a significantly lower cortisol decline throughout the day compared to HC, in both adjusted and unadjusted analyses. Lower cortisol decline among women with a current ED were associated with higher levels of psychopathology during pregnancy. Women's cortisol awakening response, CRH and CRH-BP levels did not differ across the three groups. Infants' stress response was also significantly higher among those in the C-ED group, although this effect was attenuated after controlling for confounders.

CONCLUSIONS

During pregnancy women with ED have lower cortisol declines, suggestive of blunted diurnal cortisol rhythms. Postnatally, their infants also have a heightened response to stress. This is the first study to identify HPA axis dysfunction in pregnancy in women with ED, and to show an intergenerational effect. Since dysfunctions in HPA activity during childhood may represent a risk factor for psychological and physical health problems later in life, further investigation of the potential long-term implications of these findings is crucial.

Intake of a Protein-Enriched Milk and Effects on Muscle Mass and Strength. A 12-Week Randomized Placebo Controlled Trial among Community-Dwelling Older Adults

OBJECTIVES

To investigate the effect of 20 g protein with breakfast and evening meal on muscle mass, muscle strength and functional performance in older adults.

DESIGN

A double-blinded randomized controlled study.

SETTING

Oslo and Akershus University College of Applied Sciences, Norway.

PARTICIPANTS

Healthy community-dwelling men and women (≥ 70 years) with reduced physical strength and/or performance.

INTERVENTION

Subjects were randomly assigned to receive either protein-enriched milk (2 x 0.4 L/d; protein group) or an isocaloric carbohydrate drink (2 x 0.4 L/d; control group) with breakfast and evening meal for 12 weeks.

MEASUREMENTS

The primary endpoints were muscle mass measured by dual X-ray absorptiometry, and tests of muscle strength (one repetition maximum test of chest press and leg press) and functional performance (handgrip strength, stair calimb and repeated chair rise).

RESULTS

In total, 438 subjects were screened, 50 subjects were randomized and 36 completed the study. Chest press improved significantly in the protein (1.3 kg (0.1-2.5), p=0.03) and the control group (1.5 kg (0.0-3.0), p=0.048), but with no difference between the groups (p=0.85). No significant change in leg press (p=0.93) or muscle mass (p=0.54) were observed between the protein and the control group. Nor did we observe any significant differences in the functional performance tests (p>0.05 for all tests) between the groups.

CONCLUSION

Increased protein intake (2 x 20 g/d) did not significantly improve muscle mass, muscle strength or functional performance in healthy older weight stable adults. Whether intake of > 20 g protein to each meal is necessary for preservation of muscle mass and strength in older adults should be further investigated in a larger study. This underscores the need for well-designed studies that can differentiate between the effect of protein intake and increased energy. This trial was registered at Clinicaltrials.gov (ID no. NCT02218333).

Brenna's story: A critical reflection and analysis of one mother's experience of navigating the medical system with a child with intellectual disabilities

Children with intellectual disabilities spend more time in the health-care system than mainstream children. Parents have to learn how to navigate the system by coordinating appointments, understanding the referral process, knowing what services are available, and advocating for those services. This places an incredible amount of responsibility on families. This article is one mother's personal story and reflection about her journey through the Canadian health-care system in Nova Scotia, with her daughter who has an intellectual disability. The reflection identifies moments of tension experienced by a mother and how she was expected to be a medical system navigator, doctor-educator, time manager, and care coordinator and the roles that led to feelings of repression, extreme frustration, and fear. A final discussion offers an analysis of her experience, using concepts from feminist post-structuralism.

Antenatal and postnatal psychopathology among women with current and past eating disorders: longitudinal patterns

This study aims to investigate longitudinal patterns of psychopathology during the antenatal and postnatal periods among women with current (C-ED) and past (P-ED) eating disorders. Women were recruited to a prospective longitudinal study: C-ED (n = 31), P-ED (n = 29) and healthy control (HC; n = 57). Anxiety, depression and ED symptoms were measured at four time points: first/second trimester, third trimester, 8 weeks and 6 months postpartum. Linear mixed effects models were used to test for group differences. Women with C-ED and P-ED, in all diagnostic categories, had significantly higher levels of psychopathology at all time points. ED symptoms decreased in the C-ED group, compared with an overall increase in the other two groups but subsequently increased after pregnancy. Overall, depression and state and trait anxiety scores decreased in the C-ED group compared with the HC group throughout the antenatal and postnatal periods. High levels of psychopathology are common throughout the antenatal and postnatal periods among women with current and past ED, and despite some overall reductions, symptoms remain clinically significant. © 2014 The Authors. European Eating Disorders Review published by John Wiley & Sons, Ltd.

Testing the feasibility of therapeutic identification of depression in young people in British general practice

PURPOSE

Depression in young people attending primary care is common and is associated with impairment and recurrence into adulthood. However, it remains under-recognized. This study evaluated the feasibility of training primary care practitioners (PCPs) in screening and therapeutic identification of adolescent depression, and assessed its effects on practitioner knowledge, attitudes, screening, and management.

METHODS

We trained PCPs in therapeutic identification of adolescent depression during general practice consultations. To assess changes in knowledge and attitudes, PCPs completed questionnaires before and after training. We ascertained changes in depression screening and identification rates in the 16 weeks before and after training from electronic medical records of young people aged 13-17 years. Post-training management of depression was recorded on a checklist.

RESULTS

Aspects of practitioner knowledge (of depression prevalence and treatment guidelines) and confidence (regarding depression identification and management) increased significantly (all p < .04). Overall screening rates were enhanced from .7% to 20% after the intervention and depression identification rates from .5% before training to 2% thereafter (29-fold and fourfold increases, respectively). Identification was significantly associated with PCP knowledge of prior mental health problems (Fisher's exact test, p = .026; odds ratio, 4.884 [95% confidence interval, 1.171-20.52]) and of psychosocial stressors (Fisher's exact test, p = .001; odds ratio, 17.45 [95% confidence interval, 2.055-148.2]).

CONCLUSIONS

The Therapeutic Identification of Depression in Young People program is a feasible approach to improving primary care screening for adolescent depression, with promising evidence of effectiveness. Further evaluation in a randomized trial is required to test practitioner accuracy, clinical impact, and cost benefit.

Recognising the symptoms: how common are eating disorders in pregnancy?

OBJECTIVES

This study aimed to investigate eating disorder diagnostic status and related symptoms in early pregnancy.

METHODS

Pregnant women (n=739), attending their first routine antenatal scan, were assessed using an adapted version of the Eating Disorder Diagnostic Scale (EDDS). Prevalence estimates and eating disorder symptoms were assessed during the first 3 months of pregnancy and, retrospectively, in the 6 to 12 months prior to pregnancy.

RESULTS

During pregnancy 7.5% of women met diagnostic criteria for an eating disorder, compared to prepregnancy prevalence of 9.2%. Approximately one quarter (23.4%) of women reported high weight and shape concern during pregnancy; binge eating was endorsed by 8.8%, and 2.3% of women engaged in regular compensatory behaviours.

CONCLUSIONS

Eating disorders are more common than previously thought in pregnancy. There is a clinical need for increased understanding of eating disorder symptomatology during pregnancy and for appropriate screening tools to be incorporated into antenatal care.

Therapeutic identification of depression in young people: lessons from the introduction of a new technique in general practice

BACKGROUND

Mild-to-moderate depression in young people is associated with impaired social functioning and high rates of affective disorder in adult life. Earlier recognition of depression in young people has the potential to reduce the burden of depression in adulthood. However, depression in teenagers is underdiagnosed and undertreated.

AIM

To assess the usability and usefulness of a cognitive-behavioural-therapy-based technique for Therapeutic Identification of Depression in Young people (TIDY).

DESIGN AND SETTING

A qualitative study of four group practices in northwest London.

METHOD

Face-to-face semi-structured interviews were conducted with practitioners who had been trained in the use of the TIDY technique.

RESULTS

Twenty-five GPs and six nurses were interviewed. The key themes that emerged from the interviews were: practitioners were 'making sense of teenage depression' when interpreting signs and symptoms; the training in the technique was variable in its impact on practitioners' attitudes and practice; and time factors constrained practitioners in the application of the technique.

CONCLUSION

The TIDY technique is usable in routine practice, but only if practitioners are allowed to use it selectively. This need for selectivity arises partly from concerns about time management, and partly to avoid medicalisation of psychological distress in young people. The perceived usefulness of the TIDY technique depends on the practitioner's prior knowledge, experience, and awareness.

Rational dose selection for a nonnucleoside reverse transcriptase inhibitor through use of population pharmacokinetic modeling and Monte Carlo simulation

In order to choose a rational dose for GW 420867X, we first set a goal of therapy. We hypothesized that, for optimal antiretroviral activity, the trough free drug concentration should remain above the 90% effective concentration (EC90) of human immunodeficiency virus type 1. We performed population pharmacokinetic analysis on three different doses of GW 420867X (50, 100, and 200 mg). Monte Carlo simulation was performed, assuming a log-normal distribution for 1,000 simulated subjects for each dose, and was repeated three times. The trough concentrations were divided by 76 to account for protein binding and for the difference between EC50 and EC90. We then determined the fraction of the simulated population whose free drug trough concentrations would exceed an EC90 over a broad range of values. The target attainment for all three doses exceeded 95% out to a starting EC50 of 10 nM. For 16 viral isolates, the EC50 range encountered for GW 420867X did not exceed 8 nM, implying that the three doses could not be differentiated by effect in a clinical trial in naive patients. This prediction was shown to be correct in a randomized, double-blind trial with 1 week of monotherapy with GW 420867X.

Pharmacodynamics of abacavir in an in vitro hollow-fiber model system

Abacavir is a potent new carbocyclic nucleoside analogue. We employed our hollow-fiber pharmacodynamic modeling system to examine the antiretroviral effects of different abacavir exposures, as well as the impact of the schedule of drug administration on efficacy. Dose ranging of abacavir revealed that a concentration of four times the 50% effective concentration (EC(50)) (approximately the EC(95)) was required to inhibit the replication of human immunodeficiency virus type 1 (HIV-1) (strain MN) either in a continuous-infusion hollow-fiber experiment or in a classical tissue culture flask experiment. In contrast to earlier work with another drug class (HIV-1 protease inhibitors), addition of physiological amounts of the human drug binding proteins albumin and alpha(1) acid glycoprotein revealed that there was little impact on the antiviral effect of the drug. Comparison of equivalent exposures (an area under the concentration-time curve [AUC] developed by approximately 500 mg per day of orally administered abacavir), either in a continuous-infusion mode or as a single oral dose of abacavir, demonstrated no difference in the ability to suppress either strain III(B) or strain MN. Comparison of administration of 250 mg every 12 h (q12h) versus once-daily administration of 500 mg for strain MN again showed no significant difference in suppressive effect. These experiments were carried out over 8 to 15 days. Because of these promising initial results, we extended the experiment to 30 days and examined three different schedules of administration that generated the same AUC at 24 h (AUC(24)): 300 mg q12h, 600 mg q24h, and 1,200 mg q48h. The aim of the last of these regimens was to definitively demonstrate schedule failure. There was little difference between the 1,200-mg q48h treatment group and the untreated control at 30 days. Likewise, there was little difference between the 600-mg q24h and 300-mg q12h treatment groups. However, at circa day 18 of the experiment, there was a small increase in viral output of p24 in the once-daily dosing unit. Examination of virus from all groups demonstrated no phenotypic or genotypic differences. The small difference in hollow-fiber unit p24 in the once-daily dosing group was not due to emergence of resistance over the 30-day single-drug exposure. We conclude that the dose of abacavir currently being studied in clinical trials (300 mg orally q12h) will be efficacious for the majority of sensitive clinical isolates of HIV-1. These in vitro data also suggest that this drug may be able to be administered to patients on a once-daily basis at a dose of 600 mg.

Transport characteristics of the anti-human immunodeficiency virus nucleoside analog, abacavir, into brain and cerebrospinal fluid

The role of the blood-brain and blood-cerebrospinal fluid (CSF) barriers in the distribution of anti-human immunodeficiency virus (HIV) drugs is integral to the design of effective treatment regimens for HIV infection within the brain. Abacavir (formerly 1592U89) is a nucleoside analog reverse transcriptase inhibitor, which has activity against HIV. The ability of this drug to reach the brain at therapeutic concentrations has been explored by means of an established bilateral in situ brain perfusion model in combination with high-performance liquid chromatography analysis in the anesthetized guinea pig. The influence of other drugs on the entry of abacavir into the brain was also investigated and is of special significance with the use of three of more anti-HIV drugs as the recommended treatment for HIV infection. The results of this study indicate that intact [(14)C]abacavir can cross the blood-brain and blood-CSF barriers and enter the brain and cisternal CSF. Further studies, at a perfusion time of 10 min, revealed that the uptake (R(cerebrum)) of this (14)C-labeled drug (10.1 +/- 0.6%) was not affected by the presence of 0.86 to 200 microM unlabeled abacavir (6.8 microM; 11.0 +/- 1.4%), the nucleoside transport inhibitor [10 microM 6-(4-nitrobenzyl)thio-9-beta-D-ribofuranosylpurine; 9.7 +/- 3.3%], or a substrate for the nucleobase transporter (100 microM adenine; 12.7 +/- 3.0%). This would suggest that the entry of abacavir into the brain would not be affected by the presence of other anti-HIV drugs. The results of this animal study indicate that abacavir would be a useful addition to a treatment regimen against HIV-infection within the brain.

Computer-assisted drug development (CADD): an emerging technology for designing first-time-in-man and proof-of-concept studies from preclinical experiments

Computer-assisted drug development (CADD) is an emerging technology for accelerating drug development based on the integration of mathematical modelling and simulation. This methodology provides a knowledge-based decisional tool on alternative development strategies based on the evaluation of potential risks on drug safety, and the definition of experimental design of new trials with expected power and probability of success. An example of CADD implementation is presented to design the first-time-in-man (FTIM) and the proof-of-concept (PoC) study of a new CNS compound. The final objective of the example presented is not necessarily to supply a success story of a correct prediction of human data from animal studies but to define a credible strategy suitable to design FTIM and PoC studies using preclinical data without the support of any human in vivo information. Rhesus monkey and human PK were initially estimated using allometric scaling on data collected in dogs, cynomolgus monkeys and rats. A PK/PD model was derived from a study conducted in rodent and validated by comparing the model predicted response to the one observed in a PET experiment conducted in rhesus monkey. The final PK/PD model, incorporating potential variability and uncertainty on scaled human prediction together with a receptor affinity adjustment derived from in vitro binding studies, was used to design the first-time-in-man and the proof-of-concept study.

Population pharmacokinetic-pharmacodynamic model of craving in an enforced smoking cessation population: indirect response and probabilistic modeling

PURPOSE

A population pharmacokinetic-pharmacodynamic model accounting for placebo effect was used to relate nicotine concentration and enforced smoking cessation craving score measured by the Tiffany rating scale short form.

METHODS

Twenty-four smokers were enrolled in a placebo-controlled, randomized, double-blind, three periods, crossover trial. The study objective was to describe the nicotine-induced changes on craving scores. Two modeling strategies based on a mechanistic (indirect response models with drug-related inhibition on the k(in) synthesis rate and with a drug-related stimulation of the k(out) removal rate were evaluated) and a probabilistic (logistic regression) approach were used.

RESULTS

Placebo response model properly fitted the circadian changes on craving scores. The analysis revealed that the indirect response model with inhibition on k(in) was the preferred model for the smoking data whereas the preferred model for the Nicotine Replacement Therapy data was the one with stimulation on k(out). The logistic analysis showed that the nicotine concentration was a significant predictor of reduction in craving during the free-smoking period.

CONCLUSIONS

Nicotine dosage regimen can influence the nicotine mechanism of action: an instantaneous delivery at an individually selected time seems to inhibit the onset of craving while constant delivery at a pre-defined time seems to attenuate the craving.

Absorption kinetics after inhalation of fluticasone propionate via the Diskhaler, Diskus and metered-dose inhaler in healthy volunteers

OBJECTIVE

The aim of this analysis was to assess the rate and extent of systemic availability of inhaled fluticasone propionate (FP) from 2 dry powder systems (Diskhaler and Diskus) and a metered-dose inhaler (MDI) by deconvolution analysis.

METHODS

The inhalation devices were evaluated in 3 separate studies with identical protocols. 12 healthy male volunteers were randomised to receive FP given as a 1000 microg inhaled dose and 250 microg by intravenous infusion according to a double-blind double-dummy crossover design. The bioavailability of FP after inhalation represents absorption of the drug from the lungs, since the bioavailability of the swallowed portion of the inhaled dose is negligible.

RESULTS

When corrected for the bioavailability (of FP) achieved by each inhalation device, the rate of absorption of FP over the first 2 hours was rapid from all devices. The mean time for absorption of 50% of the bioavailable dose was 1.6, 2.4, and 2.2 hours for the Diskhaler, Diskus and MDI, respectively. Thereafter, absorption from each device was prolonged, with approximately 10% of the dose remaining in the lungs 12 hours after inhalation.

CONCLUSION

Irrespective of the inhalation device used, the prolonged absorption of FP into the systemic circulation indicates a long residence time in the lungs.

Systemic exposure to fluticasone propionate administered via metered-dose inhaler containing chlorofluorocarbon or hydrofluoroalkane propellant

OBJECTIVE

The pharmacokinetic profile of a single dose of inhaled fluticasone propionate (FP) administered via a metered-dose inhaler (MDI), containing either a chlorofluorocarbon (CFC) or hydrofluoroalkane (HFA) propellant was investigated in healthy volunteers.

METHODS

Two randomised, double-blind, crossover studies were conducted, each in 12 male volunteers. Both studies compared pharmacokinetic data after a single inhaled dose of FP 1000 microg from a MDI containing either CFC (CFC MDI) or HFA (HFA MDI) with a single intravenous dose of FP 250 microg.

RESULTS

The maximum plasma FP concentrations after inhalation via the 2 types of MDI were almost identical (0.56 and 0.54 microg/L for CFC MDI and HFA MDI, respectively); bioavailability values of inhaled FP from the 2 MDIs were also similar (geometric mean values: 26.4% via the CFC MDI and 28.6% via the HFA MDI). Inhalation of FP via both MDI formulations produced similar reductions in urinary cortisol excretion over 12 and 24 hours postdose.

CONCLUSION

The bioavailability values of FP after inhalation via a CFC MDI and an HFA MDI are similar. The 2 formulations deliver comparable amounts of FP, and systemic exposures to FP from the 2 devices, measured by urinary cortisol excretion, are not significantly different.

Pharmacokinetics of fluticasone propionate inhaled via the Diskhaler and Diskus powder devices in healthy volunteers

OBJECTIVE

The aim of these studies was to determine the absolute bioavailability in healthy volunteers of inhaled fluticasone propionate (FP) administered as a single dose via the Diskhaler and Diskus powder devices, and the pharmacokinetics of inhaled FP after repeated administration via the Diskhaler device.

METHODS

In 2 of the studies, single inhaled doses of FP were administered via the Diskhaler and the Diskus powder devices, and, in the third study, repeated doses of FP were administered via the Diskhaler. In the single dose studies, 12 healthy volunteers were randomised to receive FP 1000 microg by inhalation and FP 250 microg intravenously, using a double-blind crossover design. In the repeated dose study, 24 healthy volunteers received FP 1000 microg twice daily for 7.5 days.

RESULTS

Systemic exposure to FP after administration of a single 1000 microg inhaled dose of FP via the 2 powder devices was similar; the area under the plasma FP concentration-time curve (AUC) to infinite time (AUCinfinity) was 2.08 microg/L x h [95% confidence intervals (CI): 1.63-2.64] for Diskhaler and 2.49 microg/L x h (95% CI: 2.09-2.96) for Diskus. Maximum plasma FP concentration (Cmax) was 0.34 microg/L for both devices. Mean bioavailability values via the Diskhaler and Diskus were 11.9% (95% CI: 9.0-15.7%) and 16.6% (95% CI: 13.6-20.3%), respectively. No clinically significant reductions in urinary cortisol excretion were recorded in these 2 studies. After repeated administration with the Diskhaler, steady state was achieved by dose 3 (i.e. day 2) onwards. After dose 15, the AUC up to 12 hours (AUC12h) was 2.25 microg/L x h and Cmax was 0.38 microg/L. The mean steady-state to single dose accumulation ratio after twice-daily administration was 1.49 (95% CI: 1.36-1.62).

CONCLUSION

The pharmacokinetics of FP administered by the 2 powder devices are similar in healthy volunteers, although systemic bioavailability was greater with the Diskus.

The relationship between systemic exposure to fluticasone propionate and cortisol reduction in healthy male volunteers

OBJECTIVE

The aim of this analysis was to assess the pharmacokinetic/pharmacodynamic relationship between systemic exposure to fluticasone propionate (FP) and reductions in the plasma cortisol level and urinary cortisol excretion.

METHODS

A total of 122 healthy male volunteers participating in 7 different studies received either oral (5 to 40 mg), inhaled (500 to 2000 microg) or intravenous (250 to 1000 g) single morning doses of FP or placebo. Data on systemic exposure to FP, expressed in terms of the area under the FP concentration-time curve up to 24 hours (AUC(24h,FP)) for the 3 different routes of administration were pooled, together with corresponding data on the 24-hour plasma cortisol level or urinary cortisol excretion. The data were used to develop a pharmacokinetic/pharmacodynamic model, from which parameter estimates and 95% confidence intervals (CI) for the estimates could be derived.

RESULTS

The intercept in the absence of drug (E0) was -0.5% (95% CI: -0.6, -0.3%) and the maximum drug-induced reduction in mean plasma cortisol levels (Emax) was 72% (95% CI: 64, 79%). The systemic exposure to FP that resulted in half the maximum possible reduction in plasma cortisol levels (AUC50) was 3.2 microg/L x h (95% CI: 2.8, 3.7 microg/L x h); this equates approximately to the plasma FP concentration obtained after administration of a 1000 microg inhaled dose. A similar relationship was seen between AUC50 and urinary cortisol excretion, although the variability in AUC50 for urinary cortisol was much greater than for plasma cortisol.

CONCLUSION

A pharmacokinetic/pharmacodynamic model has been established which relates systemic exposure to FP (after a single morning dose) to the percentage reduction in urinary or plasma cortisol. The relationship is independent of both dose and route of administration.