Validation, Deployment, and Real-World Implementation of a Modular Toolbox for Alzheimer's Disease Detection and Dementia Risk Reduction: The AD-RIDDLE Project

The Real-World Implementation, Deployment, and Validation of Early Detection Tools and Lifestyle Enhancement (AD-RIDDLE) project, recently launched with the support of the EU Innovative Health Initiative (IHI) public-private partnership and UK Research and Innovation (UKRI), aims to develop, test, and deploy a modular toolbox platform that can reduce existing barriers to the timely detection, and therapeutic approaches in Alzheimer's disease (AD), thus accelerating AD innovation. By focusing on health system and health worker practices, AD-RIDDLE seeks to improve and smooth AD management at and between each key step of the clinical pathway and across the disease continuum, from at-risk asymptomatic stages to early symptomatic ones. This includes innovation and improvement in AD awareness, risk reduction and prevention, detection, diagnosis, and intervention. The 24 partners in the AD-RIDDLE interdisciplinary consortium will develop and test the AD-RIDDLE toolbox platform and its components individually and in combination in six European countries. Expected results from this cross-sectoral research collaboration include tools for earlier detection and accurate diagnosis; validated, novel digital cognitive and blood-based biomarkers; and improved access to individualized preventative interventions (including multimodal interventions and symptomatic/disease-modifying therapies) across diverse populations, within the framework of precision medicine. Overall, AD-RIDDLE toolbox platform will advance management of AD, improving outcomes for patients and their families, and reducing costs.

Biologically derived epicardial patch induces macrophage mediated pathophysiologic repair in chronically infarcted swine hearts

There are nearly 65 million people with chronic heart failure (CHF) globally, with no treatment directed at the pathologic cause of the disease, the loss of functioning cardiomyocytes. We have an allogeneic cardiac patch comprised of cardiomyocytes and human fibroblasts on a bioresorbable matrix. This patch increases blood flow to the damaged heart and improves left ventricular (LV) function in an immune competent rat model of ischemic CHF. After 6 months of treatment in an immune competent Yucatan mini swine ischemic CHF model, this patch restores LV contractility without constrictive physiology, partially reversing maladaptive LV and right ventricular remodeling, increases exercise tolerance, without inducing any cardiac arrhythmias or a change in myocardial oxygen consumption. Digital spatial profiling in mice with patch placement 3 weeks after a myocardial infarction shows that the patch induces a CD45pos immune cell response that results in an infiltration of dendritic cells and macrophages with high expression of macrophages polarization to the anti-inflammatory reparative M2 phenotype. Leveraging the host native immune system allows for the potential use of immunomodulatory therapies for treatment of chronic inflammatory diseases not limited to ischemic CHF.

SAT0072 THE IMPACT OF COMORBIDITIES ON ABSENTEEISM, PRESENTEEISM AND EMPLOYMENT STATUS IN PEOPLE LIVING WITH RHEUMATOID ARTHRITIS

Background:

Many people with rheumatoid arthritis (RA) have comorbidities. However, there is limited research on the impact of multimorbidity on absenteeism (e.g. sick leave) and presenteeism (i.e. reduced productivity while at work due to ill health) in people with RA.

Objectives:

i) to explore the impact of comorbidities on absenteeism and presenteeism in patients with RA and ii) to evaluate the association between multimorbidity and employment status.

Methods:

A cross-sectional survey was conducted by the National Rheumatoid Arthritis Society (NRAS), UK, collecting information on: demographics, education, employment status (i.e. employed (Empl), stopped/retired early because of RA (Stop_RA), stopped/retired early because of other health issues (Stop_Health)), and disease related variables (e.g. symptom duration, rheumatoid arthritis impact of disease (RAID) questionnaire). Participants were asked to report whether they had or were treated for any of 15 predefined comorbidities (categorised into 0, 1, 2, 3, or ≥4 (Table)). Percentage of number of hours missed due RA (i.e. absenteeism) and presenteeism (10-point Likert scale) were assessed using the Work Productivity and Activity Impairment Questionnaire (WPAI-RA). For the purpose of this study both absenteeism and presenteeism outcomes were dichotomized (no presenteeism/absenteeism versus any) and only patients aged <65yrs were included. Logistic regression analysis were applied to assess the association between number of comorbidities and absenteeism/presenteeism, adjusting for the categorical variables age, gender and education. Chi2-square test was applied to assess frequencies of individual comorbidities between the three employment status groups.

Results:

868 participants were included; 91.7% women with a median symptom duration of 8.3 years [IQR 4.4-13.7]. The average RAID score was 5.2 (SD 2.2). 80.4% were in paid employment, including those currently on sick leave, 16.9% stopped early because of their RA and 2.7% reported stopping early because of other health reasons. In those employed most commonly occurring comorbidities were: back pain (28.8%%), osteoarthritis (21.5%), depression (26.3%) and anxiety (22.6%). Compared to people with RA with no comorbidities, the odds associated with time off work due to RA increased from 1.7 up to 3.4 with increasing number of comorbidities (Table). Although a similar trend was observed for presenteeism, the effect sizes were smaller. Significant differences (p<0.05) in frequencies of the following comorbidities were observed between the three employment status groups (Empl, Stop_RA, Stop_Health, respectively): heart disease (3.9%, 7.9%, 20.0%), blood pressure (18.0%, 29.5%, 36.7%), lung disease (5.7%, 16.3%, 26.7%), diabetes (4.4%, 4.2%, 26.7%), ulcer (6.1%, 11.1%, 13.3%), cancer (3.3%, 2.6%, 13.3%), depression (26.3%, 33.6%, 50.0%), OA (21.5%, 44.7%, 63.33%), and back pain (28.8%, 48.4%, 60.0%).

Absenteeism (yes/no)Presenteeism (yes/no)Number of comorbiditiesNOR95%CIOR95%CI0206Ref.Ref.11741.701.06-2.711.661.00-2.7321361.771.08-2.921.991.13-2.863851.751.00-3.081.530.82-2.864-15max863.381.98-5.782.641.28-5.44

OR=odds ratio; 95%CI=95% confidence interval; Comorbidities included: heart disease, blood pressure, lung disease, diabetes, ulcer or stomach disease, kidney disease, liver disease, anaemia or other blood disease, cancer, depression, anxiety, OA, back pain, osteoporosis and Sjögren. Bold figuresP<0.05.

Conclusion:

Although the study is cross-sectional and no temporal association can be determined, this study shows that not only personal and work related contextual factors should be considered when preventing worker productivity loss, but also other comorbidities.

Disclosure of Interests:

A. Bradshaw: None declared, Ailsa Bosworth Speakers bureau: a number of pharmaceutical companies for reasons of inhouse training, advisory boards etc., K. Walker-Bone: None declared, Laura Lunt: None declared, Suzanne Verstappen Grant/research support from: BMS, Consultant of: Celltrion, Speakers bureau: Pfizer

Obesity and the Built Environment: A Reappraisal

The built environment (BE) has been viewed as an important determinant of health. Numerous studies have linked BE exposure, captured using a variety of methods, to diet quality and to area prevalence of obesity, diabetes, and cardiovascular disease. First-generation studies defined the neighborhood BE as the area around the home. Second-generation studies turned from home-centric to person-centric BE measures, capturing an individual's movements in space and time. Those studies made effective uses of global positioning system tracking devices and mobile phones, sometimes coupled with accelerometers and remote sensors. Activity space metrics explored travel paths, modes, and destinations to assess BE exposure that was both person and context specific. However, as measures of the contextual exposome have become ever more fine-grained and increasingly complex, connections to long-term chronic diseases with complex etiologies, such as obesity, are in danger of being lost. Furthermore, few studies on obesity and the BE have included intermediate energy balance behaviors, such as diet and physical activity, or explored the potential roles of social interactions or psychosocial pathways. Emerging survey-based applications that identify habitual destinations and associated travel patterns may become the third generation of tools to capture health-relevant BE exposures in the long term.

Monomeric, porous type II collagen scaffolds promote chondrogenic differentiation of human bone marrow mesenchymal stem cells in vitro

Osteoarthritis (OA) is a common cause of pain and disability and is often associated with the degeneration of articular cartilage. Lesions to the articular surface, which are thought to progress to OA, have the potential to be repaired using tissue engineering strategies; however, it remains challenging to instruct cell differentiation within a scaffold to produce tissue with appropriate structural, chemical and mechanical properties. We aimed to address this by driving progenitor cells to adopt a chondrogenic phenotype through the tailoring of scaffold composition and physical properties. Monomeric type-I and type-II collagen scaffolds, which avoid potential immunogenicity associated with fibrillar collagens, were fabricated with and without chondroitin sulfate (CS) and their ability to stimulate the chondrogenic differentiation of human bone marrow-derived mesenchymal stem cells was assessed. Immunohistochemical analyses showed that cells produced abundant collagen type-II on type-II scaffolds and collagen type-I on type-I scaffolds. Gene expression analyses indicated that the addition of CS - which was released from scaffolds quickly - significantly upregulated expression of type II collagen, compared to type-I and pure type-II scaffolds. We conclude that collagen type-II and CS can be used to promote a more chondrogenic phenotype in the absence of growth factors, potentially providing an eventual therapy to prevent OA.

Dextrin Sulphate and Fucoidan are Potent Inhibitors of HIV Infection in vitro

Two sulphated polysaccharides, fucoidan (a derivative of seaweed) and the newly synthesised dextrin sulphate, were tested for their ability to inhibit human immunodeficiency virus (HIV) infection in vitro in comparison to dextran sulphate and azidothymidine. They were found to be potent inhibitors of diverse strains of HIV-1 in a variety of human cell lines and in peripheral blood lymphocytes (PBL) using a range of assays, including cell-free and cell-to-cell spread of infection. The drugs did not adversely affect cell proliferation or protein metabolism of PBL. As dextrin sulphate is less potent than dextran sulphate in prolonging thrombin-induced fibrin clotting time, it merits further development as an antiviral agent.

Measuring nursing care and compassion: the McDonaldised nurse?

In June 2008 the UK government, supported by the Royal College of Nursing, stated that nursing care would be measured for compassion. This paper considers the implications of this statement by critically examining the relationship of compassion to care from a variety of perspectives. It is argued that the current market-driven approaches to healthcare involve redefining care as a pale imitation, even parody, of the traditional approach of the nurse as "my brother's keeper". Attempts to measure such parody can only measure artificial techniques and give rise to a McDonald's-type nursing care rather than heartfelt care. The arguments of this paper, although applied to nursing, also apply to medicine and healthcare generally.

A biomagnetic assessment of colonic electrical activity in pigs

The electrical control activity of the large intestine was recorded in six pigs using a SQUID magnetometer. The study was performed in pre- and post-colectomy/sham-colectomy conditions. The biomagnetic field associated with colonic ECA changed drastically in subjects that underwent the colectomy procedure, whereas the signal for the control animals was nearly unchanged. Power spectral analysis was used to determine the average changes of dominant frequency and amplitude between baseline versus colectomy and sham-colectomy conditions. The dominant frequency was increased by 68 +/- 24% (versus 2 +/- 3% in control). The amplitude was decreased by 69 +/- 24% (versus 13 +/- 17% in control). This is the first study of transabdominal magnetic fields associated with colonic ECA, suggests some of the side effects generated in colectomy surgery and shows the utility of the biomagnetic technique in studies of the large intestine.

Synthesis of Active Controllers for Vibratory Systems

A systematic procedure for the synthesis of active controllers for vibratory systems is described. This method is based upon the use of modal control theory and is applicable to lumped-parameter linear systems possessing any number of degrees of freedom.

Measurement of haemoglobin as a screening test in general practice

OBJECTIVE

To assess the validity of using the measurement of haemoglobin as a primary screen test at point-of-care in general practice.

METHODS

1100 consecutive full blood counts carried out at Hammersmith Hospital haematology laboratory on blood samples sent by the general practitioners in the area were reviewed. Where haemoglobin was in the normal range all the parameters of a full blood count were checked and a blood film was screened in order to identify any abnormal features occurring in the absence of anaemia.

RESULTS

Haemoglobin was normal in 81% of the samples, and in 81% of this set none of the blood count components showed any abnormal features (i.e. outside two standard deviations of normal reference range). The remaining 19% of cases included 32 with iron deficiency, 26 with high MCV, 84 with leucocyte abnormalities (neutrophilia, neutropenia, lymphocytosis, eosinophilia, monocytosis) and 19 with platelet counts either too high or too low. The predictive value of a normal full blood count from a normal haemoglobin was 0.81. However, when the limits of normal reference values were set at three standard deviations only 7% of the cases showed abnormal features and the predictive value of normality from a normal haemoglobin increased to 0.92.

CONCLUSION

There are now simple and suitable devices available for measuring haemoglobin at point-of-care, away from a laboratory. This provides a useful screening test in general practice as a full blood count would, as a rule, be required only in the small proportion of cases where anaemia is detected or the patient's history and/or clinical signs specifically indicate the need for this further investigation. This approach should contribute to more efficient, convenient and economical practice without compromising clinical management.

Congenital brachial palsy: incidence, causes, and outcome in the United Kingdom and Republic of Ireland

OBJECTIVES

To determine the incidence and study the causes and outcome of congenital brachial palsy (CBP).

DESIGN

Active surveillance of newborn infants using the British Paediatric Surveillance Unit notification system and follow up study of outcome at 6 months of age.

SETTING

The United Kingdom and Republic of Ireland.

PARTICIPANTS

Newborn infants presenting with a flaccid paresis of the arm (usually one, rarely both) born between April 1998 and March 1999.

MAIN OUTCOME MEASURES

Extent of the lesion at birth and degree of recovery at 6 months of age.

FINDINGS

There were 323 confirmed cases giving an incidence of 0.42 per 1000 live births (1 in 2300). Significant associated risk factors in comparison with the normal population were shoulder dystocia (60% v 0.3%), high birth weight with 53% infants weighing more than the 90th centile, and assisted delivery (relative risk (RR) 3.4, 95% confidence interval (CI) 2.9 to 3.9, p = 0.0001). There was a considerably lower risk of CBP in infants delivered by caesarean section (RR 7, 95% CI 2 to 56, p = 0.002). At about 6 months of age, about half of the infants had recovered fully, but the remainder showed incomplete recovery including 2% with no recovery. The relative risk of partial or no recovery in infants with extensive lesions soon after birth compared with those with less extensive lesions was 11.28 (95% CI 2.38 to 63.66, p = 0.000005).

CONCLUSIONS

The incidence of CBP in the United Kingdom and Republic of Ireland is strikingly similar to that previously reported nearly 40 years ago. Most cases are due to trauma at delivery, which is not necessarily excessive or inappropriate. Given the uncertainty about the appropriate management of these infants, serious consideration should be given to a formal clinical trial of microsurgical nerve repair.

Competence and British nursing: a view from history

In the light of current political and professional debate in the United Kingdom concerning preparing nurses for competence, this paper takes an historical perspective, and considers how nursing competence was defined historically through an analysis of statutory syllabuses and nursing textbooks 1874-1977. Competence was perceived by nursing textbook writers to have four facets. Firstly, it involved the moral character of the nurse; secondly, it required technical knowledge, practical skill and procedure; thirdly, it depended on the role of the ward sister; and fourthly, it relied on the professional etiquette of right relationships. The analysis shows that the traditional system of nursing competence presumed a clearly defined purpose: the production of the bedside nurse, whose function was to care for the sick person. This raises a fundamental question for nursing today: what is the purpose of the modern nurse?

Elevated levels of Ca(II) modulate the activity and inhibition of serine proteases: implication in the mechanism of apoptosis

Elevated levels of intracellular Ca(II) are a prominent feature of apoptosis, a natural form of cell death involved in many physiological and pathological processes. Serine proteases play crucial roles in apoptosis and have been implicated in the genomic DNA degradation and the massive protein degradation that occur during apoptosis. In this study, the effects of the elevated level of Ca(II) on the activity and inhibition of serine proteases were examined by spectrophotometric methods. The effects of the elevated levels of Ca(II), Mg(II), K(I), and Na(I) on the activity and inactivation of three representative members of serine proteases were determined. The level of serine protease activity in CEM-C7-14 leukemic cells was also evaluated in the presence and absence of dexamethasone-induced apoptosis, and also in the presence of A23187, a Ca(II)-ionophore. Among the four metal-ions studied, only Ca(II) was found to significantly enhance the activity of mammalian serine proteases. Ca(II) was also found to significantly protect the enzymes from inhibition, while the other three metal-ions showed no significant effect on the inactivation of the enzymes. Compared to the control sample, the enzymic activity was found to be higher during apoptosis, and in the presence of the Ca(II)-ionophore. Results of this study indicate that Ca(II) can significantly enhance the catalytic efficiency of serine proteases during apoptosis.

Thrombocytopenia and absent radii (TAR) syndrome associated with horseshoe kidney

The TAR syndrome is an inherited disorder characterized by limb abnormalities, especially absent radii, and hypomegakaryocytic thrombocytopenia. Previous reports have included two infants with genitourinary abnormalities. We report a newborn with bilaterally absent radii and foreshortened ulnae, hypoplastic humeri, a left clubfoot, a ventricular septum defect, and persistent thrombocytopenia. This constellation of abnormalities is consistent with the TAR syndrome. In addition, he had a horseshoe kidney with parenchyma of normal appearance. This is the first report of horseshoe kidney in association with the TAR syndrome.

The virtue of nursing: the covenant of care

It is argued that the current confusion about the role and purpose of the British nurse is a consequence of the modern rejection and consequent fragmentation of the inherited nursing tradition. The nature of this tradition, in which nurses were inducted into the moral virtues of care, is examined and its relevance to patient welfare is demonstrated. Practical suggestions are made as to how this moral tradition might be reappropriated and reinvigorated for modern nursing.

Disruption of the Sparc locus in mice alters the differentiation of lenticular epithelial cells and leads to cataract formation

SPARC (secreted protein acidic and rich in cysteine) is a matricellular protein that regulates cellular adhesion and proliferation. In this report, we show that SPARC protein is restricted to epithelial cells of the murine lens and ends abruptly at the equatorial bow region where lens fiber differentiation begins. SPARC protein was not detected in the lens capsule or in differentiated lens fibers. SPARC-null mice developed cataracts at approximately 3-4 months after birth, at which time posterior subcapsular opacities were observed by slit lamp ophthalmoscopy. Histological analyses of ocular sections from 3-month old animals revealed several microscopic abnormalities present in the SPARC-null mice but absent from the wild-type animals. Fiber cell elongation was incomplete posteriorly and resulted in displacement of the lenticular nucleus to the posterior of the lens. Nuclear debris was present in the posterior subcapsular region of the lens, an indication of the abnormal migration and elongation of either fetal or anterior epithelial cells, and the bow region was disrupted and vacuolated. In the anterior lens, the capsule appeared to be thickened and was lined by atypical, plump cuboidal epithelium. Moreover, anterior cortical fibers were swollen. Polyacrylamide gel electrophoresis of the epithelial, cortical and nuclear fractions of wild-type and SPARC-null lenses indicated no significant differences among the alpha-, beta-, and gamma-crystallins. Expression of alphaB-crystallin appeared similar in fiber cells of wild-type and SPARC-null lenses, although the distribution of alphaB-crystallin was asymmetric in SPARC-null lenses as a result of abnormal lens fiber differentiation. No evidence of atypical extracellular matrix deposition in areas other than the capsule was detected in wild-type or SPARC-null lens at 3 months of age. We conclude that the disruption of the Sparc locus in mice results in the alteration of two fundamental processes of lens development: differentiation of epithelial cells and maturation of fiber cells.

Defining 'competency' in nursing (Part II): An analytical review

The reason for the present uncertainty in defining nursing competency is analysed. The prevailing educational philosophy underpinning nursing preparation for competence is subjected to a critique. The effect and outcome of this philosophy on clinical supervision, PREP and the law are considered in relation to nursing competence. It is concluded that because nursing competency is only vaguely and broadly defined, preparation and assessment of competency is haphazard and unstructured; and hence a potential safety hazard for both patient and nurse. It is suggested that the UKCC needs to assume responsibility for ascertaining nursing competence; and a four-point framework is proposed for setting and testing national standards of nursing competency.

Defining 'competency' in nursing (Part I): A policy review

How the nursing profession in England defines the basic competency of the registered general nurse is crucial for the safety of the patient and the protection of the nurse. It is also essential for determining advanced practice, extended practice and specialist practice in nursing. An historical overview of documentation from the United Kingdom Central Council for Midwifery and Health Visiting, the English National Board for Nursing, Midwifery and Health Visiting and the Royal College of Nursing shows a profound change in educational policy during the 1980s regarding the interpretation of nursing competency. The effects of this policy change on the current methods developed to define, teach and test nursing competency are examined. Preliminary conclusions show shortcomings and uncertainty in the present preparation and evaluation of nursing competency.

The spiritual dimension of hospice: the secularization of an ideal

There is increasing concern that the original hospice ethos is becoming subject to routinization and bureaucratization. Authors, drawing on Weber's concept of rationalization, have suggested that this has resulted from the loss of the original charismatic impetus and the commitment to care for the terminally ill and dying as inspired by the spiritual 'calling'. This paper argues that this original ethical ideal has been fundamental to the humane care of the dying and terminally ill. Using Alasdair MacIntyre's analysis it is suggested that as the ideal attenuates there are inevitable shifts in the ethos and culture of care. An emotivist culture in which the aesthete, the therapist and the manager are dominant characters, may seem to be occurring in palliative care. The focus on management skills and the values of efficiency and effectiveness influence attitudes to death. This brings increased medicalization, a reliance on psychosocial techniques, a predominant focus on education, research and audit and most particularly redefined attitudes to the spiritual component of care. The paper asks the question whether the original ethic has a place in preventing palliative care becoming merely a technique for professional empowerment.

Yes! There is an ethics of care: an answer for Peter Allmark

This paper is a response to Peter Allmark's thesis that 'there can be no "caring" ethics'. It argues that the current preoccupation in nursing to define an ethics of care is a direct result of breaking nursing tradition. Subsequent attempts to find a moral basis for care, whether from subjective experimental perspectives such as described by Noddings, or from rational and detached approaches derived from Kant, are inevitably flawed. Writers may still implicitly presuppose a concept of care drawn from the Judaeo-Christian tradition but without explicit recourse to its moral basis nursing is left rudderless and potentially without purpose. The very concept of 'care' cut off from its roots becomes a meaningless term without either normative or descriptive content.

Effect of arterial cannulation and contrast agents on blood coagulation

RATIONALE AND OBJECTIVES

Nonionic contrast media have been considered by some to have thrombogenic properties. We prospectively assessed the effect of femoral artery catheterization and both nonionic and ionic contrast media on the coagulation parameters--fragment 1 + 2 (F1 + 2) and fibrinopeptide A (FpA)--during clinical angiography.

METHODS

Seventeen patients undergoing aortography were included. Blood samples were obtained before and after arterial puncture and before and up to 30 min after contrast administration.

RESULTS

An increase in FpA was observed after arterial puncture (range = 8.4 +/- 1.9 to 13.6 +/- 2.3 ng/ml, p < .004; data are written as mean +/- standard error of the mean). There was an observed increase in F1 + 2 after arterial puncture that was not statistically significant (2.0 +/- 0.4 to 2.3 +/- 0.4 nmol/l). No further increase was observed in either FpA or F1 + 2 levels after nonionic or ionic contrast media administration.

CONCLUSION

The increased activity of the coagulation system during angiography is related to the arterial puncture, and nonionic and ionic contrast media have no thrombogenic potential in vivo.

Has nursing lost its way? Nursing and medicine: cooperation or conflict?

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What are nurses doing to patients? A review of theories of nursing past and present

This paper looks critically at the nature of nursing theory from three perspectives. Firstly, it examines the current state of nursing theory with a particular focus on Patricia Benner's work. This examination concludes that nursing theory is currently beset by the problems of scientific and moral relativism and philosophical incoherence because it has abandoned a traditional realist approach to the care of patients. Secondly, the roots of this contemporary nursing position are analysed and the conclusion is reached that nursing theorists are implicitly presuming this traditional 'common sense' view of nursing, although their own philosophical assumptions do not support it and indeed are removing the ground from beneath it. The traditional theory underpinning the quality of the nurse's care, and hence the ethos of nursing, is rearticulated. In conclusion it is suggested that nursing needs to debate the modernist views that are now holding sway in nursing and rediscover a theory for the care of patients that holds together the personal, the pastoral, the scientific and the technological aspects of patient care.