All-cause, premature, and cardiovascular death attributable to socioeconomic and ethnic disparities among New Zealanders with type 1 diabetes 1994-2019: a multi-linked population-based cohort study

BACKGROUND

New Zealand (NZ) research into type 1 diabetes mellitus (T1DM) mortality can inform policy and future research. In this study we aimed to quantify the magnitude to which ethnicity and socioeconomic disparities influenced mortality at the population level among people with Type 1 diabetes (T1DM) in Auckland, New Zealand (NZ).

METHODS

The cohort data were derived from the primary care diabetes audit program the Diabetes Care Support Service (DCSS), and linked with national primary care, pharmaceutical claims, hospitalisation, and death registration databases. People with T1DM enrolled in DCSS between 1994-2018 were included. All-cause, premature, and cardiovascular mortalities were estimated by Poisson regression models with adjustment for population-level confounders. The mortality rates ratio (MRR) was standardized against the DCSS type 2 diabetes population. Mortality rates were compared by ethnic group (NZ European (NZE) and non-NZE) and socioeconomic deprivation quintile. The population attributable fraction (PAF) was estimated for ethnic and socioeconomic disparities by Cox regression adjusting for demographic, lifestyle, and clinical covariates. The adjusted slope index inequality (SII) and relative index of inequality (RII) were used to measure the socioeconomic disparity in mortalities.

RESULTS

Overall, 2395 people with T1DM (median age 34.6 years; 45% female; 69% NZE) were enrolled, among whom the all-cause, premature and CVD mortalities were 6.69 (95% confidence interval: 5.93-7.53), 3.30 (2.77-3.90) and 1.77 (1.39-2.23) per 1,000 person-years over 25 years. The overall MRR was 0.39 (0.34-0.45), 0.65 (0.52-0.80), and 0.31 (0.24-0.41) for all-cause, premature and CVD mortality, respectively. PAF attributable to ethnicity disparity was not significantly different for mortality. The adjusted PAF indicated that 25.74 (0.84-44.39)% of all-cause mortality, 25.88 (0.69-44.69)% of premature mortality, 55.89 (1.20-80.31)% of CVD mortality could be attributed to socioeconomic inequality. The SII was 8.04 (6.30-9.78), 4.81 (3.60-6.02), 2.70 (1.82-3.59) per 1,000 person-years and RII was 2.20 (1.94-2.46), 2.46 (2.09-2.82), and 2.53 (2.03-3.03) for all-cause, premature and CVD mortality, respectively.

CONCLUSIONS

Our results suggest that socioeconomic disparities were responsible for a substantial proportion of all-cause, premature and CVD mortality in people with T1DM in Auckland, NZ. Reducing socioeconomic barriers to management and self-management would likely improve clinical outcomes.

Association Between Onset of Type 2 Diabetes and Risk of Atrial Fibrillation in New Zealanders With Impaired Glucose Tolerance Over 25 Years

Background The association between the onset of type 2 diabetes (T2D) and atrial fibrillation (AF) risk in individuals with impaired glucose tolerance (IGT) remains unclear. This study aimed to investigate the relationship between the incident onset of T2D and 5- and 10-year (after the landmark period) risks of AF in people with IGT identified in South and West Auckland primary care settings between 1994 and 2019. Methods and Results We compared AF risk in patients with IGT with and without newly diagnosed T2D within a 1- to 5-year exposure window. Tapered matching and landmark analysis (to address immortal bias) were used to control for confounding variables. The cohorts incorporated 785 patients who had T2D newly diagnosed within 5 years from enrollment (landmark date) and 15 079 patients without a T2D diagnosis. Patients progressing to T2D exhibited significantly higher 5-year (after the landmark period) AF risk (hazard ratio [HR], 1.34 [95% CI, 1.10-1.63]) and 10-year (after the landmark period) AF risk (HR, 1.28 [95% CI, 1.02-1.62]) compared with those without incident T2D. The association was more pronounced among men, older patients, socioeconomically deprived individuals, current smokers, those with higher metabolic measures, and lower renal function. New Zealand European ethnicity was associated with a lower 5- and 10-year risk of AF. Conclusions This study found a mediating effect of T2D on the risk of AF in a population with IGT in New Zealand. The development of risk scores and future replication studies can help identify and guide management of individuals with IGT at the highest risk of AF following incident T2D.

Effect of onset of type 2 diabetes on risks of cardiovascular disease and heart failure among new Zealanders with impaired glucose tolerance over 25 years: tapered-matched landmark analysis

BACKGROUND

This study aimed to examine the association between the incident onset of T2DM and 5- and 10-year risks of CVD and HF in people with IGT identified in primary care in South and West Auckland, New Zealand (NZ) between 1994 and 2019.

METHODS

We compared CVD and HF risks in patients with IGT and with/without T2D newly diagnosed within the exposure window (1-5 years). Tapered matching and landmark analysis (to account for immortal bias) were used to control for potential effects of known confounders.

RESULTS

Among 26,794 patients enrolled with IGT, 845 had T2D newly diagnosed within 5 years from enrolment (landmark date) and 15,452 did not have T2D diagnosed. Patients progressing to T2D (vs. those not progressing) had a similar 5-year risk for CVD (hazard ratio 1.19; 95% CI 0.61-2.32) but significantly higher 10-year risk of CVD (2.45(1.40-4.29)), 5-year risk of HF (1.94(1.20-3.12)) and 10-year risk of HF (2.84(1.83-4.39). The association between the onset of T2D and risk of 10-year risk of CVD, 5-year and 10-year risk of HF was more likely among men, the socioeconomically deprived, those currently smoking, patients with higher metabolic measures and/or those with lower renal function. Patients of NZ European ethnicity had a lower 10-year risk of CVD.

CONCLUSIONS

The study suggests that the diagnosis of T2D mediates the risk of CVD and HF in people with IGT. The development of risk scores to identify and better manage individuals with IGT at high risk of T2D is warranted.

Empagliflozin and dulaglutide: community awareness project promotes improved access to newly funded medications for Pacific patients with type 2 diabetes

AIM

The aims of our awareness campaign were to increase the number of inquiries by patients to doctors for two new diabetes drugs funded by Pharmac on 1 February 2021 and 1 September 2021 respectively, to increase the number of applications for special authority, and to trial a "grass roots" community dissemination of information that appeals to explicit individual benefit from the new medicines. The campaign used an approach tailored primarily to the Pasifika community.

METHODS

The campaign ran from April 2021 to July 2021 and targeted Counties Manukau communities using a talanoa approach by primarily by sharing key messages informally through social networks face-to-face by word-of-mouth. The key messages about the new medicines were shared orally with local organisations, family, friends, influential community leaders and colleagues such as justices of peace, kapa haka leaders, committee representatives from local schools, sports, cultural and hobby clubs. A printed pamphlet translated in Māori, Samoan, Tongan and English with the key messages was also distributed widely. The campaign notified 102 primary care practices, used Pacific equity teams to disseminate the information, promoted the message on Māori and Pasifika radio stations, and engaged a public relations company who contacted the South Auckland Community Trust, councillors, community boards and local churches. This approach was intended to spread the message through the community to reach people with type 2 diabetes and/or their families to prompt them to contact their doctor and see if they are eligible. To gauge how effective the campaign was, we gathered data from Pharmac that quantified new prescriptions for the new medicines by location and ethnicity.

RESULTS

An estimated 45,000 people were exposed to our campaign materials or were told about the new medicines by people they knew. These estimations were conservatively based on the known membership, listenership, and reach of the various delivery arms by which this campaign was delivered. These data show Pacific patients, the focus of about 64% of our project work, were 40% more likely to apply and receive a prescription for empagliflozin in Counties Manukau than anywhere else in the country.

CONCLUSION

Direct-to-consumer marketing is an effective way of increasing health awareness and uptake of newly funded diabetes medicine amongst Pacific patients with type 2 diabetes.

Adverse Clinical Outcomes Attributable to Socioeconomic and Ethnic Disparities Among People with Type 2 Diabetes in New Zealand Between 1994-2018: A Multiple Linked Cohort Study

Purpose

The study aimed to examine the separate population-level contributions of the ethnic and socioeconomic disparities among people with type 2 diabetes mellitus (T2DM) and residence in New Zealand (NZ).

Patients and Methods

A prospective cohort enrolled T2DM patients from 01/01/1994 into the Diabetes Care Support Service, a primary care audit program in Auckland, NZ. The cohort was linked to national registry databases (socioeconomic status, pharmaceutical claim, hospitalization, and death registration). Each cohort member was followed up till death or the study end time (31/12/2019), whichever came first. Incident clinical events (stroke, myocardial infarction (MI), heart failure (HF), end-stage renal disease (ESRD), and premature mortality (PM)) were used as outcomes. The attributable fractions (AFs) were estimated for the whole population and for specific population with NZ Europeans (NZE) and/or least deprived population as reference, both unadjusted and with adjustment for covariables by Cox Regression models.

Results

Among 36,267 patients, adjusted population AFs indicated 6.6(-30.8-33.3)% of PM, 17.1(5.8-27.0)% of MI, 35.3(22.6-46.0)% of stroke, 14.3(3.2-24.2)% of HF, and 15.9(6.7-24.2)% of ESRD could be attributed to deprivation; while 14.3(3.3-25.4)% of PM, -3.3(-8.3-1.5)% of MI, -0.5(-6.7-5.3)% of stroke, 4.7(0.3-8.8)% of HF, 13.3(9.9-16.6)% of ESRD could be attributed to ethnicity. Deprivation contributed a significant AF to stroke, while ethnicity was important for ESRD. Gradient of AF for deprivation indicated NZE and Asians were most affected by deprivation across outcomes. Conversely, Māori, with the highest AFs for ethnicity of PM and ESRD, were unaffected by deprivation. At same deprivations, the AFs of MI and stroke were greatest among NZE compared with other ethnic groups; the AF of ESRD was greatest among Māori and Pasifika.

Conclusion

Both socioeconomic deprivation and ethnicity are strongly associated with outcomes in patients with T2DM in NZ, although the extent of the deprivation gradient is greatest among NZE and Asians, and least among Māori.

Ethnic differences in 25-year risk of incident chronic kidney disease among people with type 2 diabetes in New Zealand

INTRODUCTION

Insights into ethnic differences in the natural history of chronic kidney disease (CKD) among people with type 2 diabetes mellitus (T2DM) might inform clinical strategies to address disparities in hospitalization and mortality. Risks of CKD II-V stages over a 25-year period between New Zealand Europeans (NZEs), Māori and Pasifika, and with T2DM in Auckland, New Zealand (NZ) were compared.

RESEARCH DESIGN AND METHODS

As a primary care audit program in Auckland, the Diabetes Care Support Service was linked with national registration databases. People with existing CKD II-V were ruled out. To balance potential confounders, we applied a tapered matching method . 'Quasi-trial'-matched cohorts were set up separately between Māori and NZE and between Pasifika and NZE. Ethnic population differences in risk of any and each stage of CKD over 1994-2018 were examined by weighted Cox regression model.

RESULTS

The HRs for developing any CKD, CKD stages II-V for Māori (n=2215) versus NZE (n=2028) were 1.18 (95% CI 0.99 to 1.41), 1.10 (95% CI 0.91 to 1.32), 1.70 (95% CI 1.19 to 2.43), 3.93 (95% CI 2.16 to 7.14), and 3.74 (95% CI 1.74 to 8.05), respectively. Compared with NZE (n=2474), the HRs for developing any CKD, CKD stages II-V for Pasifika (n=3101) were 1.31 (95% CI 1.09 to 1.57), 1.26 (95% CI 1.05 to 1.52), 1.71 (95% CI 1.14 to 2.57), 3.75 (95% CI 1.40 to 10.05), and 4.96 (95% CI 1.56 to 15.75), respectively.

CONCLUSIONS

Among people with T2DM in NZ, significant ethnic differences exist in the risk of progressing to each stage of CKD (stage V in particular). Mechanism studies underlying these differences, as well as the need for identification of biomarkers to predict the early onset renal lesion, are warranted.

Ethnic differences in metabolic achievement between Māori, Pacific, and European New Zealanders with type 2 diabetes

AIMS

To compare variations in metabolic target achievement by ethnicity (Europeans, Māori and Pasifika) among patients with type 2 diabetes (T2DM) in Auckland, New Zealand (NZ) between 1994 and 2013.

METHODS

32,237 patients were enrolled. Adjusted marginal difference (European as reference) of systolic blood pressure (SBP), body mass index (BMI), HbA1c and total cholesterol, alongside the proportion achieving metabolic targets were estimated using multivariable mixed effect models at baseline, 1-, 2-, 3-, 4-, and 5-years, adjusted for covariates.

RESULTS

Compared with Europeans, Māori and Pasifika had continuously, significantly higher HbA1c (by 0.3% (+3.5 mmol/mol) and 0.6% (+6.8 mmol/mol) respectively and BMI (+1.5 and +0.3 kg/m² respectively) but lower SBP (-1.8 and -3.4 mmHg respectively) and TG (-0.03 and -0.34 mmol/L respectively), and insignificantly TC (+0.004 and +0.01 respectively), by 5-years of follow-up. While 49% Europeans were within target HbA1c, this was achieved by only 30% Māori and 27% Pasifika. Conversely, 41% Europeans, 46% Māori and 59% Pasifika achieved the SBP target (all P < 0.0001).

CONCLUSIONS

Managing hyperglycemia appears to be more challenging than treating hypertension and dyslipidemia among Māori and Pasifika. New anti-hyperglycemia treatments, addressing health literacy, socioeconomic and any cultural barriers to management and self-management are urgently needed to reduce these disparities.

Ethnic Differences in Cancer Rates Among Adults With Type 2 Diabetes in New Zealand From 1994 to 2018

IMPORTANCE

People with type 2 diabetes have greater risk for some site-specific cancers, and risks of cancers differ among racial and ethnic groups in the general population of Aotearoa New Zealand. The extent of ethnic disparities in cancer risks among people with type 2 diabetes in New Zealand is unclear.

OBJECTIVE

To compare the risks of 21 common adult cancers among Māori, Pasifika, and New Zealand European individuals with type 2 diabetes in New Zealand from 1994 to 2018.

DESIGN, SETTING, AND PARTICIPANTS

This population-based, matched cohort study used data from the primary care audit program in Auckland, New Zealand, linked with national cancer, death, and hospitalization registration databases, collected from January 1, 1994, to July 31, 2018, with follow-up data obtained through December 31, 2019. Using a tapered matching method to balance potential confounders (sociodemographic characteristics, lifestyle, anthropometric and clinical measurements, treatments [antidiabetes, antihypertensive, lipid-lowering, and anticoagulant], period effects, and recorded duration of diabetes), comparative cohorts were formed between New Zealand European and Māori and New Zealand European and Pasifika individuals aged 18 years or older with type 2 diabetes. Sex-specific matched cohorts were formed for sex-specific cancers.

EXPOSURES

Māori, Pasifika, and New Zealand European (reference group) ethnicity.

MAIN OUTCOMES AND MEASURES

The incidence rates of 21 common cancers recorded in nationally linked databases between 1994 and 2018 were the main outcomes. Weighted Cox proportional hazards regression was used to assess ethnic differences in risk of each cancer.

RESULTS

A total of 33 524 adults were included: 15 469 New Zealand European (mean [SD] age, 61.6 [13.2] years; 8522 [55.1%] male), 6656 Māori (mean [SD] age, 51.2 [12.4] years; 3345 [50.3%] female), and 11 399 Pasifika (mean [SD] age, 52.8 [12.7] years; 5994 [52.6%] female) individuals. In the matched New Zealand European and Māori cohort (New Zealand European: 8361 individuals; mean [SD] age, 58.9 [12.9] years; 4595 [55.0%] male; Māori: 5039 individuals; mean [SD] age, 51.4 [12.3] years; 2542 [50.5%] male), significant differences between New Zealand European and Māori individuals were identified in the risk for 7 cancers. Compared with New Zealand European individuals, the hazard ratios (HRs) among Māori individuals were 15.36 (95% CI, 4.50-52.34) for thyroid cancer, 7.94 (95% CI, 1.57-40.24) for gallbladder cancer, 4.81 (95% CI, 1.08-21.42) for cervical cancer (females only), 1.97 (95% CI, 1.30-2.99) for lung cancer, 1.81 (95% CI, 1.08-3.03) for liver cancer, 0.56 (95% CI, 0.35-0.90) for colon cancer, and 0.11 (95% CI, 0.04-0.27) for malignant melanoma. In the matched New Zealand European and Pasifika cohort (New Zealand European: 9340 individuals; mean [SD] age, 60.6 [13.1] years; 4885 [52.3%] male; Pasifika: 8828 individuals; mean [SD] age, 53.1 [12.6] years; 4612 [52.2%] female), significant differences between New Zealand European and Pasifika individuals were identified for 6 cancers. Compared with New Zealand European individuals, HRs among Pasifika individuals were 25.10 (95% CI, 3.14-200.63) for gallbladder cancer, 4.47 (95% CI, 1.25-16.03) for thyroid cancer, 0.48 (95% CI, 0.30-0.78) for colon cancer, 0.21 (95% CI, 0.09-0.48) for rectal cancer, 0.21 (95% CI, 0.07-0.65) for malignant melanoma, and 0.01 (95% CI, 0.01-0.10) for bladder cancer.

CONCLUSIONS AND RELEVANCE

In this cohort study, differences in the risk of 21 common cancers were found between New Zealand European, Māori, and Pasifika groups of adults with type 2 diabetes in New Zealand from 1994 to 2018. Research into the mechanisms underlying these differences as well as additional screening strategies (eg, for thyroid and gallbladder cancers) appear to be warranted.

Local Exhaust Ventilation to Control Dental Aerosols and Droplets

Dental procedures produce aerosols that may remain suspended and travel significant distances from the source. Dental aerosols and droplets contain oral microbes, and there is potential for infectious disease transmission and major disruption to dental services during infectious disease outbreaks. One method to control hazardous aerosols often used in industry is local exhaust ventilation (LEV). The aim of this study was to investigate the effect of LEV on aerosols and droplets produced during dental procedures. Experiments were conducted on dental mannequins in an 825.4-m³ open-plan clinic and a 49.3-m³ single surgery. Ten-minute crown preparations were performed with an air-turbine handpiece in the open-plan clinic and 10-min full-mouth ultrasonic scaling in the single surgery. Fluorescein was added to instrument irrigation reservoirs as a tracer. In both settings, optical particle counters (OPCs) were used to measure aerosol particles between 0.3 and 10.0 µm, and liquid cyclone air samplers were used to capture aerosolized fluorescein tracer. In addition, in the open-plan setting, fluorescein tracer was captured by passive settling onto filter papers in the environment. Tracer was quantified fluorometrically. An LEV device with high-efficiency particulate air filtration and a flow rate of 5,000 L/min was used. LEV reduced aerosol production from the air-turbine handpiece by 90% within 0.5 m, and this was 99% for the ultrasonic scaler. OPC particle counts were substantially reduced for both procedures and air-turbine settled droplet detection reduced by 95% within 0.5 m. The effect of LEV was substantially greater than suction alone for the air-turbine and was similar to the effect of suction for the ultrasonic scaler. LEV reduces aerosol and droplet contamination from dental procedures by at least 90% in the breathing zone of the operator, and it is therefore a valuable tool to reduce the dispersion of dental aerosols.

165Ethnic differences in type 2 diabetes mortality and hospitalisation rates in a New Zealand population1994-2018

Background

Type 2 Diabetes (T2DM) affects different populations disproportionately including in New Zealand (NZ), where long-term temporal trends in cause-specific clinical outcomes between Māori, European and Pacific people remain unclear.

Methods

Data from patients with T2DM, aged 35-84 years enrolled 1994-2018 in a NZ primary care audit programme (the Diabetes Care Support Service) were linked with national death registration, hospitalisation, pharmaceutical claims and primary care databases. Cause-specific death and hospitalisation rates were adjusted for gender, age, smoking, obesity, social-economic status and time periods by age-period-cohort models.

Results

Overall, 79,912 (50.6% female, mean-age 56±15 years, median follow-up 9.7 years) patients with T2DM were enrolled. For Europeans vs Māori, adjusted incidence rates ratio (IRR) and absolute risk difference /1000 person-years were 1.96 (95% CI: 1.80- 2.14) and 22.85 (19.93-25.77) for all-cause mortality, 1.93 (1.63-2.29) and 6.97 (5.14-8.80) for cardiovascular (CVD) mortality, 1.64 (1.40-1.93) and 3.08 (2.25-3.92) for cancer mortality, 1.26 (1.25-1.28) and 42.70 (41.32-44.08) for CVD hospitalisation, 1.31 (1.28-1.34) and 44.76 (42.37-47.15) for cancer hospitalisation, 2.05 (1.96-2.14) and 31.44 (29.67-33.21) for end-stage renal disease (ESRD) hospitalisation. Pacific rates were significantly less than Māori, but higher than Europeans for ESRD (IRR:1.59 (1.52-1.67)) and CVD (1.09 (1.07-1.10)) hospitalisation.

Conclusions

Poorer health outcomes have persisted among Māori and Pacific people with T2DM for &gt;20 years. New policies supporting more intensive management of T2DM are urgently needed. Differences in outcomes between Māori and Pacific people warrant further research.

Key messages

Outcome disparities have persisted among Māori and Pacific people with T2DM for &gt;20 years.

Financial health and obesity

We use individual-level panel data from the English Longitudinal Survey of Ageing over the period 2004-2013 to investigate the links between financial health and obesity. We find that having no debt (high savings) is associated with a 3.6 (1.6) percentage point lower probability of having a Body Mass Index in excess of 30. Our results are robust to using different estimation methods, to measuring financial health with a subjective indicator, and adiposity with waist circumference. A lower rate of time preference and lower stress levels may be mechanisms which help to explain the association between good financial health and obesity.

Continuous digital hypothermia in the prevention and treatment of acute equine laminitis

PICO question Does continuous digital hypothermia improve clinical outcome in equids with acute laminitis compared to supportive treatment alone?   Clinical bottom line Category of research question Treatment The number and type of study designs reviewed Six experimental randomised controlled trials and one multicentre retrospective case series were reviewed Strength of evidence Moderate Outcomes reported The outcomes reported were reduced severity of histopathological lamellar lesions in limbs treated with continuous digital hypothermia (CDH; initiated prior to or soon after the onset of experimentally induced acute laminitis) compared to limbs remaining at an ambient temperature in all five experimental studies where histology was performed. A significant reduction was observed in the prevalence or severity of clinical signs of laminitis in limbs treated with CDH compared to limbs remaining at an ambient temperature. In a single retrospective case series, significantly reduced prevalence of clinical laminitis was reported amongst animals receiving CDH compared to those that did not in a referral hospital population of animals treated for colitis Conclusion There is moderate evidence to support that CDH when used prior to or in the early stages of clinical signs, may reduce the severity and progression of lamellar lesions in acute laminitis and no evidence demonstrating that it improves clinical outcome compared to supportive treatment alone. Further research into the clinical outcome of equids treated for acute laminitis using CDH is warranted   How to apply this evidence in practice The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources. Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.  

Uterotonic drugs to prevent postpartum haemorrhage: a network meta-analysis

BACKGROUND

Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Prophylactic uterotonic drugs can reduce blood loss and are routinely recommended. There are several uterotonic drugs for preventing PPH, but it is still debatable which drug or combination of drugs is the most effective.

OBJECTIVES

To identify the most effective and cost-effective uterotonic drug(s) to prevent PPH, and generate a ranking according to their effectiveness and side-effect profile.

METHODS

The Cochrane Pregnancy and Childbirth's Trials Register (1 June 2015), ClinicalTrials.gov and the World Health Organization (WHO)'s International Clinical Trials Registry Platform (ICTRP) were searched for unpublished trial reports (30 June 2015). In addition, reference lists of retrieved studies (updated October 2017) were searched for randomised trials evaluating uterotonic drugs for preventing PPH. The study estimated relative effects and rankings for preventing PPH, defined as blood loss of ≥ 500 ml and ≥ 1000 ml. Pairwise meta-analyses and network meta-analysis were performed to determine the relative effects and rankings of all available drugs and combinations thereof [ergometrine, misoprostol (Cytotec^®; Pfizer Inc., New York, NY, USA), misoprostol plus oxytocin (Syntocinon^®; Novartis International AG, Basel, Switzerland), carbetocin (Pabal^®; Ferring Pharmaceuticals, Saint-Prex, Switzerland), ergometrine plus oxytocin (Syntometrine^®; Alliance Pharma plc, Chippenham, UK), oxytocin, and a placebo or no treatment]. Primary outcomes were stratified according to the mode of birth, prior risk of PPH, health-care setting, drug dosage, regimen and route of drug administration. Sensitivity analyses were performed according to study quality and funding source, among others. A model-based economic evaluation compared the relative cost-effectiveness separately for vaginal births and caesareans with or without including side effects.

RESULTS

From 137 randomised trials and 87,466 women, ergometrine plus oxytocin, carbetocin and misoprostol plus oxytocin were found to reduce the risk of PPH blood loss of ≥ 500 ml compared with the standard drug, oxytocin [ergometrine plus oxytocin: risk ratio (RR) 0.69, 95% confidence interval (CI) 0.57 to 0.83; carbetocin: RR 0.72, 95% CI 0.52 to 1.00; misoprostol plus oxytocin: RR 0.73, 95% CI 0.6 to 0.9]. Each of these three strategies had 100% cumulative probability of being ranked first, second or third most effective. Oxytocin was ranked fourth, with an almost 0% cumulative probability of being ranked in the top three. Similar rankings were noted for the reduction of PPH blood loss of ≥ 1000 ml (ergometrine plus oxytocin: RR 0.77, 95% CI 0.61 to 0.95; carbetocin: RR 0.70, 95% CI 0.38 to 1.28; misoprostol plus oxytocin: RR 0.90, 95% CI 0.72 to 1.14), and most secondary outcomes. Ergometrine plus oxytocin and misoprostol plus oxytocin had the poorest ranking for side effects. Carbetocin had a favourable side-effect profile, which was similar to oxytocin. However, the analysis was restricted to high-quality studies, carbetocin lost its ranking and was comparable to oxytocin. The relative cost-effectiveness of the alternative strategies is inconclusive, and the results are affected by both the uncertainty and inconsistency in the data reported on adverse events. For vaginal delivery, when assuming no adverse events, ergometrine plus oxytocin is less costly and more effective than all strategies except carbetocin. The strategy of carbetocin is both more effective and more costly than all other strategies. When taking adverse events into consideration, all prevention strategies, except oxytocin, are more costly and less effective than carbetocin. For delivery by caesarean section, with and without adverse events, the relative cost-effectiveness is different, again because of the uncertainty in the available data.

LIMITATIONS

There was considerable uncertainty in findings within the planned subgroup analyses, and subgroup effects cannot be ruled out.

CONCLUSIONS

Ergometrine plus oxytocin, carbetocin and misoprostol plus oxytocin are more effective uterotonic drug strategies for preventing PPH than the current standard, oxytocin. Ergometrine plus oxytocin and misoprostol plus oxytocin cause significant side effects. Carbetocin has a favourable side-effect profile, which was similar to oxytocin. However, most carbetocin trials are small and of poor quality. There is a need for a large high-quality trial comparing carbetocin with oxytocin; such a trial is currently being conducted by the WHO. The relative cost-effectiveness is inconclusive, and results are affected by uncertainty and inconsistency in adverse events data.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015020005; Cochrane Pregnancy and Childbirth Group (substudy) reference number 0871; PROSPERO-Cochrane (substudy) reference number CRD42015026568; and sponsor reference number ERN_13-1414 (University of Birmingham, Birmingham, UK).

FUNDING

Funding for this study was provided by the National Institute for Health Research Health Technology Assessment programme in a research award to the University of Birmingham and supported by the UK charity Ammalife (UK-registered charity 1120236). The funders of the study had no role in study design, data collection, data synthesis, interpretation or writing of the report.

Accelerated partner therapy (APT) partner notification for people with Chlamydia trachomatis: protocol for the Limiting Undetected Sexually Transmitted infections to RedUce Morbidity (LUSTRUM) APT cross-over cluster randomised controlled trial

INTRODUCTION

Partner notification (PN) is a process aiming to identify, test and treat the sex partners of people (index patients) with sexually transmitted infections (STIs). Accelerated partner therapy (APT) is a PN method whereby healthcare professionals assess sex partners, by telephone consultation, before giving the index patient antibiotics and STI self-sampling kits to deliver to their sex partner(s). The Limiting Undetected Sexually Transmitted infections to RedUce Morbidity programme aims to determine the effectiveness of APT in heterosexual women and men with chlamydia and determine whether APT could affect Chlamydia trachomatis transmission at population level.

METHODS AND ANALYSIS

This protocol describes a cross-over cluster randomised controlled trial of APT, offered as an additional PN method, compared with standard PN. The trial is accompanied by an economic evaluation, transmission dynamic modelling and a qualitative process evaluation involving patients, partners and healthcare professionals. Clusters are 17 sexual health clinics in areas of England and Scotland with contrasting patient demographics. We will recruit 5440 heterosexual women and men with chlamydia, aged ≥16 years.The primary outcome is the proportion of index patients testing positive for C. trachomatis 12-16 weeks after the PN consultation. Secondary outcomes include: proportion of sex partners treated; cost effectiveness; model-predicted chlamydia prevalence; experiences of APT.The primary outcome analysis will be by intention-to-treat, fitting random effects logistic regression models that account for clustering of index patients within clinics and trial periods. The transmission dynamic model will be used to predict change in chlamydia prevalence following APT. The economic evaluation will use mathematical modelling outputs, taking a health service perspective. Qualitative data will be analysed using interpretative phenomenological analysis and framework analysis.

ETHICS AND DISSEMINATION

This protocol received ethical approval from London-Chelsea Research Ethics Committee (18/LO/0773). Findings will be published with open access licences.

TRIAL REGISTRATION NUMBER

ISRCTN15996256.

Abstract I26: Investigating the immune microenvironment in mouse models of pancreatic cancer

Pancreatic cancer is predicted to become the second most common cause of cancer death in the Western world by ~2025. The focus of our research has been to better understand the disease and identify more effective and targeted therapies, in particular, using genetically engineered mouse models, which develop pancreatic tumors reminiscent of the human disease including development of a complex microenvironment. The pancreatic cancer microenvironment is characterized by significant infiltration of immune cells, but a distinct lack of T cells. Thus, immunotherapies have had little efficacy in PC despite promise in other cancers. Recent data have suggested that genomic instability and increased mutation burden may predict the efficacy of immune checkpoint inhibitors. To investigate this, we have generated a model of APOBEC mutagenesis in pancreatic cancer. The APOBEC family of cytidine deaminase enzymes, whose normal function is to protect from viral infections, have been revealed as drivers of mutation in a variety of human tumors, including pancreatic cancer. We have engineered mice to express Cre-inducible APOBEC3B and crossed these with the KPC genetically engineered mouse model of pancreatic cancer. We find that overexpressing APOBEC3B results in a poorer prognosis in these animals and some changes in the immune microenvironment. We are currently performing genomic and transcriptomic analyses to determine mutational burden and tumor subtype in an effort to identify therapeutic opportunities in patients bearing this signature. In contrast with T cells, recent studies have suggested that B cells may be tumor promoting in pancreatic cancer. However, clinical trials targeting B cells have been conducted recently and the results have been very disappointing. We have now generated an autochthonous model of B-cell depletion and find that B cells are not tumor promoting in this setting. We are now investigating the mechanisms behind this and the microenvironmental differences that are observed in spontaneous versus allograft models.

Citation Format: Karen Pickering, Laura Lapienyte, Saadia Karim, Douglas Strathdee, Owen Sansom, Jen Morton. Investigating the immune microenvironment in mouse models of pancreatic cancer [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer: Advances in Science and Clinical Care; 2019 Sept 6-9; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2019;79(24 Suppl):Abstract nr I26.

Uterotonic Drugs for the Prevention of Postpartum Haemorrhage: A Cost-Effectiveness Analysis

OBJECTIVE

The objective of this study was to estimate the relative cost effectiveness for the full range of uterotonic drugs available for preventing postpartum haemorrhage (PPH).

METHODS

A model-based economic evaluation was constructed using effectiveness data from a network meta-analysis, and supplemented by the literature. A UK National Health Service (NHS) perspective was adopted for the analysis, which is based on UK costs from published sources. The primary outcome measure is cost per case of PPH avoided (≥ 500 mL blood loss), with secondary outcome measures of cost per case of severe PPH avoided (≥ 1000 mL) and cost per major outcome (surgery) averted also being analysed.

RESULTS

Carbetocin is shown to be the most effective strategy. Excluding adverse events, 'ergometrine plus oxytocin' was shown to be the least costly strategy. The incremental cost-effectiveness ratio for prevention of PPH with carbetocin compared with prevention with 'ergometrine plus oxytocin' was £1889 per case of PPH ≥ 500 mL avoided; £30,013 per case of PPH ≥ 1000 mL avoided; and £1,172,378 per major outcome averted. Including adverse events in the analysis showed oxytocin to be the least costly strategy. The incremental cost-effectiveness ratio for prevention of PPH with carbetocin compared with prevention with oxytocin was £928 per case of PPH ≥ 500 mL avoided; £22,900 per case of PPH ≥ 1000 mL avoided; and £894,514 per major outcome averted.

CONCLUSION

The results suggest carbetocin, oxytocin and 'ergometrine plus oxytocin' could all be favourable options for being the most cost-effective strategy for preventing PPH. Carbetocin could be the preferred choice, especially if the price of carbetocin decreased. Mixed findings mean a clear-cut conclusion cannot be made as to which uterotonic is the most cost effective. Future research should focus on collecting more robust evidence on the probability of having adverse events from the uterotonic drugs, and on adapting the model for low- and middle-income countries.

Systems level expression correlation of Ras GTPase regulators

BACKGROUND

Proteins of the ubiquitously expressed core proteome are quantitatively correlated across multiple eukaryotic species. In addition, it was found that many protein paralogues exhibit expression anticorrelation, suggesting that the total level of protein with a given functionality must be kept constant.

METHODS

We performed Spearman's rank correlation analyses of gene expression levels for the RAS GTPase subfamily and their regulatory GEF and GAP proteins across tissues and across individuals for each tissue. A large set of published data for normal tissues from a wide range of species, human cancer tissues and human cell lines was analysed.

RESULTS

We show that although the multidomain regulatory proteins of Ras GTPases exhibit considerable tissue and individual gene expression variability, their total amounts are balanced in normal tissues. In a given tissue, the sum of activating (GEFs) and deactivating (GAPs) domains of Ras GTPases can vary considerably, but each person has balanced GEF and GAP levels. This balance is impaired in cell lines and in cancer tissues for some individuals.

CONCLUSIONS

Our results are relevant for critical considerations of knock out experiments, where functionally related homologs may compensate for the down regulation of a protein.

Time to tighten the belts? Exploring the relationship between savings and obesity

BACKGROUND

Literature suggests that the higher the rate of time preference people have, the less likely they are to save for the future. Likewise, it has been hypothesised that rising rates of being overweight/obesity are associated with an increase in peoples' marginal rate of time preference.

AIM

To investigate the relationship between being overweight/ obese and the rate of time preference in an older English population, using savings as a proxy for time preference.

METHODS

Three different econometric methods-Random-effects Probit Estimation, Fixed-effects Estimation, and Generalised Method of Moments Estimation-were used to explore the link between being overweight/ obese and rate of time preference in the English Longitudinal Study of Ageing dataset. Six waves of panel data spanning eleven years provided the data to test whether savings variables are related to being overweight/ obese.

RESULTS

The decision to save was shown to hold a statistically significant negative relationship with body mass index but only in the Generalised Method of Moments model. Placing savings in safe, low risk investments was significantly related to a lower probability of being obese but only in the random-effects Probit model. The proportion that people saved relative to their income was not found to be significantly associated with the probability of being overweight/ obese in any of the models.

CONCLUSION

There is an unclear relationship between saving behaviour and being overweight/ obese in an older English population. A financial variable such as savings is a potentially appropriate but imperfect proxy for the rate of time preference of the population. Further research is required to clarify the relationship in order to help develop strategies for obesity prevention. The inconsistency in the results between methods highlights the importance of using a wide range of alternative techniques before implementing important policy decisions.

TIAM1 Antagonizes TAZ/YAP Both in the Destruction Complex in the Cytoplasm and in the Nucleus to Inhibit Invasion of Intestinal Epithelial Cells

Aberrant WNT signaling drives colorectal cancer (CRC). Here, we identify TIAM1 as a critical antagonist of CRC progression through inhibiting TAZ and YAP, effectors of WNT signaling. We demonstrate that TIAM1 shuttles between the cytoplasm and nucleus antagonizing TAZ/YAP by distinct mechanisms in the two compartments. In the cytoplasm, TIAM1 localizes to the destruction complex and promotes TAZ degradation by enhancing its interaction with βTrCP. Nuclear TIAM1 suppresses TAZ/YAP interaction with TEADs, inhibiting expression of TAZ/YAP target genes implicated in epithelial-mesenchymal transition, cell migration, and invasion, and consequently suppresses CRC cell migration and invasion. Importantly, high nuclear TIAM1 in clinical specimens associates with increased CRC patient survival. Together, our findings suggest that in CRC TIAM1 suppresses tumor progression by regulating YAP/TAZ activity.

Par3/Bazooka and phosphoinositides regulate actin protrusion formation during Drosophila dorsal closure and wound healing

Effective wound closure mechanisms are essential for maintenance of epithelial structure and function. The repair of wounded epithelia is primarily driven by the cells bordering the wound, which become motile after wounding, forming dynamic actin protrusions along the wound edge. The molecular mechanisms that trigger wound edge cells to become motile following tissue damage are not well understood. Using wound healing and dorsal closure in Drosophila, we identify a direct molecular link between changes in cell-cell adhesion at epithelial edges and induction of actin protrusion formation. We find that the scaffolding protein Par3/Bazooka and the lipid phosphatase Pten are specifically lost from cell-cell junctions at epithelial edges. This results in a localized accumulation of phosphatidylinositol 3,4,5-trisphosphate (PIP3), which promotes the formation of actin protrusions along the epithelial edge. Depleting PIP3 results in defective epithelial closure during both dorsal closure and wound healing. These data reveal a novel mechanism that directly couples loss of epithelial integrity to activation of epithelial closure.

Abstract C130: Plucked human scalp hairs: Potential utility as a surrogate tissue for the assessment of therapies targeting the androgen receptor

Objective: Evaluate whether plucked human scalp or eyebrow hairs obtained from male elderly healthy normal volunteers (HNVs) are suitable for assessing RNA expression patterns linked to the androgen receptor.

Procedure: For each of 12 HNV subjects plucked eyebrow and scalp hairs were obtained at 2 time points. For each time point up to three individual anagen hairs were selected for RNA extraction and representative cDNA amplification. For each sample RNA quality was assessed by agarose gel electrophoresis and cDNA quality assessed by qPCR analysis of 3 reference or “housekeeping” genes. Expression levels of a panel of 20 androgen receptor regulated genes were measured by qPCR for samples passing both RNA and cDNA quality criteria.

Results : Of the 72 scalp hairs analysed 64 (89 %) passed both RNA and cDNA quality criteria with 23 out of 24 (96%) sample collection points yielding 2 or more analysable hairs. This high success translated into available data for both time points in 11 out of 12 HNVs (92 %). In contrast, for the 72 eyebrow hairs analysed only 2 (3 %) passed RNA quality criteria with none of the collection points yielded 2 or more analysable hairs. Of the 20 test genes qPCR analysis identified a short list of 7 genes with expression levels similar to “housekeeping” genes indicating that they should be reliably detected in the majority of scalp hairs. These results are in keeping with a previous HNV study of younger male and female donors and indicate that plucked scalp hairs may be of value in the early phases of clinical development of androgen receptor based therapies.

Citation Information: Mol Cancer Ther 2009;8(12 Suppl):C130.

Ethnic differences in Type 2 diabetes care and outcomes in Auckland: a multiethnic community in New Zealand

INTRODUCTION

In New Zealand, Maori and Pacific (mostly of Samoan, Tongan, Niuean, or Cook Islands origin) people with Type 2 diabetes are more likely to suffer poor outcomes than other New Zealanders. Responsibility for addressing this outcome differential is falling on primary care and general practice in particular. This paper compares the general practice care provided to people with Type 2 diabetes in South and West Auckland, according to ethnicity.

METHOD

An external audit of general practice diabetes care is carried out in South and West Auckland by the Diabetes Care Support Service. The results of 5917 routine patient audits carried out in 2003 are included in this study. Number of visits, recording of important information, risk factors, and treatments are compared between different ethnic groups.

RESULTS

Maori and Pacific people with diabetes who attend a regular GP had a higher average number of consultations than Europeans (5.7, 5.4, and 4.8 visits per year respectively). They were as likely as Europeans to have undergone important regular examinations and investigations. Maori were more likely than Europeans to be on some treatments. However, Maori and Pacific people were more likely to have a range of adverse risk factors for diabetes complications than Europeans. These include being a smoker (35, 18, and 13% respectively), having an HbA1c greater than 8% (50, 56, 23%), and having microalbuminuria (55, 50, 27%).

DISCUSSION

Although there were no large differences in the process measures of general practice diabetes care provided to different ethnic groups in South and West Auckland, Maori and Pacific people were not achieving the same outcomes of care in terms of risk factors for diabetes complications. Many of these risk factors are influenced by other factors in the wider community; however the New Zealand health system needs to consider how it can better address these differences.

Intravenous leiomyomatosis with massive ascites

A case of intravenous leiomyomatosis with massive ascites is reported. This is the first such recorded case. The patient was treated with a subtotal abdominal hysterectomy and bilateral salpingo-oophorectomy. Pathological examination established a vessel wall origin. There is no evidence of recurrence up to 20 months after initial treatment.

Thyrotoxic hypokalaemic paralysis in a pregnant Afro-Caribbean woman. A case report and review of the literature

This paper reports the case of a 21-year-old Afro-Caribbean pregnant woman with hyperthyroidism and hypokalaemic quadriparesis and reviews the literature on the topic. Thyrotoxic periodic paralysis is a very rare condition in the Caribbean. This case reminds West Indian physicians to consider this rare condition in any patient that presents with paralysis.

Ancient chronology. Astronomical orientation of the pyramids

Spence speculates that Egypt's pyramid builders found true north by using a plumb line: when the stars Kochab and Mizar were seen on the same vertical, one was facing north. As evidence in support of this hypothesis, she points to the proposed interstar-line precession past the north celestial pole at a rate of 27' per century (cy). We argue that a mathematical error affects this result, which when corrected points more strongly to a different pair of stars. This suggests that the conventional ancient chronology, instead of being compressed, may actually have to be expanded slightly.

Family settings and children's adjustment: differential adjustment within and across families

BACKGROUND

Children in stepfamilies and single-parent families exhibit elevated levels of behavioural and emotional problems compared with children in intact (biological) families, but there is variation within and across these family types.

AIMS

To examine the sources of variation in children's behavioural and emotional problems across diverse family settings.

METHOD

Levels of behavioural and emotional problems in children from diverse stepfamilies and single-parent families were compared with children living with both biological parents. Psychosocial risks were measured at the individual child and family levels.

RESULTS

Behavioural and emotional problems were elevated in children in stepmother/complex stepfamilies and single-parent families, but not in simple stepfather families, relative to 'biological' families. Psychopathology associated with family type was explained by compromised quality of the parent-child relationship, parental depression and socio-economic adversity. Sibling similarity in behavioural and emotional problems was most pronounced in high-risk family settings.

CONCLUSIONS

Family type is a proxy for exposure to psychosocial risks; the extent of family-wide influence on children's development may be strongest in high-stress settings.

Siblings, parents, and partners: family relationships within a longitudinal community study. ALSPAC study team. Avon Longitudinal Study of Pregnancy and Childhood

Links between sibling relationships, mother-partner, and parent-child relationships were studied in a longitudinal community sample of 3681 sibling pairs. Individual differences in sibling relationship quality were related to mother-partner affection and hostility assessed 4 years earlier, to contemporary parent-child negativity, and to indices of social adversity. Evidence for both direct and indirect pathways (via parent-child relations) linking mother-partner and sibling relations were found. Comparisons of prediction for non-stepfamilies and stepfather families showed similarities in patterns of association, but also differences: In stepfather families, mother-partner hostility was unrelated to parent-child negativity and sibling relationship quality. Both positivity and negativity towards young siblings decreased with the age of older siblings, and older sisters were more positive than older brothers.

Genetic "clocks" and "soft" events: a twin model for pubertal development and other recalled sequences of developmental milestones, transitions, or ages at onset

We propose and explore a twin model to examine the basis for synchrony that often characterizes different facets of normal development. In so doing we also present an approach to the analysis of "soft" events; events for which available reports of dates or ages of occurrence are unreliable or inconsistent. Discrepancies among reports are accounted for by a statistical measurement model. This combines current status error reflecting uncertain definition of onset and two mechanisms for the phenomenon of "telescoping," namely, systematic compression of the time scale and heteroscedastic random measurement error. Statistically, the model can be viewed as a mixed generalized linear model with random effects within both mean and variance functions or, alternatively, as involving multiplicative random effects. We apply the model to multiple maternal reports on menarche and onset of breast development in twin daughters. Fitted to data from the Virginia Twin Study Of Adolescent and Behavioral Development by the use of penalized/predictive quasi-likelihood, the model provided much improved estimates of the true age-at-onset distribution as compared to those from a naive analysis. Results suggested that the observed variance was made up almost entirely of genetic variance and measurement error variance due to telescoping and current status errors and that the timing of breast development and menarche are largely under the control of a common set of genes. Results also indicated that maternal recollections of the onset of breast development were both more poorly defined and subject to greater recall errors than maternal recollections of menarche.

Family structure and depressive symptoms in men preceding and following the birth of a child. The Avon Longitudinal Study of Pregnancy and Childhood Study Team

OBJECTIVE

The prevalence and etiology of pre- and postpartum depressive symptoms in women in a variety of family forms have been well documented, but relatively little research has been conducted on the adjustment of their male partners. The authors' goals in this study were 1) to estimate rates of depression during the pregnancy and 8 weeks following the birth of a child in a large representative community sample of fathers in different family structures and 2) to explore the role of stressful life events, social and emotional support, the quality of the partner relationship, and socioeconomic circumstances.

METHOD

This study describes the relations of family setting and other correlates to men's depressive symptoms during the pregnancies (18 weeks gestation, on average) and 8 weeks after the births of children for 7,018 partners of female participants in the Avon Longitudinal Study of Pregnancy and Childhood.

RESULTS

Men living in stepfamilies had-significantly higher levels of depressive symptoms before and after the birth than did men in more traditional families. The effect of stepfamily status on depression was mediated by education, life events, social support, social network, and level of aggression in the partnership.

CONCLUSIONS

There are similarities in the patterns and correlates of depression after the birth of a child for men and women. These findings point to the importance of family and partnership ecology in the adjustment of men before and after the birth of a child.

Possibility of in vitro alterations in cultures of mammary carcinoma cells, and altered immunological response in the rat: acquired capacity to reject injections of mammary carcinoma cells and implants of mammary carcinoma

Cell cultures derived from a mammary adenocarcinoma carried in inbred Fisher (CDF) strain female rats, have been shown to possess oncogenic activities and on injection into control rats to produce mammary carcinomata with a failure rate of only one out of 25 rats (i.e. 4%). Efforts have been made to alter the cultured cells, or to select populations from them, so that the response in rats to their antigenic characteristics might leave them with the ability to then reject injections of the active, untreated cancer cells. We have found that continuous treatment of the cultures by their own cell debris (sonicate), or by relatively high concentrations of intact, salmon-sperm DNA, lead to cell populations which have a decreased potential to produce mammary carcinomata, with a combined failure rate of 9 out of 12 rats (i.e. 75%): 5 out of these 12 rats (i.e. 41·7%) did not exhibit any growth (carcinomata or granulomata) after injection of these treated cells, and now all 5 (i.e. 100%) have the capacity to reject injections of the untreated, active cancer cells. Four of these rats (one died under anaesthesia) have now been found to also reject implants of the carcinoma itself.