Adolescent Asthma Monitoring: A Preliminary Study of Audio and Spirometry Modalities

Asthma patients' sleep quality is correlated with how well their asthma symptoms are controlled. In this paper, deep learning techniques are explored to improve forecasting of forced expiratory volume in one second (FEV1) by using audio data from participants and test whether auditory sleep disturbances are correlated with poorer asthma outcomes. These are applied to a representative data set of FEV1 collected from a commercially available sprirometer and audio spectrograms collected overnight using a smartphone. A model for detecting nonverbal vocalizations including coughs, sneezes, sighs, snoring, throat clearing, sniffs, and breathing sounds was trained and used to capture nightly sleep disturbances. Our preliminary analysis found significant improvement in FEV1 forecasting when using overnight nonverbal vocalization detections as an additional feature for regression using XGBoost over using only spirometry data.Clinical relevance- This preliminary study establishes up to 30% improvement of FEV1 forecasting using features generated by deep learning techniques over only spirometry-based features.

International recruitment of radiographers and the development of a workplace integration support package: Project evaluation

INTRODUCTION

In October 2020, a regional workforce action group was established jointly by Health Education England (HEE) and NHS England and Improvement (NHSEI) in the South West to work collaboratively to address the workforce challenges within diagnostic imaging. Fifty-eight internationally recruited radiographers were offered employment in departments across the region, the majority of them taking up their posts in the UK in early 2021. The aim of the study presented here was to evaluate the efficacy of a training resource developed by Plymouth Marjon University, with input from HEE and NHSEI, to support workplace and cultural integration for the new recruits.

METHODS

The training package to help newly recruited radiographers from outside the UK integrate into their host departments was developed using flexible learning opportunities centred on reusable digital learning assets. Self-paced e-learning sessions were augmented by group 'connected' sessions online. Two surveys were undertaken, exploring the impact of this workforce integration programme for International radiographers joining the NHS.

RESULTS

Survey results indicate that the integration programme's three-phase strategy has seen an impact on 6 out of 12 self-efficacy measures, raised awareness of challenges, and increased personal awareness of implications for practice. By the end of the programme, delegates were in the top two quintiles for their average well-being score.

CONCLUSION

Principal recommendations include ensuring digital accessibility for new recruits as part of the on-boarding process, considering the timing of delivery of any online connected support sessions, the provision of long-term pastoral support; and mandating the training requirement for managers and team leaders.

IMPLICATIONS FOR PRACTICE

Success of international recruitment campaigns can be enhanced through the implementation of an online integration package.

POS0793 IMPROVED RELAPSE-FREE SURVIVAL WITH THE NORWICH PREDNISOLONE REGIMEN FOR GIANT CELL ARTERITIS

Background

Glucocorticoid therapy is the mainstay treatment for GCA. There is no consensus on the dose of prednisolone to be used. Prednisolone regimens used in clinical trials have reported relapse rates of 66 to 92%. The long-term follow-up of Tocilizumab and prednisolone for 1-year showed a relapse rate of 74% at 2 years. The Norwich Regimen is a bespoke prednisolone plan with an initial dose of 1mg/kg of lean body mass. It delivers 164.64 mg/kg of lean body mass in a logarithmic taper over 100 weeks. It was devised to reduce the risk of relapse and allow patients to be in control of their prednisolone reduction.

Objectives

To document drug-free survival at 150 weeks of people with GCA treated with a bespoke prednisolone taper

Methods

All patients were diagnosed by biopsy, ultrasonography or PET scan and provided with a printed prednisolone plan at diagnosis. All individuals were assessed at approximately 3-6 monthly intervals in addition to suspected relapse, toxicity or other need for course correction. Relapses were confirmed objectively using a modification of the Kerr criteria. Relapse free survival was recorded at 100 weeks. Patients were given an open invite to contact us in the event of a suspected relapse after coming off prednisolone. A notes review was done to record events at 150 weeks.

Results

150 consecutive people with objectively diagnosed GCA (mean age 74) since 10/01/2012 have completed 150 weeks since starting prednisolone. Drug-free, relapse-free survival at 100 weeks was met by 133/150 (89%). 7 individuals died and 20 relapsed. A further 5 died and 15 relapsed by week 150; 103/150 (69%) survivors were in prednisolone-free remission. Of the 12 deaths – 6 died of cancer, 1 subdural haemorrhage, 1 ischaemic bowel, 1 septicaemia, 1 general decline (aged 93). The cause of death was not available for 2 individuals who died in the community. The median time to relapse for the 35 individuals was 80 weeks (IQR 64,109).

Conclusion

We report the first results of a bespoke prednisolone taper to be used in real life. The Norwich Regimen for the treatment of GCA results in drug-free relapse-free survival of 89% at 100 weeks and 69% at 150 weeks, which is superior to all other reports published so far.

References

[1]Mukhtyar, C, Cate, H, Graham, C, Merry, P, Mills, K, and Misra, A, 2019, ‘Development of an evidence-based regimen of prednisolone to treat giant cell arteritis – the Norwich regimen’ Rheumatology Advances in Practice, Volume 3, Issue 1, 2019, rkz001, https://doi.org/10.1093/rap/rkz001

[2]Hellmich B, Agueda A, Monti S, et al2018 Update of the EULAR recommendations for the management of large vessel vasculitis Annals of the Rheumatic Diseases 2020;79:19-30.

Disclosure of Interests

None declared

Radiographer advanced and consultant practice and community diagnostic hubs - a vision for the future

OBJECTIVES

This article combines a brief narrative review of the Richards Report with an overview of current radiographer advanced and consultant clinical practice (ACCP) to provide suggestions for future ACCP within radiography.

KEY FINDINGS

The 'Diagnostics: Recovery and Renewal' report by Professor Sir Mike Richards, published in 2020, has identified a need for improvements to be made to diagnostic services. His recommendations include the introduction of Community Diagnostic Hubs (CDHs) that would provide quicker and easier access to diagnostic tests for patients⁽¹⁾ A narrative review around the concept of Advanced and Consultant Clinical Practice (ACCP) for radiographers demonstrates the capability of the radiographers to expand their role. The article concludes with a vision of how CDHs could potentially provide multiple career pathways for radiographers working at this level of practice.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

It is acknowledged that some of these concepts are a combination of visionary and aspirational in outlook rather than being entirely based on current practice. The intention of this article, and the implications for practice, are to support on-going discussions to enable radiography, as a profession, to seek ways and opportunities to do things differently whilst ensuring that the patient remains at the centre of the services delivered.

Reasons for intending to accept or decline kidney cancer screening: thematic analysis of free text from an online survey

OBJECTIVES

Kidney cancer has been identified as a disease for which screening might provide significant benefit for patients. The aim of this study was to understand in detail the facilitators and barriers towards uptake of a future kidney cancer screening programme, and to compare these across four proposed screening modalities.

DESIGN

An online survey including free-text responses.

SETTING

UK PARTICIPANTS: 668 adults PRIMARY AND SECONDARY OUTCOME MEASURES: The survey assessed participants' self-reported intention to take-up kidney cancer screening with four different test methods (urine test, blood test, ultrasound scan and low-dose CT). We conducted thematic analysis of 2559 free-text comments made within the survey using an inductive approach.

RESULTS

We identified five overarching themes that influenced screening intention: 'personal health beliefs', 'practicalities', 'opinions of the test', 'attitudes towards screening' and 'cancer apprehension'. Overall, participants considered the tests presented as simple to complete and the benefits of early detection to outweigh any drawbacks to screening. Dominant facilitators and barriers varied with patterns of intention to take up screening across the four tests. Most intended to take up screening by all four tests, and for these participants, screening was seen as a positive health behaviour. A significant minority were driven by practicalities and the risks of the tests offered. A smaller proportion intended to reject all forms of screening offered, often due to fear or worry about results and unnecessary medical intervention or a general negative view of screening.

CONCLUSIONS

Most individuals would accept kidney cancer screening by any of the four test options presented because of strong positive attitudes towards screening in general and the perceived simplicity of the tests. Providing information about the rationale for screening in general and the potential benefits of early detection will be important to optimise uptake among uncertain individuals.

Incorporating a brief intervention for personalised cancer risk assessment to promote behaviour change into primary care: a multi-methods pilot study

BACKGROUND

Approximately 40% of cancers could be prevented if people lived healthier lifestyles. We have developed a theory-based brief intervention to share personalised cancer risk information and promote behaviour change within primary care. This study aimed to assess the feasibility and acceptability of incorporating this intervention into primary care consultations.

METHOD

Patients eligible for an NHS Health Check or annual chronic disease review at five general practices were invited to participate in a non-randomised pilot study. In addition to the NHS Health Check or chronic disease review, those receiving the intervention were provided with their estimated risk of developing the most common preventable cancers alongside tailored behaviour change advice. Patients completed online questionnaires at baseline, immediately post-consultation and at 3-month follow-up. Consultations were audio/video recorded. Patients (n = 12) and healthcare professionals (HCPs) (n = 7) participated in post-intervention qualitative interviews that were analysed using thematic analysis.

RESULTS

62 patients took part. Thirty-four attended for an NHS Health Check plus the intervention; 7 for a standard NHS Health Check; 16 for a chronic disease review plus the intervention; and 5 for a standard chronic disease review. The mean time for delivery of the intervention was 9.6 min (SD 3) within NHS Health Checks and 9 min (SD 4) within chronic disease reviews. Fidelity of delivery of the intervention was high. Data from the questionnaires demonstrates potential improvements in health-related behaviours following the intervention. Patients receiving the intervention found the cancer risk information and lifestyle advice understandable, useful and motivating. HCPs felt that the intervention fitted well within NHS Health Checks and facilitated conversations around behaviour change. Integrating the intervention within chronic disease reviews was more challenging.

CONCLUSIONS

Incorporating a risk-based intervention to promote behaviour change for cancer prevention into primary care consultations is feasible and acceptable to both patients and HCPs. A randomised trial is now needed to assess the effect on health behaviours. When designing that trial, and other prevention activities within primary care, it is necessary to consider challenges around patient recruitment, the HCP contact time needed for delivery of interventions, and how best to integrate discussions about disease risk within routine care.

Fidelity of the delivery of NHS Health Checks in general practice: an observational study

BACKGROUND

The NHS Health Check programme aims to reduce the risk of common preventable diseases by providing risk information and behaviour change advice. Failure to deliver the consultation appropriately could undermine its efficacy. To date, to the authors' knowledge, there are no published data on the fidelity of delivery of NHS Health Checks.

AIM

To assess the fidelity of delivery of NHS Health Checks in general practice.

DESIGN & SETTING

Fidelity assessment of video and audio recordings of NHS Health Check consultations conducted in four GP practices across the East of England.

METHOD

A secondary analysis of 38 NHS Health Check consultations, which were video or audio recorded as part of a pilot study of introducing discussions of cancer risk into NHS Health Checks. Using a checklist based on the NHS Health Check Best Practice Guidance, fidelity of delivery was assessed as the proportion of key elements completed during the consultations.

RESULTS

The mean number of elements of the NHS Health Check completed across all consultations was 14.5/18 (80.6%), with a range of 10 to 17 (55.6% to 94.4%). The mean fidelity for risk assessment, risk communication, and risk management sections was 8.7/10 (87.0%), 4.1/5 (82.0%), and 1.7/3 (56.7%), respectively. Clinically appropriate lifestyle advice was given in 34/38 consultations. Elements with the lowest fidelity were ethnicity assessment (n = 12/38; 31.6%), family history of cardiovascular disease (CVD) assessment (n = 25/38; 65.8%), AUDIT-C communication (n = 13/38; 34.2%), and dementia risk management (n = 6/38; 15.8%).

CONCLUSION

Although fidelity of delivery was high overall, important elements of the NHS Health Check were being regularly omitted. Opportunities for behaviour change, particularly relating to alcohol consumption and dementia risk management, may be being missed.

A randomised controlled trial of the effect of providing online risk information and lifestyle advice for the most common preventable cancers

Few trial data are available concerning the impact of personalised cancer risk information on behaviour. This study assessed the short-term effects of providing personalised cancer risk information on cancer risk beliefs and self-reported behaviour. We randomised 1018 participants, recruited through the online platform Prolific, to either a control group receiving cancer-specific lifestyle advice or one of three intervention groups receiving their computed 10-year risk of developing one of the five most common preventable cancers either as a bar chart, a pictograph or a qualitative scale alongside the same lifestyle advice. The primary outcome was change from baseline in computed risk relative to an individual with a recommended lifestyle (RRI)1 at three months. Secondary outcomes included: health-related behaviours, risk perception, anxiety, worry, intention to change behaviour, and a newly defined concept, risk conviction. After three months there were no between-group differences in change in RRI (p = 0.71). At immediate follow-up, accuracy of absolute risk perception (p < 0.001), absolute and comparative risk conviction (p < 0.001) and intention to increase fruit and vegetables (p = 0.026) and decrease processed meat (p = 0.033) were higher in all intervention groups relative to the control group. The increases in accuracy and conviction were only seen in individuals with high numeracy and low baseline conviction, respectively. These findings suggest that personalised cancer risk information alongside lifestyle advice can increase short-term risk accuracy and conviction without increasing worry or anxiety but has little impact on health-related behaviour. Trial registration: ISRCTN17450583. Registered 30 January 2018.

A Phase 2a Randomized, Double-Blind, Dose-Optimizing Study to Evaluate the Immunogenicity and Safety of a Bivalent DNA Vaccine for Hemorrhagic Fever with Renal Syndrome Delivered by Intramuscular Electroporation

Hantaan virus (HTNV) and Puumala virus (PUUV) are pathogenic hantaviruses found in Asia and Europe, respectively. DNA vaccines targeting the envelope glycoproteins of these viruses have been constructed and found to elicit neutralizing antibodies when delivered to humans by various technologies including intramuscular electroporation. Here, we report findings from a Phase 2a clinical trial of a combined HTNV/PUUV DNA vaccine delivered at varying doses and administration schedules using the Ichor Medical Systems TriGrid intramuscular electroporation delivery technology. The study was designed to characterize the effects of DNA vaccine dose and number of administrations on the frequency and magnitude of immunological response. Subjects (n = 120) were divided into four cohorts. Cohorts 1 and 2 received a dose of 2 mg of DNA (1 mg per plasmid), and cohorts 3 and 4 received a dose of 1 mg of DNA (0.5 mg per plasmid) each vaccination. Each of the four cohorts received a series of four administrations (days 0, 28, 56 and 168). For cohorts 1 and 3, the DNA vaccine candidate was delivered at each of the four administrations. For cohorts 2 and 4, in order to maintain blinding, subjects received the DNA vaccine on days 0, 56 and 168, but on day 28 received only the phosphate buffered saline vehicle rather the DNA vaccine. Sera were collected on days 0, 28, 56, 84, 140, 168, 196, 252 and 365 and evaluated for the presence of neutralizing antibodies by PUUV and HTNV pseudovirion neutralization assays (PsVNAs). Day 84 was also evaluated by a plaque reduction neutralization test (PRNT). Overall the PsVNA50 geometric mean titers (GMTs) and seropositivity rates among cohorts were similar. Cohort 3 exhibited the highest frequency of subjects that became seropositive to both PUUV and HTNV after vaccination, the highest peak GMT against both viruses, and the highest median titers against both viruses.

Risk factors for pediatric cerebral sinovenous thrombosis: A case-control study with case validation

INTRODUCTION

Cerebral sinovenous thrombosis (CSVT) represents the second most common type of venous thromboembolism (VTE) in children. Current literature includes limited evidence on risk factors for CSVT, particularly in the pediatric population. We sought to determine risk factors for CSVT in pediatric patients through a single-institutional case-control study. In addition, we evaluated thrombophilias, treatments and outcomes in CSVT among cases.

METHODS

A case-control study was performed at Johns Hopkins All Children's Hospital on patients admitted from March 31, 2006 through April 1, 2018. Cases were identified using diagnostic codes and confirmed based on electronic health record (EHR) and neuroimaging review. Controls were matched in a 2:1 fashion accounting for the month and year of admission.

RESULTS

A total of 60 CSVT cases and 120 controls were identified. Median (range) age was 4.8 years (0-21.3 years) for cases and 5.6 years (0-20.0 years) for controls. Factors putatively associated with CSVT in unadjusted analyses were: corticosteroid use, presence of a central venous catheter, mechanical ventilation, systemic infection, head/neck infection, head/neck trauma, and chronic inflammatory disease. In the multivariable model, head/neck infection (OR: 13.8, 95% CI: 4.87-38.7; P < 0.01), head/neck trauma (OR: 12.7, 95% CI: 2.88-56.2; P < 0.01), and mechanical ventilation (OR: 9.32, 95% CI: 2.35-36.9; P = 0.01) remained independent, statistically-significant risk factors. 61% of patients were subacutely treated with anticoagulants and of those, only two developed relevant bleeding after initiation of therapy.

CONCLUSIONS

This single-institutional case-control study reveals that head/neck infection, head/neck trauma, and mechanical ventilation are independent risk factors for pediatric CSVT. These findings will be further investigated via a cooperative registry of pediatric hospital-acquired VTE, by which a risk model for pediatric CSVT will be developed and validated, in order to inform future preventive strategies in at-risk pediatric patients.

Is the Patient Activation Measure a valid measure of osteoarthritis self-management attitudes and capabilities? Results of a Rasch analysis

BACKGROUND

The Patient Activation Measure (PAM-13) was developed using Rasch analysis to assess knowledge, skills and confidence in the management of one's health. Previous studies report positive relationships between PAM-13 scores, self-management behaviours and longitudinal health outcomes in adults with chronic disease. There is little extant measurement property evidence for the use of PAM-13 in specific osteoarthritis (OA) populations. This study tested measurement properties of the PAM-13 in people living with hip and knee OA.

METHODS

Item response frequency analysis was conducted. Rasch analysis evaluated the fit of the PAM-13 data to the Rasch model. Model-data fit was evaluated using infit and outfit statistics; person/item reliability and person separation indices were computed. Unidimensionality was evaluated using Principal Components Analysis of Rasch residuals and the data were assessed for item redundancy. Differential Item Functioning (DIF) examined bias in respondent subgroups and correlations tested relationships between PAM-13 and other patient-reported outcomes.

RESULTS

Two-hundred-and-seventeen PAM-13 surveys were completed; there were no missing responses, floor or ceiling effects. Person and item reliability were acceptable (0.98 and 0.87 respectively) with good separation (person separation index 2.58). Unidimensionality was evaluated, with 49.4% of the variance explained by the first eigenvector. There was evidence of potential local response-dependence. The Rasch fit statistics were acceptable (except for item-2). There were some issues identified with targeting of the PAM-13 items to people with higher ability and the item difficulty order was different to that proposed in original cohorts. Significant DIF was identified for sex and educational level for a small number of items. PAM-13 scores were moderately correlated with depressive symptoms on the Depression Anxiety Stress Scale and Assessment of Quality of Life-6D. There were small correlations between PAM-13 and Knee injury and Osteoarthritis Outcome Score pain and activities of daily living scores.

CONCLUSIONS

This study provides some evidence of adequate person and item reliability, unidimensionality, and construct validity to support the use of PAM-13 to measure patient activation in people living with hip and knee OA. Possible limitations regarding targeting, different item difficulty order, DIF and local response dependence should be investigated in future research.

The evolving role of surface electromyography in amyotrophic lateral sclerosis: A systematic review

OBJECTIVE

Amyotrophic lateral sclerosis (ALS) is an adult-onset neurodegenerative disease that leads to inexorable motor decline and a median survival of three years from symptom onset. Surface EMG represents a major technological advance that has been harnessed in the development of novel neurophysiological biomarkers. We have systematically reviewed the current application of surface EMG techniques in ALS.

METHODS

We searched PubMed to identify 42 studies focusing on surface EMG and its associated analytical methods in the diagnosis, prognosis and monitoring of ALS patients.

RESULTS

A wide variety of analytical techniques were identified, involving motor unit decomposition from high-density grids, motor unit number estimation and measurements of neuronal hyperexcitability or neuromuscular architecture. Some studies have proposed specific diagnostic and prognostic criteria however clinical calibration in large ALS cohorts is currently lacking. The most validated method to monitor disease is the motor unit number index (MUNIX), which has been implemented as an outcome measure in two ALS clinical trials.

CONCLUSION

Surface EMG offers significant practical and analytical flexibility compared to invasive techniques. To capitalise on this fully, emphasis must be placed upon the multi-disciplinary collaboration of clinicians, bioengineers, mathematicians and biostatisticians.

SIGNIFICANCE

Surface EMG techniques can enrich effective biomarker development in ALS.

Effect of a Skin Self-monitoring Smartphone Application on Time to Physician Consultation Among Patients With Possible Melanoma: A Phase 2 Randomized Clinical Trial

IMPORTANCE

Melanoma is among the most lethal skin cancers; it has become the fifth most common cancer in the United Kingdom, and incidence rates are rising. Population approaches to reducing incidence have focused on mass media campaigns to promote earlier presentation and potentially improve melanoma outcomes; however, interventions using smartphone applications targeting those with the greatest risk could promote earlier presentation to health care professionals for individuals with new or changing skin lesions.

OBJECTIVE

To study the effect of a commercially available skin self-monitoring (SSM) smartphone application among individuals with increased risk of melanoma on their decision to seek help for changing skin lesions.

DESIGN, SETTING, AND PARTICIPANTS

This phase 2 randomized clinical trial was conducted in 12 family practices in Eastern England between 2016 and 2017. A total of 238 participants, aged 18 to 75 years and with an increased risk of melanoma, were identified using a real-time melanoma risk assessment tool in family practice waiting rooms. Analysis was intention to treat. Participants were observed for 12 months, and data analysis was conducted from January to August 2018.

INTERVENTION

The intervention and control groups received a consultation with standard written advice on sun protection and skin cancer detection. The intervention group had an SSM application loaded on their smartphone and received instructions for use and monthly self-monitoring reminders.

MAIN OUTCOMES AND MEASURES

The coprimary outcomes were skin consultation rates with family practice physicians and patient intervals, measured as the time between noticing a skin change and consulting with a family practice clinician. Follow-up questionnaires were sent at 6 and 12 months, and consultation rates were extracted from family practice records. Secondary outcomes included skin self-examination benefits and barriers, self-efficacy for consulting without delay, perceived melanoma risk, sun protection habits, and potential harms.

RESULTS

A total of 238 patients were randomized (median [interquartile range] age, 55 [43-65] years, 131 [55.0%] women, 227 [95.4%] white British; 119 [50.0%] randomized to the intervention group). Overall, 51 participants (21.4%) had consultations regarding skin changes during the 12 months of follow-up, and 157 participants (66.0%) responded to at least 1 follow-up questionnaire. There were no significant differences in skin consultation rates (adjusted risk ratio, 0.96; 95% CI, 0.56 to 1.66; P = .89), measures of SSM (adjusted mean difference, 0.08; 95% CI, -0.83 to 1.00; P = .86), or psychological harm (eg, Melanoma Worry Scale: adjusted mean difference, -0.12; 95% CI, -0.56 to 0.31; P = .58).

CONCLUSIONS AND RELEVANCE

In this study, recruitment, retention, and initial delivery of the intervention were feasible, and this research provided no evidence of harm from the SSM smartphone application. However, no evidence of benefit on skin self-examination or health care consulting was found, and there is no reason at this stage to recommend its implementation in this population at increased risk of melanoma.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN16061621.

Development and usability testing of a very brief intervention for personalised cancer risk assessment to promote behaviour change in primary care using normalisation process theory

BACKGROUND

Cancer is the second leading cause of death worldwide. Lifestyle choices play an important role in the aetiology of cancer with up to 4 in 10 cases potentially preventable. Interventions delivered by healthcare professionals (HCPs) that incorporate risk information have the potential to promote behaviour change. Our aim was to develop a very brief intervention incorporating cancer risk, which could be implemented within primary care.

METHODS

Guided by normalisation process theory (NPT), we developed a prototype intervention using literature reviews, consultation with patient and public representatives and pilot work with patients and HCPs. We conducted focus groups and interviews with 65 HCPs involved in delivering prevention activities. Findings were used to refine the intervention before 22 HCPs completed an online usability test and provided further feedback via a questionnaire incorporating a modified version of the NoMAD checklist.

RESULTS

The intervention included a website where individuals could provide information on lifestyle risk factors view their estimated 10-year risk of developing one or more of the five most common preventable cancers and access lifestyle advice incorporating behaviour change techniques. Changes incorporated from feedback from the focus groups and interviews included signposting to local services and websites, simplified wording and labelling of risk information. In the usability testing, all participants felt it would be easy to collect the risk information. Ninety-one percent felt the intervention would enable discussion about cancer risk and believed it had potential to be easily integrated into National Health Service (NHS) Health Checks. However, only 36% agreed it could be delivered within 5 min.

CONCLUSIONS

With the use of NPT, we developed a very brief intervention that is acceptable to HCPs in primary care and could be potentially integrated into NHS Health Checks. However, further work is needed to assess its feasibility and potential effectiveness.

Preprocessing surface EMG data removes voluntary muscle activity and enhances SPiQE fasciculation analysis

•

A novel preprocessing step removes the need for manual selection of relaxed surface EMG data.

•

SPiQE provides reliable fasciculation analysis from raw thirty-minute recordings in ALS.

•

This paves the way for clinical calibration of a potential novel biomarker of disease progression.

Objectives

Fasciculations are a clinical hallmark of amyotrophic lateral sclerosis (ALS). The Surface Potential Quantification Engine (SPiQE) is a novel analytical tool to identify fasciculation potentials from high-density surface electromyography (HDSEMG). This method was accurate on relaxed recordings amidst fluctuating noise levels. To avoid time-consuming manual exclusion of voluntary muscle activity, we developed a method capable of rapidly excluding voluntary potentials and integrating with the established SPiQE pipeline.

Methods

Six ALS patients, one patient with benign fasciculation syndrome and one patient with multifocal motor neuropathy underwent monthly thirty-minute HDSEMG from biceps and gastrocnemius. In MATLAB, we developed and compared the performance of four Active Voluntary IDentification (AVID) strategies, producing a decision aid for optimal selection.

Results

Assessment of 601 one-minute recordings permitted the development of sensitive, specific and screening strategies to exclude voluntary potentials. Exclusion times (0.2–13.1 minutes), processing times (10.7–49.5 seconds) and fasciculation frequencies (27.4–71.1 per minute) for 165 thirty-minute recordings were compared. The overall median fasciculation frequency was 40.5 per minute (10.6–79.4 IQR).

Conclusion

We hereby introduce AVID as a flexible, targeted approach to exclude voluntary muscle activity from HDSEMG recordings.

Significance

Longitudinal quantification of fasciculations in ALS could provide unique insight into motor neuron health.

Current concepts in joint pain in knee osteoarthritis

Joint pain attributable to osteoarthritis (OA) is complex and influenced by a myriad of factors beyond local joint pathology. Current practice continues to predominantly adopt a biomedical approach to OA despite emerging evidence of the importance of a more holistic approach. This paper will summarise evidence for the presence of multidimensional pain profiles in knee joint pain and the presence of subgroups characterized by systemic features such as psychological distress, high comorbidity load or sensitisation of the nervous system. These factors have the potential to influence patient outcomes making them relevant for clinicians and highlighting the necessity of a broader multifactorial approach to assessment and treatment. This review describes the current state of the evidence for treatments of people with knee OA-related pain, including those receiving strong recommendations from current clinical guidelines, namely exercise, weight loss, self-management advice and pharmacological approaches. Other pain-modulating treatment options are emerging such as sleep and psychological interventions, pain education and multisensory retraining. The evidence and rationale for these newer therapeutic approaches is discussed. Finally, this review will highlight some of the limitations of current international guidelines for the management of OA and make recommendations for future research.

2019 Chitranjan S. Ranawat Award: Elective joint arthroplasty outcomes improve in malnourished patients with nutritional intervention: a prospective population analysis demonstrates a modifiable risk factor

AIMS

To date, no study has demonstrated an improvement in postoperative outcomes following elective joint arthroplasty with a focus on nutritional intervention for patients with preoperative hypoalbuminaemia. In this prospective study, we evaluated differences in the hospital length of stay (LOS), rate of re-admission, and total patient charges for a malnourished patient study population who received a specific nutrition protocol before surgery.

PATIENTS AND METHODS

An analytical report was extracted from the electronic medical record (EMR; Epic, Verona, Wisconsin) of a five-hospital network joint arthroplasty patient data set between 2014 and 2017. A total of 4733 patients underwent joint arthroplasty and had preoperative measurement of albumin levels: 2220 at four hospitals and 2513 at the study hospital. Albumin ≤ 3.4 g/l, designated as malnutrition, was found in 543 patients (11.5%). A nutritional intervention programme focusing on a high-protein, anti-inflammatory diet was initiated in January 2017 at one study hospital. Hospital LOS, re-admission rate, and 90-day charges were compared for differential change between patients in study and control hospitals for all elective hip and knee arthroplasty patients, and for malnourished patients over time as the nutrition intervention was implemented.

RESULTS

Malnourished patients with nutritional intervention at the study hospital had shorter hospital LOS beginning in 2017 than malnourished patients at control hospitals during the same period (p = 0.04). Similarly, this cohort had significantly lower primary hospitalization charges, charges associated with hospital re-admissions, and 90-day total charges (p < 0.001). Inclusion of covariant potential confounders (age, anaemia, diabetes, and obesity) did not alter the conclusions of the primary statistical analysis.

CONCLUSION

Joint arthroplasty outcomes were positively affected in study patients with low albumin when a high-protein, anti-inflammatory diet was encouraged. Elective surgery was neither cancelled nor delayed with a malnutrition designation. While the entire network population experienced improved postoperative outcomes, malnourished control patients did not experience this improvement. This study demonstrated that education on malnutrition can benefit patients. Cite this article: Bone Joint J 2019;101-B(7 Supple C):17-21.

SPiQE: An automated analytical tool for detecting and characterising fasciculations in amyotrophic lateral sclerosis

OBJECTIVES

Fasciculations are a clinical hallmark of amyotrophic lateral sclerosis (ALS). Compared to concentric needle EMG, high-density surface EMG (HDSEMG) is non-invasive and records fasciculation potentials (FPs) from greater muscle volumes over longer durations. To detect and characterise FPs from vast data sets generated by serial HDSEMG, we developed an automated analytical tool.

METHODS

Six ALS patients and two control patients (one with benign fasciculation syndrome and one with multifocal motor neuropathy) underwent 30-minute HDSEMG from biceps and gastrocnemius monthly. In MATLAB we developed a novel, innovative method to identify FPs amidst fluctuating noise levels. One hundred repeats of 5-fold cross validation estimated the model's predictive ability.

RESULTS

By applying this method, we identified 5,318 FPs from 80 minutes of recordings with a sensitivity of 83.6% (+/- 0.2 SEM), specificity of 91.6% (+/- 0.1 SEM) and classification accuracy of 87.9% (+/- 0.1 SEM). An amplitude exclusion threshold (100 μV) removed excessively noisy data without compromising sensitivity. The resulting automated FP counts were not significantly different to the manual counts (p = 0.394).

CONCLUSION

We have devised and internally validated an automated method to accurately identify FPs from HDSEMG, a technique we have named Surface Potential Quantification Engine (SPiQE).

SIGNIFICANCE

Longitudinal quantification of fasciculations in ALS could provide unique insight into motor neuron health.

Rural competencies in emerging medical practitioners: Beyond clinical skills

PROBLEM

Recruitment and retention of rural doctors remains a challenge in Australia. The Queensland Rural Generalist Program was developed to address this challenge and provides a range of tailored professional development opportunities to support rural medical training, recruitment and retention. The Rural Generalist Vocational Preparation Workshop was developed to maintain connection with trainees during a known attrition risk period and address a gap in training that focused on competencies required for rural practice.

DESIGN

The Rural Generalist Vocational Preparation Workshop, designed using adult learning principles, includes an optimal balance between theory, scenario-based learning and facilitated group discussions. A cross-sectional survey design was employed to evaluate the workshops delivered between 2015 and 2017.

SETTING

The workshops were attended by Queensland Rural Generalist Program trainees in the year prior to undertaking a vocational training position in a rural hospital or general practice. Participants were from 10 Hospital and Health Services in the Queensland public health sector at the time of attendance.

KEY MEASURES FOR IMPROVEMENT

An evaluation survey captured participant feedback about the workshop, its value, impact and their intention to implement changes in practice.

STRATEGIES FOR CHANGE

Fifty-one trainees attended the workshops across four locations.

EFFECTS OF CHANGE

Eight-eight per cent of participants reported intentions to implement changes to practice in: pursuit of career options and enhanced team work, leadership skills and networking.

LESSONS LEARNT

Evaluation results indicated that Rural Generalist Vocational Preparation Workshop was a highly valued opportunity. It provided future rural medical practitioners with professional support and networking opportunities, promoted identity formation and stimulated rural career planning.

Cost-effectiveness of Humanitarian Pediatric Cardiac Surgery Programs in Low- and Middle-Income Countries

IMPORTANCE

Endorsement of global humanitarian interventions is based on either proven cost-effectiveness or perceived public health benefits. The cost-effectiveness and long-term benefits of global humanitarian pediatric cardiac surgery are unknown, and funding for this intervention is insufficient.

OBJECTIVES

To determine the cost-effectiveness of the intervention (multiple 2-week-long humanitarian pediatric cardiac surgery program assistance trips to various low- and middle-income countries [LMICs]) and to produce a measure of the long-lasting effects of global humanitarian programs.

DESIGN, SETTING, AND PARTICIPANTS

International, multicenter cost-effectiveness analysis of a cohort of children (aged <16 years) undergoing surgical treatment of congenital heart disease during 2015 in LMICs, including China, Macedonia, Honduras, Iran, Iraq, Libya, Nigeria, Pakistan, Russia, and Ukraine. The study also assessed estimated improvement in the United Nations Human Development Indicators (life expectancy, years of schooling, and gross national income) for each individual survivor, as a proxy for long-term benefits of the intervention.

MAIN OUTCOMES AND MEASURES

The primary outcome was cost-effectiveness of the intervention. The secondary outcomes were potential gains in life expectancy, years of schooling, and gross national income per capita for each survivor.

RESULTS

During 2015, 446 patients (192 [43%] female; mean [SD] age, 3.7 [5.4] years) were served in 10 LMICs at an overall cost of $3 210 873. Of them, 424 were children. The cost-effectiveness of the intervention was $171 per disability-adjusted life-year averted. Each survivor in the cohort (390 of 424) potentially gained 39.9 disability-adjusted life-years averted, 3.5 years of schooling, and $159 533 in gross national income per capita during his or her extended lifetime at purchasing power parity and 3% discounting.

CONCLUSIONS AND RELEVANCE

Humanitarian pediatric cardiac surgery in LMICs is highly cost-effective. It also leaves behind a lasting humanitarian footprint by potentially improving individual development indices.

A randomised controlled trial of the effect of providing online risk information and lifestyle advice for the most common preventable cancers: study protocol

BACKGROUND

Cancer is a leading cause of mortality and morbidity worldwide. Prevention is recognised by many, including the World Health Organization, to offer the most cost-effective long-term strategy for the control of cancer. One approach that focuses on individuals is the provision of personalised risk information. However, whether such information motivates behaviour change and whether the effect is different with varying formats of risk presentation is unclear. We aim to assess the short-term effect of providing information about personalised risk of cancer in three different formats alongside lifestyle advice on health-related behaviours, risk perception and risk conviction.

METHODS

In a parallel group, randomised controlled trial 1000 participants will be recruited through the online platform Prolific. Participants will be allocated to either a control group receiving cancer-specific lifestyle advice alone or one of three intervention groups receiving the same lifestyle advice alongside their estimated 10-year risk of developing one of the five most common preventable cancers, calculated from self-reported modifiable behavioural risk factors, in one of three different formats (bar chart, pictograph or qualitative scale). The primary outcome is change from baseline in computed risk relative to an individual with a recommended lifestyle at three months. Secondary outcomes include: perceived risk of cancer; anxiety; cancer-related worry; intention to change behaviour; and awareness of cancer risk factors.

DISCUSSION

This study will provide evidence on the short-term effect of providing online information about personalised risk of cancer alongside lifestyle advice on risk perception and health-related behaviours and inform the development of interventions.

TRIAL REGISTRATION

ISRCTN17450583. Registered 30 January 2018.

Movement patterns of California brown pelicans (Pelecanus occidentalis californicus) following oiling and rehabilitation

Direct mortality of wildlife is generally used to quantify the damage caused by pollution events. However, free-ranging wildlife that survive initial exposure to pollutants may also experience long-term consequences. Individuals that are rehabilitated following oil exposure have a known history of oiling and provide a useful study population for understanding behavior following pollution events. We GPS-tracked 12 rehabilitated brown pelicans and compared their movements to those of eight non-oiled, non-rehabilitated controls over 87-707 (mean = 271) days. Rehabilitated pelicans traveled farther, spent more time in long-distance movements, and occupied more productive waters than controls. These differences were more apparent among females than males. Rehabilitated pelicans also visited breeding colonies and nest sites at lower rates than controls. Our results indicate that, although rehabilitated pelicans undertake long-distance movements, they may display increased dispersion and reduced breeding investment, particularly among females. Such behavioral changes could have long-term effects on populations.

Effect of interventions incorporating personalised cancer risk information on intentions and behaviour: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To provide a comprehensive review of the impact on intention to change health-related behaviours and health-related behaviours themselves, including screening uptake, of interventions incorporating information about cancer risk targeted at the general adult population.

DESIGN

A systematic review and random-effects meta-analysis.

DATA SOURCES

An electronic search of MEDLINE, EMBASE, CINAHL and PsycINFO from 1 January 2000 to 1 July 2017.

INCLUSION CRITERIA

Randomised controlled trials of interventions including provision of a personal estimate of future cancer risk based on two or more non-genetic variables to adults recruited from the general population that include at least one behavioural outcome.

RESULTS

We included 19 studies reporting 12 outcomes. There was significant heterogeneity in interventions and outcomes between studies. There is evidence that interventions incorporating personalised cancer risk information do not affect intention to attend or attendance at screening (relative risk 1.00 (0.97-1.03)). There is limited evidence that they increase smoking abstinence, sun protection, adult skin self-examination and breast examination, and decrease intention to tan. However, they do not increase smoking cessation, parental child skin examination or intention to protect skin. No studies assessed changes in diet, alcohol consumption or physical activity.

CONCLUSIONS

Interventions incorporating personalised cancer risk information do not affect uptake of screening, but there is limited evidence of effect on some health-related behaviours. Further research, ideally including objective measures of behaviour, is needed before cancer risk information is incorporated into routine practice for health promotion in the general population.

Protocol for the melatools skin self-monitoring trial: a phase II randomised controlled trial of an intervention for primary care patients at higher risk of melanoma

INTRODUCTION

Melanoma is the fifth most common cancer in the UK. Incidence rates have quadrupled over the last 30 years and continue to rise, especially among younger people. As routine screening of the general population is not currently recommended in the UK, a focus on secondary prevention through early detection and prompt treatment in individuals at increased risk of melanoma could make an important contribution to improve melanoma outcomes. This paper describes the protocol for a phase II, multisite, randomised controlled trial, in the primary care setting, for patients at increased risk of melanoma. A skin self-monitoring (SSM) smartphone 'App' was used to improve symptom appraisal and encourage help seeking in primary care, thereby promoting early presentation with skin changes suspicious of melanoma.

METHODS AND ANALYSIS

We aim to recruit 200 participants from general practice waiting rooms in the East of England. Eligible patients are those identified at higher melanoma risk (using a real-time risk assessment tool), without a personal history of melanoma, aged 18 to 75 years. Participants will be invited to a primary care nurse consultation, and randomised to the intervention group (standard written advice on skin cancer detection and sun protection, loading of an SSM 'App' onto the participant's smartphone and instructions on use including self-monitoring reminders) or control group (standard written advice alone). The primary outcomes are consultation rates for changes to a pigmented skin lesion, and the patient interval (time from first noticing a skin change to consultation). Secondary outcomes include patient sun protection behaviours, psychosocial outcomes, and measures of trial feasibility and acceptability.

ETHICS AND DISSEMINATION

NHS ethical approval has been obtained from Cambridgeshire and Hertfordshire research ethics committee (REC reference 16/EE/0248). The findings from the MelaTools SSM Trial will be disseminated widely through peer-reviewed publications and scientific conferences.

TRIAL REGISTRATION NUMBER

ISCTRN16061621.

Views of commissioners, managers and healthcare professionals on the NHS Health Check programme: a systematic review

OBJECTIVE

To synthesise data concerning the views of commissioners, managers and healthcare professionals towards the National Health Service (NHS) Health Check programme in general and the challenges faced when implementing it in practice.

DESIGN

A systematic review of surveys and interview studies with a descriptive analysis of quantitative data and thematic synthesis of qualitative data.

DATA SOURCES

An electronic literature search of MEDLINE, Embase, Health Management Information Consortium, Cumulative Index of Nursing and Allied Health Literature, Global Health, PsycInfo, Web of Science, OpenGrey, the Cochrane Library, NHS Evidence, Google Scholar, Google, ClinicalTrials.gov and the International Standard Randomised Controlled Trial Number registry from 1 January 1996 to 9 November 2016 with no language restriction and manual screening of reference lists of all included papers.

INCLUSION CRITERIA

Primary research reporting views of commissioners, managers or healthcare professionals on the NHS Health Check programme and its implementation in practice.

RESULTS

Of 18 524 citations, 15 articles met the inclusion criteria. There was evidence from both quantitative and qualitative studies that some commissioners and general practice (GP) healthcare professionals were enthusiastic about the programme, whereas others raised concerns around inequality of uptake, the evidence base and cost-effectiveness. In contrast, those working in pharmacies were all positive about programme benefits, citing opportunities for their business and staff. The main challenges to implementation were: difficulties with information technology and computer software, resistance to the programme from some GPs, the impact on workload and staffing, funding and training needs. Inadequate privacy was also a challenge in pharmacy and community settings, along with difficulty recruiting people eligible for Health Checks and poor public access to some venues.

CONCLUSIONS

The success of the NHS Health Check Programme relies on engagement by those responsible for its commissioning, management and delivery. Recognising and addressing the challenges identified in this review, in particular the concerns of GPs, are important for the future of the programme.

Understanding symptom appraisal and help-seeking in people with symptoms suggestive of pancreatic cancer: a qualitative study

OBJECTIVE

Pancreatic cancer has poor survival rates due to non-specific symptoms leading to later diagnosis. Understanding how patients interpret their symptoms could inform approaches to earlier diagnosis. This study sought to explore symptom appraisal and help-seeking among patients referred to secondary care for symptoms suggestive of pancreatic cancer.

DESIGN

Qualitative analysis of semistructured in-depth interviews. Data were analysed iteratively and thematically, informed by the Model of Pathways to Treatment.

PARTICIPANTS AND SETTING

Pancreatic cancer occurs rarely in younger adults, therefore patients aged ≥40 years were recruited from nine hospitals after being referred to hospital with symptoms suggestive of pancreatic cancer; all were participants in a cohort study. Interviews were conducted soon after referral, and where possible, before diagnosis.

RESULTS

Twenty-six interviews were conducted (cancer n=13 (pancreas n=9, other intra-abdominal n=4), non-cancer conditions n=13; age range 48-84 years; 14 women). Time from first symptoms to first presentation to healthcare ranged from 1 day to 270 days, median 21 days. We identified three main themes. Initial symptom appraisal usually began with intermittent, non-specific symptoms such as tiredness or appetite changes, attributed to diet and lifestyle, existing gastrointestinal conditions or side effects of medication. Responses to initial symptom appraisal included changes in meal type or frequency, or self-medication. Symptom changes such as alterations in appetite and enjoyment of food or weight loss usually prompted further appraisal. Triggers to seek help included a change or worsening of symptoms, particularly pain, which was often a 'tipping point'. Help-seeking was often encouraged by others. We found no differences in symptom appraisal and help-seeking between people diagnosed with cancer and those with other conditions.

CONCLUSIONS

Greater public and healthcare professional awareness of the combinations of subtle and intermittent symptoms, and their evolving nature, is needed to prompt timelier help-seeking and investigation among people with symptoms of pancreatic cancer.

Instruments assessing attitudes toward or capability regarding self-management of osteoarthritis: a systematic review of measurement properties

OBJECTIVE

To make a recommendation on the "best" instrument to assess attitudes toward and/or capabilities regarding self-management of osteoarthritis (OA) based on available measurement property evidence.

METHODS

Electronic searches were performed in MEDLINE, EMBASE, CINAHL and PsychINFO (inception to 27 December 2016). Two reviewers independently rated measurement properties using the Consensus-based Standards for the selection of Health Measurement Instruments (COSMIN) 4-point scale. Best evidence synthesis was determined by considering COSMIN ratings for measurement property results and the level of evidence available for each measurement property of each instrument.

RESULTS

Eight studies out of 5653 publications met the inclusion criteria, with eight instruments identified for evaluation: Multidimensional Health Locus of Control (MHLC), Perceived Behavioural Control (PBC), Patient Activation Measure (PAM), Educational Needs Assessment (ENAT), Stages of Change Questionnaire in Osteoarthritis (SCQOA), Effective Consumer Scale (EC-17) and Perceived Efficacy in Patient-Physician Interactions five item (PEPPI-5) and ten item scales. Measurement properties assessed for these instruments included internal consistency (k = 8), structural validity (k = 8), test-retest reliability (k = 2), measurement error (k = 1), hypothesis testing (k = 3) and cross-cultural validity (k = 3). No information was available for content validity, responsiveness or minimal important change (MIC)/minimal important difference (MID). The Dutch PEPPI-5 demonstrated the best measurement property evidence; strong evidence for internal consistency and structural validity but limited evidence for reliability and construct validity.

CONCLUSION

Although PEPPI-5 was identified as having the best measurement properties, overall there is a poor level of evidence currently available concerning measurement properties of instruments to assess attitudes toward and/or capabilities regarding osteoarthritis self-management. Further well-designed studies investigating measurement properties of existing instruments are required.

Sensory neuron regulation of gastrointestinal inflammation and bacterial host defence

Sensory neurons in the gastrointestinal tract have multifaceted roles in maintaining homeostasis, detecting danger and initiating protective responses. The gastrointestinal tract is innervated by three types of sensory neurons: dorsal root ganglia, nodose/jugular ganglia and intrinsic primary afferent neurons. Here, we examine how these distinct sensory neurons and their signal transducers participate in regulating gastrointestinal inflammation and host defence. Sensory neurons are equipped with molecular sensors that enable neuronal detection of diverse environmental signals including thermal and mechanical stimuli, inflammatory mediators and tissue damage. Emerging evidence shows that sensory neurons participate in host-microbe interactions. Sensory neurons are able to detect pathogenic and commensal bacteria through specific metabolites, cell-wall components, and toxins. Here, we review recent work on the mechanisms of bacterial detection by distinct subtypes of gut-innervating sensory neurons. Upon activation, sensory neurons communicate to the immune system to modulate tissue inflammation through antidromic signalling and efferent neural circuits. We discuss how this neuro-immune regulation is orchestrated through transient receptor potential ion channels and sensory neuropeptides including substance P, calcitonin gene-related peptide, vasoactive intestinal peptide and pituitary adenylate cyclase-activating polypeptide. Recent studies also highlight a role for sensory neurons in regulating host defence against enteric bacterial pathogens including Salmonella typhimurium, Citrobacter rodentium and enterotoxigenic Escherichia coli. Understanding how sensory neurons respond to gastrointestinal flora and communicate with immune cells to regulate host defence enhances our knowledge of host physiology and may form the basis for new approaches to treat gastrointestinal diseases.

Impact of baseline vitamin B12 status on the effect of vitamin B12 supplementation on neurologic function in older people: secondary analysis of data from the OPEN randomised controlled trial

BACKGROUND/OBJECTIVES

The available evidence from randomised controlled trials suggests that vitamin B12 supplementation does not improve neurologic function in older people with marginal but not deficient Vitamin B12 status. This secondary analysis used data from the Older People and Enhanced Neurological function (OPEN) randomised controlled trial to assess whether baseline vitamin B12 status or change in vitamin B12 status over 12 months altered the effectiveness of dietary vitamin B12 supplementation on neurologic function in asymptomatic older people with depleted vitamin B12 status at study entry.

SUBJECTS/METHODS

Vitamin B12 status was measured as serum concentrations of vitamin B12, holotranscobalamin, homocysteine and via a composite indicator (cB12). Neurological function outcomes included eleven electrophysiological measures of sensory and motor components of peripheral and central nerve function. Linear regression analyses were restricted to participants randomised into the intervention arm of the OPEN trial (n=91).

RESULTS

Analyses revealed an inconsistent pattern of moderate associations between some measures of baseline vitamin B12 status and some neurological responses to supplementation. The directions of effect varied and heterogeneity in effect across outcomes could not be explained according to type of neurological outcome. There was no evidence of differences in the neurological response to vitamin B12 supplementation according to change from baseline over 12 months in any indicator of B12 status.

CONCLUSIONS

This secondary analysis of high-quality data from the OPEN trial provides no evidence that baseline (or change from baseline) vitamin B12 status modifies the effect of vitamin B12 supplementation on peripheral or central nerve conduction among older people with marginal vitamin B12 status. There is currently insufficient evidence of efficacy for neurological function to support population-wide recommendations for vitamin B12 supplementation in healthy asymptomatic older people with marginal vitamin B12 status.

Predicting recovery in patients with acute low back pain: A Clinical Prediction Model

BACKGROUND

There is substantial variability in the prognosis of acute low back pain (LBP). The ability to identify the probability of individual patients recovering by key time points would be valuable in making informed decisions about the amount and type of treatment to provide. Predicting recovery based on presentation 1-week after initially seeking care is clinically important and may be more accurate than predictions made at initial presentation. The aim of this study was to predict the probability of recovery at 1-week, 1-month and 3-months after 1-week review in patients who still have LBP 1-week after initially seeking care.

METHODS

The study sample comprised 1070 patients with acute LBP, with a pain score of ≥2 1-week after initially seeking care. The primary outcome measure was days to recovery from pain. Ten potential prognostic factors were considered for inclusion in a multivariable Cox regression model.

RESULTS

The final model included duration of current episode, number of previous episodes, depressive symptoms, intensity of pain at 1-week, and change in pain over the first week after seeking care. Depending on values of the predictor variables, the probability of recovery at 1-week, 1-month and 3-months after 1-week review ranged from 4% to 59%, 19% to 91% and 30% to 97%, respectively. The model had good discrimination (C = 0.758) and calibration.

CONCLUSIONS

This study found that a model based on five easily collected variables could predict the probability of recovery at key time points in people who still have LBP 1-week after seeking care.

SIGNIFICANCE

A clinical prediction model based on five easily collected variables was able to predict the likelihood of recovery from an episode of acute LBP at three key time points. The model had good discrimination (C = 0.758) and calibration.

A targeted proteomic multiplex CSF assay identifies increased malate dehydrogenase and other neurodegenerative biomarkers in individuals with Alzheimer's disease pathology

Alzheimer's disease (AD) is the most common cause of dementia. Biomarkers are required to identify individuals in the preclinical phase, explain phenotypic diversity, measure progression and estimate prognosis. The development of assays to validate candidate biomarkers is costly and time-consuming. Targeted proteomics is an attractive means of quantifying novel proteins in cerebrospinal and other fluids, and has potential to help overcome this bottleneck in biomarker development. We used a previously validated multiplexed 10-min, targeted proteomic assay to assess 54 candidate cerebrospinal fluid (CSF) biomarkers in two independent cohorts comprising individuals with neurodegenerative dementias and healthy controls. Individuals were classified as 'AD' or 'non-AD' on the basis of their CSF T-tau and amyloid Aβ1-42 profile measured using enzyme-linked immunosorbent assay; biomarkers of interest were compared using univariate and multivariate analyses. In all, 35/31 individuals in Cohort 1 and 46/36 in Cohort 2 fulfilled criteria for AD/non-AD profile CSF, respectively. After adjustment for multiple comparisons, five proteins were elevated significantly in AD CSF compared with non-AD CSF in both cohorts: malate dehydrogenase; total APOE; chitinase-3-like protein 1 (YKL-40); osteopontin and cystatin C. In an independent multivariate orthogonal projection to latent structures discriminant analysis (OPLS-DA), these proteins were also identified as major contributors to the separation between AD and non-AD in both cohorts. Independent of CSF Aβ1-42 and tau, a combination of these biomarkers differentiated AD and non-AD with an area under curve (AUC)=0.88. This targeted proteomic multiple reaction monitoring (MRM)-based assay can simultaneously and rapidly measure multiple candidate CSF biomarkers. Applying this technique to AD we demonstrate differences in proteins involved in glucose metabolism and neuroinflammation that collectively have potential clinical diagnostic utility.

Symptoms and patient factors associated with diagnostic intervals for pancreatic cancer (SYMPTOM pancreatic study): a prospective cohort study

Background

Pancreatic cancer is the tenth most common cancer in the UK; however, outcomes are poor, in part due to late diagnosis. We aimed to identify symptoms and other clinical and sociodemographic factors associated with pancreatic cancer diagnosis and diagnostic intervals.

Methods

We did this prospective cohort study at seven hospitals in two regions in England. We recruited participants aged 40 years or older who were referred for suspicion of pancreatic cancer. Data were collected by use of a patient questionnaire and primary care and hospital records. Descriptive and regression analyses were done to examine associations between symptoms and patient factors with the total diagnostic interval (time from onset of the first symptom to the date of diagnosis), comprising patient interval (time from first symptom to first presentation) and health system interval (time from first presentation to diagnosis).

Findings

We recruited 391 participants between Jan 1, 2011, and Dec 31, 2014 (24% response rate). 119 (30%) participants were diagnosed with pancreatic cancer (41 [34%] had metastatic disease), 47 (12%) with other cancers, and 225 (58%) with no cancer. 212 (54%) patients had multiple first symptoms whereas 161 (41%) patients had a solitary first symptom. In this referred population, no initial symptoms were reported more frequently by patients with cancer than by those with no cancer. Several subsequent symptoms predicted pancreatic cancer: jaundice (51 [49%] of 105 patients with pancreatic cancer vs 25 [12%] of 211 patients with no cancer; p<0·0001), fatigue (48/95 [51%] vs 40/155 [26%]; p=0·0001), change in bowel habit (36/87 [41%] vs 28/175 [16%]; p<0·0001), weight loss (55/100 [55%] vs 41/184 [22%]; p<0·0001), and decreased appetite (41/86 [48%] vs 41/156 [26%]; p=0·0011). There was no difference in any interval between patients with pancreatic cancer and those with no cancer (total diagnostic interval: median 117 days [IQR 57–234] vs 131 days [IQR 66–284]; p=0·32; patient interval 18 days [0–37] vs 15 days [1–62]; p=0·22; health system interval 76 days [28–161] vs 79 days [30–156]; p=0·68). Total diagnostic intervals were shorter when jaundice (hazard ratio [HR] 1·38, 95% CI 1·07–1·78; p=0·013) and decreased appetite (1·42, 1·11–1·82; p=0·0058) were reported as symptoms, and longer in patients presenting with indigestion (0·71, 0·56–0·89; p=0·0033), back pain (0·77, 0·59–0·99; p=0·040), diabetes (0·71, 0·52–0·97; p=0·029), and self-reported anxiety or depression, or both (0·67, 0·49–0·91; p=0·011). Health system intervals were likewise longer with indigestion (0·74, 0·58–0·95; p=0·0018), back pain (0·76, 0·58–0·99; p=0·044), diabetes (0·63, 0·45–0·89; p=0·0082), and self-reported anxiety or depression, or both (0·63, 0·46–0·88; p=0·0064), but were shorter with male sex (1·41, 1·1–1·81; p=0·0072) and decreased appetite (1·56, 1·19–2·06; p=0·0015). Weight loss was associated with longer patient intervals (HR 0·69, 95% CI 0·54–0·89; p=0·0047).

Interpretation

Although we identified no initial symptoms that differentiated people diagnosed with pancreatic cancer from those without pancreatic cancer, key additional symptoms might signal the disease. Health-care professionals should be vigilant to the possibility of pancreatic cancer in patients with evolving gastrointestinal and systemic symptoms, particularly in those with diabetes or mental health comorbidities.

Funding

National Institute for Health Research and Pancreatic Cancer Action.

The development of peer reflective supervision amongst nurse educator colleagues: An action research project

This action research study developed the use of peer reflective supervision (PRS) amongst eight nurse educators contributing to an undergraduate Adult Nursing programme at a UK University. During the academic year (2013-14), nurse educator co-researchers met for an introductory workshop and then met regularly in pairs to facilitate each other's reflection. This provided an opportunity for nurse educators to reflect on identified issues linked to their role with a facilitative peer. Educators met three additional times in a Reflexive Learning Group (RLG), to gather data on their use of PRS. Audio-recordings from the RLGs were transcribed and analysed using Norton's (2009) thematic analysis framework. Co-researchers iteratively validated the data and an external validation group critically viewed the evidence. Overall, seven themes were generated from the three research cycles. These were: PRS as a Valuable Affirming Experience; Time Issues; Facilitation- Support, Trust and Challenge; Developing a Flexible 'Toolbox'; To Write or Not to Write; Drawing on Literature; and Requirement for Action. Findings add new evidence regarding use of a flexible toolbox of resources to develop reflection and offer practical guidance on the development of PRS. Nurse educators often experienced similar concerns, and a facilitative supervision structure allowed co-researchers to positively explore these. Recognition of work pressures and requirement for time and space for reflection was highlighted, particularly regarding writing, and exploring the literature, to develop critical analysis of experiences. The importance of action as part of the reflective process was emphasised. Co-researchers reported positive personal change as well as the opportunity to highlight issues through their reflection for further action within the organisation. The study adds constructive evidence for the use of reflection to explore professional work, make sense of experiences and develop positive action. It has transferability to a wider international audience interested in the development of reflection amongst colleagues and the use of insider research techniques to challenge and develop practice.

Minimal important improvement thresholds for the six-minute walk test in a knee arthroplasty cohort: triangulation of anchor- and distribution-based methods

Background

The 6-minute walk test (6MWT) is a commonly used metric for measuring change in mobility after knee arthroplasty, however, what is considered an improvement after surgery has not been defined. The determination of important change in an outcome assessment tool is controversial and may require more than one approach. This study, nested within a combined randomised and observational trial, aimed to define a minimal important improvement threshold for the 6MWT in a knee arthroplasty cohort through a triangulation of methods including patient-perceived anchor-based thresholds and distribution-based thresholds.

Methods

Individuals with osteoarthritis performed a 6MWT pre-arthroplasty then at 10 and 26 weeks post-surgery. Each rated their perceived improvement in mobility post-surgery on a 7-point transition scale anchored from “much better” to “much worse”. Based on these responses the cohort was dichotomised into ‘improved’ and ‘not improved’. The thresholds for patient-perceived improvements were then identified using two receiver operating curve methods producing sensitivity and specificity indices. Distribution-based change thresholds were determined using two methods utilising effect size (ES). Agreement between the anchor- and distribution-based methods was assessed using kappa.

Results

One hundred fifty-eight from 166 participants in the randomised cohort and 222 from 243 in the combined randomised and observational cohort were included at 10 and 26 weeks, respectively. The slightly or more patient-perceived improvement threshold at 26 weeks (an absolute improvement of 26 m) was the only one to demonstrate sensitivity and specificity results both better than chance. At 10- and 26-weeks, the ES based on the mean change score divided by the baseline standard deviation (SD), was an absolute change of 24.5 and 37.9 m, respectively. The threshold based on a moderate ES (a 0.5 SD of the baseline score) was a change of 55.0 and 55.4 m at 10- and 26-weeks, respectively. The level of agreement between the 26-week anchor-based and distribution-based minimal absolute changes was very good (k = 0.88 (95 % CI 0.81 0.95)).

Conclusion

A valid threshold of improvement for the 6MWT can only be proposed for changes identified from baseline to 26 weeks post-surgery. The level of agreement between anchor- and distribution-based methods indicates that a true minimal or more threshold of meaningful improvement following surgery is likely within the ranges proposed by the triangulation of all four methods, that is, 26 to 55 m.

Symptoms and patient factors associated with longer time to diagnosis for colorectal cancer: results from a prospective cohort study

Background:

The objective of this study is to investigate symptoms, clinical factors and socio-demographic factors associated with colorectal cancer (CRC) diagnosis and time to diagnosis.

Methods:

Prospective cohort study of participants referred for suspicion of CRC in two English regions. Data were collected using a patient questionnaire, primary care and hospital records. Descriptive and regression analyses examined associations between symptoms and patient factors with total diagnostic interval (TDI), patient interval (PI), health system interval (HSI) and stage.

Results:

A total of 2677 (22%) participants responded; after exclusions, 2507 remained. Participants were diagnosed with CRC (6.1%, 56% late stage), other cancers (2.0%) or no cancer (91.9%). Half the cohort had a solitary first symptom (1332, 53.1%); multiple first symptoms were common. In this referred population, rectal bleeding was the only initial symptom more frequent among cancer than non-cancer cases (34.2% vs 23.9%, P=0.004). There was no evidence of differences in TDI, PI or HSI for those with cancer vs non-cancer diagnoses (median TDI CRC 124 vs non-cancer 138 days, P=0.142). First symptoms associated with shorter TDIs were rectal bleeding, change in bowel habit, ‘feeling different' and fatigue/tiredness. Anxiety, depression and gastro-intestinal co-morbidities were associated with longer HSIs and TDIs. Symptom duration-dependent effects were found for rectal bleeding and change in bowel habit.

Conclusions:

Doctors and patients respond less promptly to some symptoms of CRC than others. Healthcare professionals should be vigilant to the possibility of CRC in patients with relevant symptoms and mental health or gastro-intestinal comorbidities.

Symptom appraisal and healthcare-seeking for symptoms suggestive of colorectal cancer: a qualitative study

OBJECTIVES

Timely diagnosis of colorectal cancer is important to improve survival. This study explored symptom appraisal and help-seeking among patients referred to specialist services with symptoms of colorectal cancer.

DESIGN

Qualitative in-depth interview study.

SETTING AND PARTICIPANTS

Participants were recruited on referral to gastroenterology clinics (North East and East of England); interviews were conducted soon after referral. We purposively sampled participants to ensure a range of accounts in terms of age, sex, diagnosis and geographical location.

METHODS

Data collection and analysis were underpinned by the Model of Pathways to Treatment. Framework analysis was used to explore the data within and across cases, focusing on patient beliefs and experiences, disease factors and healthcare influences.

RESULTS

40 participants were interviewed (aged 43-87 years, 17 women, 18 diagnosed with colorectal cancer). Patients diagnosed with and without colorectal cancer had similar symptom pathways. We found a range of interacting and often competing biopsychosocial, contextual and cultural influences on the way in which people recognised, interpreted and acted on their symptoms. People attempted to 'maintain normality' through finding benign explanations for their symptoms. Bodily changes were appraised within the context of usual bowel patterns, comorbidities and life events, and decisions to seek help were made in relation to expectations about the course of symptoms. The 'private nature' of colorectal cancer symptoms could affect both their identification and discussions with others including healthcare professionals. Within the context of the National Health Service, people needed to legitimise appropriate use of healthcare services and avoid being thought of as wasting doctors' time.

CONCLUSIONS

Findings provide guidance for awareness campaigns on reducing stigma around appraising and discussing bowel movements, and the importance of intermittent and non-specific symptoms. Altering perceptions about the appropriate use of health services could have a beneficial effect on time to presentation.