Endocan: A biomarker for endothelial dysfunction and inflammation, linking maternal obesity and pediatric obesity in a cohort of preterm neonates

OBJECTIVES

Numerous animal and epidemiologic studies have demonstrated a positive association between maternal obesity in pregnancy and obesity in offspring. The biologic mechanisms of this association remain under investigation. One proposed mechanism includes fetoplacental endothelial dysfunction secondary to inflammation. Endocan is a relatively new biomarker for endothelial dysfunction and inflammation. Our objectives were to examine (1) the association between maternal obesity and neonatal serum endocan at birth, and (2) the association between neonatal serum endocan at birth and pediatric obesity at 24-36 months of age.

STUDY DESIGN

This was a secondary analysis of a prospective cohort of neonates born < 33 weeks gestation. Serum endocan was collected within 48 hours of birth. Serum endocan levels were compared in neonates born to obese mothers vs. those born to non-obese mothers. BMI data were retrospectively collected from cohort neonates between 24 and 36 months of age.

RESULTS

The analysis included 120 mother/neonate dyads. Neonates born to obese mothers had higher median serum endocan at birth compared to neonates born to non-obese mothers (299 ng/L [205-586] vs. 251 ng/L [164-339], p = 0.045). In a linear regression modeled on neonatal serum endocan level, maternal obesity had a statistically significant positive association (p = 0.021). Higher mean serum endocan level at birth was associated with pediatric obesity between 24 and 36 months (obese vs. non-obese offspring; 574 ng/L (222) vs. 321 ng/L (166), p = 0.005).

CONCLUSIONS

In our cohort of preterm neonates, elevated serum endocan at birth was associated with both maternal obesity and downstream pediatric obesity. More research is needed to understand intergenerational transmission of obesity. A large focus has been on epigenetic modification. Endothelial dysfunction and inflammation may play important roles in these pathways. Effective biomarkers, including endocan, may also serve as intermediate outcomes in future pregnancy research.

Home-based versus supervised group exercise in men with prostate cancer on androgen deprivation therapy: A randomized controlled trial and economic analysis

INTRODUCTION

Differences between health outcomes, participation/adoption, and cost-effectiveness of home-based (HOME) interventions and supervised group-based training (GROUP) in men with prostate cancer (PC) on androgen deprivation therapy (ADT) are currently unknown. The objective of this study was to assess the clinical efficacy, adherence, and cost-effectiveness of HOME versus GROUP in men on ADT for PC.

MATERIALS AND METHODS

This was a multicentre, 2-arm non-inferiority randomized controlled trial and companion cost-effectiveness analysis. Men with PC on ADT were recruited from August 2016 to March 2020 from four Canadian centres and randomized 1:1 to GROUP or HOME. All study participants engaged in aerobic and resistance training four to five days weekly for six months. Fatigue [Functional Assessment of Cancer Therapy-Fatigue (FACT-F)] and functional endurance [6-min walk test (6MWT)] at six months were the co-primary outcomes. Secondary outcomes included quality of life, physical fitness, body composition, blood markers, sedentary behaviour, and adherence. Between-group differences in primary outcomes were compared to margins of 3 points for FACT-F and 40 m for 6MWT using a Bayesian analysis of covariance (ANCOVA). Secondary outcomes were compared with ANCOVA, Costs included Ministry of Health costs, program costs, patient out-of-pocket, and time costs.

TRIAL REGISTRATION

#NCT02834416.

RESULTS

Thirty-eight participants (mean [standard deviation (SD)] age, 70 [9.0] years) were enrolled (GROUP n = 20; HOME n = 18). There was an 89.8% probability that HOME was non-inferior to GROUP for both fatigue and functional endurance and a 9.5% probability that HOME reduced fatigue compared to GROUP (mean [SD] change, 12.1 [8.1] vs 3.6 [6.1]; p = 0.040) at six months. Adherence was similar among study arms. HOME was cost-saving (mean difference: -$4122) relative to GROUP.

DISCUSSION

A HOME exercise intervention appears non-inferior to GROUP for fatigue and functional endurance and requires fewer resources to implement. HOME appears to ameliorate fatigue more than GROUP, but has comparable effects on other clinically relevant outcomes. Although limited by sample size and attrition, these results support further assessment of home-based programs.

Lessons learnt from the COVID-19 pandemic in selected countries to inform strengthening of public health systems: a qualitative study

INTRODUCTION

The COVID-19 pandemic has prompted governments internationally to consider strengthening their public health systems. To support the work of Ireland's Public Health Reform Expert Advisory Group, the Health Information and Quality Authority, an independent governmental agency, was asked to describe the lessons learnt regarding the public health response to COVID-19 internationally and the applicability of this response for future pandemic preparedness.

METHODS

Semi-structured interviews with key public health representatives from nine countries were conducted. Interviews were conducted in March and April 2022 remotely via Zoom and were recorded. Notes were taken by two researchers, and a thematic analysis undertaken.

RESULTS

Lessons learnt from the COVID-19 pandemic related to three main themes: 1) setting policy; 2) delivering public health interventions; and 3) providing effective communication. Real-time surveillance, evidence synthesis, and cross-sectoral collaboration were reported as essential for policy setting; it was noted that having these functions established prior to the pandemic would lead to a more efficient implementation in a health emergency. Delivering public health interventions such as testing, contact tracing, and vaccination were key to limiting and or mitigating the spread of the SARS-CoV-2 virus. However, a number of challenges were highlighted such as staff capacity and burnout, delays in vaccination procurement, and reduced delivery of regular healthcare services. Clear, consistent, and regular communication of the scientific evidence was key to engaging citizens with mitigation strategies. However, these communication strategies had to compete with an infodemic of information being circulated, particularly through social media.

CONCLUSIONS

Overall, functions relating to policy setting, public health interventions, and communication are key to pandemic response. Ideally, these should be established in the preparedness phase so that they can be rapidly scaled-up during a pandemic.

Case Report

The illegal practice of combining organophosphates (OPs) with other compounds such as carbamates and pyrethroids, creating 'streetpesticides', is common in South Africa. These agents contain mostly unknown quantities of unregulated toxins and contribute to atypicaland unpredictable clinical presentations following human ingestion. We present such a case in a patient with intentional rodenticideingestion. The initial presentation in the emergency department was a classic cholinergic toxidrome, and clinical resolution was achievedafter provision of atropine. This was followed 12 hours later by an acute decompensation resulting from an apparent sympatheticallydriven episode of autonomic instability and acute pulmonary oedema requiring immediate respiratory and haemodynamic support. In ourdiscussion, we explore this secondary decompensation and suggest various pathophysiological explanations for this atypical clinical coursefollowing what had appeared to be OP poisoning. The patient was discharged home after a total of 6 days in hospital.

High level review of configuration and reform of Public Health systems in selected countries

Background

The impact of the COVID-19 pandemic has prompted governments internationally to consider reform and strengthening of their Public Health systems. To support this work in Ireland, we undertook a review Public Health systems internationally (research question [RQ] 1), and identified lessons learned from the COVID-19 pandemic (RQ2).

Methods

Data relating to Public Health systems (RQ1), and lessons learned (RQ2) for a select group of 12 countries were identified from organisations’ websites, an electronic database and grey literature search and representatives from key national-level organisations. Data for RQ1 were extracted, mapped to the 12 Essential Public Health functions (EPHFs) at national, regional and local levels, and verified by participating representatives. For RQ2, thematic analysis of semi-structured interviews with participating representatives was undertaken and.

Results

Typically, across all included countries, there is national strategic oversight of all EPHFs and, for certain functions, there is regional and local level implementation. Lessons learned from the COVID-19 pandemic broadly related to the themes of legislation and decision making; data collection, surveillance, evidence synthesis and collaboration; public health interventions; public participation, public messaging and communication; continuation of healthcare services; and workforce capacity and resilience.

Conclusions

When structuring Public Health systems, there is a need to identify which functions, and or which elements of a function, should be delivered at a national, regional or local level to ensure a sustainable and comprehensive Public Health system. Appropriate IT infrastructure, strong communication and an established evidence synthesis function are key to timely and informed decision making. Ideally, these functions should be established during periods of relative stability to permit a faster response during a pandemic or emergency situation.

Organisational perspectives on Public Health delivery in Ireland: Lessons learned from COVID-19

Background

The COVID-19 pandemic has placed healthcare systems worldwide under unprecedented pressure, with the Irish Public Health system no different. To strengthen delivery of Essential Public Health Functions (EPHFs) and increase future pandemic preparedness, Public Health leaders are now focused on identifying learnings from the pandemic. Within Ireland, given their experience, organisations situated within the Public Health system may be in a unique position to provide valuable information around the delivery of EPHFs, both prior to and in light of the COVID-19 pandemic, and how this can be improved in the future.

Methods

An online survey was distributed by the Department of Health, from 2 March 2022 to 25 March 2022, amongst organisations situated within the Public Health domain in Ireland. The survey consisted of six open-ended questions around the delivery of EPHFs prior to and in light of the pandemic, success stories that could provide scalable solutions to EPHF delivery and current health system barriers, key areas in the public health system that require strengthening, and barriers to achieving these actions. Thematic analysis to identify key themes was conducted on survey responses.

Results

Twenty-eight organisational responses were received. Themes around the workforce were apparent throughout, with staff training, staff diversity and staff morale, identified as areas for strengthening EPHF delivery. Themes around ICT, data collection and research were frequently identified with a lack of adequate ICT identified as a key lesson from the pandemic, while the Public Health ICT strategy was identified as key to strengthening future EPHF delivery.

Conclusions

In general, themes around the workforce; leadership, management and governance and ICT, data collection and research were reoccurring across organisational responses and therefore may be key areas for consideration when strengthening delivery of the EPHFs in Ireland.

Speakers/Panelist

Louise Hendricks

Department of Health, Ireland

Sohel Saikat

WHO, Geneva, Switzerland

Increasing the use of perioperative risk scoring in emergency laparotomy: nationwide quality improvement programme

Background

Emergency laparotomy is associated with high morbidity and mortality. The early identification of high-risk patients allows for timely perioperative care and appropriate resource allocation. The aim of this study was to develop a nationwide surgical trainee-led quality improvement (QI) programme to increase the use of perioperative risk scoring in emergency laparotomy.

Methods

The programme was structured using the active implementation framework in 15 state-funded Irish hospitals to guide the staged implementation of perioperative risk scoring. The primary outcome was a recorded preoperative risk score for patients undergoing an emergency laparotomy at each site.

Results

The rate of patients undergoing emergency laparotomy receiving a perioperative risk score increased from 0–11 per cent during the exploratory phase to 35–100 per cent during the full implementation phase. Crucial factors for implementing changes included an experienced central team providing implementation support, collaborator engagement, and effective communication and social relationships.

Conclusions

A trainee-led QI programme increased the use of perioperative risk assessment in patients undergoing emergency laparotomy, with the potential to improve patient outcomes and care delivery.

Media coverage of evidence outputs during the COVID-19 pandemic: findings from one national agency

Background

The COVID-19 Evidence Synthesis Team within the Health Information and Quality Authority (HIQA) in Ireland produced a range of evidence-based reports on a broad range of public health topics related to COVID-19. These evidence outputs (EO) arose directly from questions posed by policy makers and clinicians supporting Ireland's National Public Health Emergency Team (NPHET). Findings from these EOs informed the national response to the COVID-19 pandemic in Ireland and influenced international public health guidance. How research findings are presented through domestic news can influence behaviour and risk perceptions.

Methods

We investigated traditional media coverage of nine COVID-19 EOs and associated press releases, published (April to July 2020) by HIQA. NVivo was used for conceptual content analysis of manifest content. ‘Core messages' from each evidence output were proposed and 488 sources from national and regional broadcast, print, and online media were coded at the phrase level. The presence of political and public health actors in coverage were also coded.

Results

Coverage largely did not distort or misrepresent the results of the EOs, however, there was variability in terms of what content was reported on and to what extent different stakeholders were involved in the contextualization of the findings of the EOs. Coverage appeared to focus more on ‘human-interest' stories as opposed to more technical reports (e.g. focusing on viral load, antibodies, testing, etc.). Selective reporting and the variability in the use of quotes from governmental and public health stakeholders changed and contextualized results in different manners than perhaps originally intended in the press release.

Conclusions

Our findings provide a case-study of European media coverage of evidence reports produced by a national agency. Results highlighted several strengths and weaknesses of current communication efforts.

Evaluating rapid review provision to inform policy during the COVID-19 pandemic

Background

Evidence based decision making is central to population health, particularly during a pandemic. Few studies examine the production and use of evidence in decision-making during crisis management. This study describes and evaluates the provision of rapid evidence products by a single agency to support national decision making.

Methods

Semi-structured interviews were conducted with a convenience sample of evidence providers (who gathered and disseminated the required evidence) and service users (policy makers). Interviews were transcribed verbatim and analysed using thematic analysis. Quantitative data of work activity were summarised descriptively.

Results

Three themes were generated from the data: the work, the use and the future, with a fourth theme cross-cutting across these: the team. The work followed clear protocols and was centrally managed. The scope and changing nature of the evidence were highlighted as issues. The service providers reported a strong sense of team work and ‘being in this together', however, the majority of the participants felt that the workload was huge and exhausting and not sustainable long-term. Overall the service users thought the rapid evidence synthesis was indispensable to the decision-making process and had trust and confidence in the work, largely based on existing working relationships with the team. While they recognised that the evidence synthesis support would be an essential component of the continued pandemic response, they did query the sustainability of the process and reflected on the amount of work the team performed.

Conclusions

This evaluation, drawing on qualitative data, has highlighted that, across the services users and evidence providers, the support provided by HIQA was generally perceived as positive. From the service users' perspective, having access to the team was indispensable to the decision making process. However, the sustainability of the work load was identified as a major challenge.

COVID-19 Public Health Guidance Database

Background

Since March 2020, members of the Health Technology Assessment (HTA) team in HIQA have been identifying, reviewing and presenting COVID-19 public health guidance produced by international organisations. The aim of this work has been to inform the development of public health guidance and policy by the Health Protection Surveillance Centre (HPSC), Department of Health and Health Service Executive (HSE), using international evidence and best practice.

Methods

International resources are searched on a weekly basis to identify new or updated public health guidance on COVID-19. The three distinct steps in the process include, searching relevant international resources, reviewing identified relevant public health guidance for COVID-19, and presenting new or updated guidance in a COVID-19 Public Health Guidance Database, which was created by the team using Microsoft Excel. The international organisations reviewed include the World Health Organisation, European Centre for Disease Prevention and Control and Centers for Disease Control and Prevention, as well as a range of ministries of health and public health agencies from 10 countries. These were chosen, based on guidance being available in English, widespread use of the organisation's advice, and/or the working constraints of the HTA team.

Results

The COVID-19 Public Health Guidance Database is updated weekly and provided to the relevant individuals within HPSC, Department of Health, and HSE, who are responsible for developing public health and infection, prevention and control guidance related to COVID-19 in Ireland. Following this the database is published online and may be utilised by the public or other international organisations.

Conclusions

The COVID-19 Public Health Guidance Database is used to inform the ongoing response to the COVID-19 pandemic, specifically, to inform the development of public health and infection, prevention and control guidance to prevent the spread of COVID-19.

COVID-19 - Interventions and lifestyle factors that prevent infection or minimise progression to severe disease

Background

This evidence summary synthesised the evidence relating to pharmacological and non-pharmacological interventions in the community to prevent COVID-19/progression to severe disease. An additional aim was to identify potentially modifiable lifestyle factors associated with reduced risk of infection/progression to severe disease.

Methods

A systematic search of published peer-reviewed articles and non-peer-reviewed pre-prints was undertaken from 1 January 2020 to 19 April 2021; no language restrictions were applied. All potentially eligible papers were exported to Covidence. Titles/abstracts and full texts were single screened for relevance. Data extraction and quality appraisal of included studies was completed by a single reviewer and checked by a second.

Results

In total, 50 studies, three randomised controlled trials (RCTs), one non-RCT and 46 cohort studies were included. The four included controlled trials tested variations of the pharmacological intervention, ivermectin. While these controlled trials reported a protective effect for ivermectin use, these trials were of poor quality and had serious risk of bias. Across 46 cohort studies, the modifiable lifestyle risk factors identified were obesity, smoking, vitamin D status, physical activity, alcohol consumption and processed meat consumption. These studies reported mixed results in terms of the association between modifiable lifestyle risk factors and poor COVID-19 outcomes.

Conclusions

At the time of writing there is no high quality evidence of benefit to support pharmacological interventions to prevent COVID-19. Although there were mixed results for the risk factors identified, maintenance of healthy weight, smoking cessation, engaging in physical activity and moderation of alcohol and processed meat consumption are likely to be beneficial to health and should continue to be encouraged.

A mixed-reality holographic viewing platform enabling interaction with 3D electroanatomical maps using the HoloLens

Introduction

Three dimensional (3D) electroanatomical maps (EAMs) created during electrophysiology procedures are traditionally displayed on 2D monitors connected to mapping systems. This has limitations, such as the lack of interaction with EAMs, the need for another user to control them, and the size of EAM displayed, which is limited by the resolution of these monitors. To overcome these, we created a novel technology to display EAMs on a mixed reality (MR) platform.

Methods

We used the Microsoft® HoloLens to create this MR platform. Studies from patients who had already undergone catheter ablation for atrial fibrillation, where EAMs of the left atria had been generated using different mapping systems (CARTO®, Rhythmia™ and EnSite Precision™) were utilised. These EAMs consisting of 3D coordinates and annotations (e.g. voltage & activation times) were exported from the mapping system. EAMs were then compiled and transferred to the HoloLens using custom-developed functions on Unity©, Microsoft® C# and VisualStudio. Subsequently, feedback was obtained from 3 independent electrophysiologists on this technology.

Results

We successfully exported the EAMs generated on CARTO®, Rhythmia™ and EnSite Precision™ mapping systems as holograms on to the HoloLens (Figure). Positive feedback included themes such as 1) the ability to use hand gestures and voice commands to interact with EAMs independent of another user unlike traditional cardiac mapping systems 2) offering an interactive 3D holographic experience whilst preserving the operators' physical interaction in the cardiac catheter lab 3) the capacity to better appreciate 3D geometry of EAMs in comparison to 2D monitors. The challenge of wearing a headset during long procedures was perceived as a disadvantage.

Conclusion

This technology, which can be used with any mapping system, is currently optimised for offline display. Our software will be made available as an opensource teaching and simulation tool. Users will be able to explore EAMs for research, planning complex cases and immersive learning. The future directions will include extending this toolkit for real-time cardiac mapping with catheter localisation, and could potentially be translated to other cardiac imaging modalities.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Cardiovascular diseases charitable fund (CDCF) at Guy's and St Thomas' NHS Foundation Trust. Process of creating Holograms of EAMsVoltage map of left atrium as a Hologram

Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation

Background

Early warning systems (EWSs) are used to assist clinical judgment in the detection of acute deterioration to avoid or reduce adverse events including unanticipated cardiopulmonary arrest, admission to the intensive care unit and death. Sometimes healthcare professionals (HCPs) do not trigger the alarm and escalate for help according to the EWS protocol and it is unclear why this is the case. The aim of this qualitative evidence synthesis was to answer the question ‘why do HCPs fail to escalate care according to EWS protocols?’ The findings will inform the update of the National Clinical Effectiveness Committee (NCEC) National Clinical Guideline No. 1 Irish National Early Warning System (INEWS).

Methods

A systematic search of the published and grey literature was conducted (until February 2018). Data extraction and quality appraisal were conducted by two reviewers independently using standardised data extraction forms and quality appraisal tools. A thematic synthesis was conducted by two reviewers of the qualitative studies included and categorised into the barriers and facilitators of escalation. GRADE CERQual was used to assess the certainty of the evidence.

Results

Eighteen studies incorporating a variety of HCPs across seven countries were included. The barriers and facilitators to the escalation of care according to EWS protocols were developed into five overarching themes: Governance, Rapid Response Team (RRT) Response, Professional Boundaries, Clinical Experience, and EWS parameters. Barriers to escalation included: Lack of Standardisation, Resources, Lack of accountability, RRT behaviours, Fear, Hierarchy, Increased Conflict, Over confidence, Lack of confidence, and Patient variability. Facilitators included: Accountability, Standardisation, Resources, RRT behaviours, Expertise, Additional support, License to escalate, Bridge across boundaries, Clinical confidence, empowerment, Clinical judgment, and a tool for detecting deterioration. These are all individual yet inter-related barriers and facilitators to escalation.

Conclusions

The findings of this qualitative evidence synthesis provide insight into the real world experience of HCPs when using EWSs. This in turn has the potential to inform policy-makers and HCPs as well as hospital management about emergency response system-related issues in practice and the changes needed to address barriers and facilitators and improve patient safety and quality of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00403-9.

The Effect of Yoga Interventions on Cancer-Related Fatigue and Quality of Life for Women with Breast Cancer: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background:

Women with breast cancer (BC) are living longer with debilitating side effects such as cancer-related fatigue (CRF) that affect overall well-being. Yoga promotes health, well-being and may be beneficial in reducing CRF. Although there have been previous systematic reviews and meta-analyses, the effects of yoga on CRF and quality of life (QOL) remain unclear, particularly in comparison with other types of physical activity (PA). Our objective is to carry out a systematic review and meta-analysis of the effects of yoga on CRF and QOL in women with BC.

Methods:

Electronic databases were searched (MEDLINE, Embase Classic+Embase and EMB Reviews, Cochrane Central CT) from inception to May 2018. Randomized controlled trials were included if they were full text, in English, included a yoga intervention, a comparator (including non-PA usual care or alternate PA intervention), and reported on CRF or QOL. Effects of yoga were pooled using standardized mean difference (SMD) via a random effects model.

Results:

Of the 2468 records retrieved, 24 trials were included; 18 studies compared yoga to a non-PA comparator and 6 to a PA comparator. Yoga demonstrated statistically significant improvements in CRF over non-PA (SMD −0.30 [−0.51; −0.08]) but not PA (SMD −0.17 [−0.50; 0.17]) comparators. Additionally, yoga demonstrated statistically significant improvements in QOL over non-PA (SMD −0.27 [−0.46; −0.07]) but not PA (SMD 0.04 [−0.22; +0.31]) comparators.

Discussion:

This meta-analysis found that yoga provides small to medium improvements in CRF and QOL compared to non-PA, but not in comparison to other PA interventions.

Aerobic capacity attainment and reasons for cardiopulmonary exercise test termination in people with cancer: a descriptive, retrospective analysis from a single laboratory

PURPOSE

Aerobic exercise prescriptions in clinical populations commonly involve target intensities based on cardiopulmonary exercise tests (CPET). CPETs are often discontinued prior to a patient achieving true maximum oxygen consumption (VO₂ max) which can adversely affect exercise dose and efficacy monitoring; however, reasons for early discontinuation are poorly reported. Accordingly, we explored the CPET termination reasons in persons with cancer participating in exercise intervention studies.

METHODS

This study comprised of an exploratory, descriptive analysis of retrospective CPET data (VO₂ and anaerobic threshold) and termination reasons in a convenience sample of people with cancer participating in exercise intervention studies in a single laboratory. CPETs were standardized using the modified Bruce treadmill protocol with expired gas collection and analysis using a metabolic cart. VO₂ max was considered "met" when participants demonstrated (a) oxygen consumption plateau or (b) two of the following criteria: rating of perceived exertion ≥ 9/10, respiratory exchange ratio ≥ 1.15, and/or heart rate of 95% of age-predicted maximum. The frequency and distribution of reasons for test termination relative to the number of CPET exposures for the participants were reported.

RESULTS

Forty-four participants engaged in exercise studies between February 2016 and March 2018 provided data for the analysis. Participants completed up to three CPETs during this period (total of 78 CPETs in the current analysis). Eighty-six percent of all CPETs were terminated prior to achieving VO₂ max verification criteria and no tests resulted in an oxygen consumption plateau. For those that did not demonstrate achievement of VO₂ max verification criteria, reasons for discontinuation were distributed as follows: equipment discomfort-49%, volitional peak-36%, and physical discomfort-14.9%. For those who met VO₂ max criteria, volitional peak was the most common reason for test termination (45.5%), followed by physical discomfort (36.4%), and equipment discomfort (18.2%).

CONCLUSIONS

In our sample of cancer survivors, VO₂ max criteria were infrequently met with equipment discomfort being a primary reason for participant-driven test termination. Protocol and equipment considerations are necessary for interpretation and application of CPET findings in clinical practice.

Improving the effectiveness of communication in hospitals for people with communication difficulties: results of an online Phase II survey

BACKGROUND

In a recent paper a working group set up by the Lay Advisory Committee of the Royal College of Physicians of Edinburgh (RCPE) had looked into the problems of patients with severe communication difficulties in hospital (J R Coll Physicians Edinb 2017; 47: 211-3). The present online survey expands on this with the objective of garnering the views of physicians on this matter.

METHOD

An invitation aimed at physicians to complete an online survey was made through the recently published paper. The survey was open between September and December 2017.

RESULTS

There were 83 completed surveys. A total of 69 of the returns were UK based, with the remainder from Asia, Australia, Africa and non-UK Europe and one unidentified location. The majority (44) were consultants, the remainder included those in core medical training, general practice and psychology. A wide range of medical departments were represented in the returns, with the largest returns coming from care of the elderly and acute medical departments. Four key themes were highlighted by responders: time, training, resources and environment.

CONCLUSION

Based on these results, the working group have embarked upon the next phase of the project with three main tasks: firstly, to work with the RCPE to disseminate the survey findings to a wider audience; secondly, to collate the detailed suggestions for improvement to be used alongside the survey findings and any subsequent documentation or advice; thirdly, to formulate with the RCPE a strategy to promote good practice in hospitals related to the experiences of patients with severe communication difficulties.

Repair and remodelling in the shells of the limpet Patella vulgata

Limpets and other molluscs rely on shells to protect them from physical damage, predation, dehydration, etc. If the shell becomes damaged, this may significantly impair its function. In this work, experiments were carried out to investigate the effect of damage on the strength of shells of the common limpet (Patella vulgata) and their ability to repair this damage effectively. Shells were damaged in three ways: (i) low-energy impacts; (ii) abrasion of the outer layer; and (iii) creation of a small hole in the apex of the shell. Shells were left to repair for several time periods (0, 10, 30 and 60 days). The mechanical strength was evaluated by impacting the shells with a weight dropped from a known height. The damage reduced the strength (defined as impact energy to failure) by 50-70% depending on damage type. After 60 days, limpets in all three groups had repaired their shells significantly, bringing their strength to 79-91% of the control value (in each case, samples were statistically indistinguishable from their control counterparts). Measurements of the thickness of the shell at the apex suggest that the main effect of low-energy impact and abrasion is reduction in thickness, which correlates linearly with the impact energy needed for failure. The method of repair is believed to be by the growth of fresh shell material on the inside of the shell, though we could not identify this new material specifically. Even after 60 days, the shells were still statistically thinner than the controls. Consequently, there may be some other strengthening mechanism at work. This work has demonstrated the remarkable ability of limpets to detect the mechanical weakening of their shells caused by relatively subtle forms of damage and to take appropriate action to restore shell strength.

Perceptions of Study Newsletters for Older Cancer Patients in Longitudinal Studies

To date, no study has examined the value of providing study newsletters in educating and motivating participants taking part in longitudinal intervention studies and reducing attrition in studies. The study team examined perceptions and satisfaction towards study newsletters, and their potential benefits, in a population of older men with prostate cancer participating in two ongoing longitudinal trials. Two study newsletters issues were mailed out 4 months apart to prostate cancer patients participating in a bone health and/or exercise intervention trial. Participants (n = 133) were invited to complete an 18-item custom-designed survey examining perceptions towards and satisfaction with the newsletter, and provide feedback about what makes an ideal study newsletter. Analyses were primarily descriptive. Resources required to produce a study newsletter were also calculated. Of 133 participants, 83 usable surveys were returned (response rate 62.4%). The mean satisfaction rating for the newsletter was 8.5/10 (SD 1.9) (10 = highly satisfied). Seventy eight percent said the newsletter encouraged them to continue to participate in the study, and 93% indicated that providing such study newsletters should be optional (64%) or mandatory (29%). Each newsletter required 31 h of study personnel time (mostly research student) to produce. Study participants were very satisfied with the newsletter and the majority indicated that study newsletters should be a regular practice in all long-term studies and may improve participant retention. Producing a newsletter is a low-cost method of educating participants in longitudinal studies. Its impact on recruitment and retention should be examined in clinical trials.

Effects of a 6-month moderate-intensity exercise program on metabolic parameters and bone mineral density in men on androgen deprivation therapy for prostate cancer

237

Background: Androgen deprivation therapy (ADT) is commonly used to treat prostate cancer (PC) but is associated with significant side effects including metabolic abnormalities and bone loss. Although multiple trials have demonstrated that exercise is associated with improvements in multiple side effects of ADT, its effects on metabolic and skeletal outcomes is unclear. We conducted a phase II randomized controlled trial (RCT) comparing three different exercise delivery models. The present analysis examined prespecified endpoints of change in metabolic parameters and bone mineral density. Methods: Men with stage TxNxMx PC starting or continuing ADT for at least 6 months were enrolled and randomized equally to personal training (n = 18), supervised group training (n = 14), or home-based training (n = 16). Participants in all intervention arms underwent moderate to vigorous physical activity with a target of 150 minutes per week for 6 months. Fasting blood work and dual x-ray absorptiometry (DXA) were done at baseline and 6 months (blood work) and 12 months (DXA). Paired t-tests and ANCOVA were used to analyze findings. Results: 48 participants (mean age 69.9 years) were enrolled. The primary analysis demonstrated no significant difference between arms on most quality of life and fitness outcomes so groups were combined for the present analysis. Exercise was not associated with statistically significant changes in hemoglobin, total cholesterol, low density lipoprotein, high density lipoprotein, triglycerides, or fasting blood glucose (p = 0.075 to 0.87). Similarly, exercise was not associated with changes in bone mineral density at lumbar spine, total hip, or femoral neck sites on DXA (p = 0.44 to 0.71). Mean weight change was +0.8 kg. There was no difference between exercise arms on any outcome. Conclusions: Although our study is limited by a small sample size, our results suggest that 6 months of moderate intensity exercise is not associated with improvements in either metabolic or skeletal outcomes in men on ADT. More intensive behavioural interventions and/or pharmacological interventions will be required to reverse the deleterious effects of ADT. Clinical trial information: NCT02046837.

An 18 year population-based study on site of origin and outcome of patients with peritoneal malignancy in Ireland

Peritoneal malignancy (PM) is predominantly metastatic spread from advanced gastrointestinal or gynaecological cancer. PM is generally considered incurable and therefore has rarely been the focus of novel therapeutic strategies. This study assessed patterns and survival outcomes for patients with PM in Ireland. The National Cancer Registry Ireland database was interrogated to identify patients diagnosed with PM during the period 1994-2012. Patient and tumour characteristics were retrieved and survival outcomes calculated. 5791 patients were diagnosed during the study period. Median age at diagnosis was 68 years; females accounted for 62%. The incidence increased annually from 228 in 1994 to 401 in 2012. Primary PM accounted for 3% of cases. Colorectal (22%), ovarian (16%) and gastric (13%) cancers accounted for the majority of cases of secondary PM. Almost 75% of patients had PM at initial presentation. Almost 40% of patients (n = 2274) underwent surgical intervention, while 44% (n = 2560) had tumour directed chemotherapy. The median survival (MS) in patients with secondary PM was 6.6 months, and did not improve significantly during the study period. Outcomes were best in patients with ovarian cancer (MS 15.9 months) and colorectal cancer (MS 14.3 months) and worst in patients with lung (MS 2.4 months) and pancreas (MS 1.9 months) cancers. This is the first population-based study from Ireland to report the incidence and outcomes for PM. PM is more common than previously reported and survival remains poor. These findings highlight the need for greater clinician awareness and the need to focus on new therapeutic approaches to improve patient outcomes.

The neurocognitive basis of borrowed context information

Falsely remembered items can be accompanied by episodic context retrieval. This finding is difficult to explain because there is no episode that binds the remembered item to the experimenter-controlled context features. The current study examines the neural correlates of false context retrieval when the context features can be traced to encoding episodes of semantically-similar items. Our neuroimaging results support a "dissociated source" mechanism for context borrowing in false memory. We found that parahippocampal cortex (PHc) activation, thought to indicate context retrieval, was greater during trials that involved context borrowing (an incorrect, but plausible source decision) than during baseline correct context retrieval. In contrast, hippocampal activation, thought to indicate retrieval of an episodic binding, was stronger during correct source retrieval than during context borrowing. Vivid context retrieval during false recollection experiences was also indicated by increased activation in visual perceptual regions for context borrowing as compared to other incorrect source judgments. The pattern of findings suggests that context borrowing can arise when unusually strong activation of a semantically-related item's contextual features drives relatively weak retrieval of the associated episodic binding with failure to confirm the item information within that binding. This dissociated source retrieval mechanism suggests that context-driven episodic retrieval does not necessarily lead to retrieval of specific item details. That is, source information can be retrieved in the absence of item memory.

Frontotemporal function]al connectivity and executive functions contribute to episodic memory performance

The contributions of hemispheric-specific electrophysiology (electroencephalogram or EEG) and independent executive functions (inhibitory control, working memory, cognitive flexibility) to episodic memory performance were examined using abstract paintings. Right hemisphere frontotemporal functional connectivity during encoding and retrieval, measured via EEG alpha coherence, statistically predicted performance on recency but not recognition judgments for the abstract paintings. Theta coherence, however, did not predict performance. Likewise, cognitive flexibility statistically predicted performance on recency judgments, but not recognition. These findings suggest that recognition and recency operate via separate electrophysiological and executive mechanisms.

Operational Definition of Active and Healthy Ageing (AHA): A Conceptual Framework

Health is a multi-dimensional concept, capturing how people feel and function. The broad concept of Active and Healthy Ageing was proposed by the World Health Organisation (WHO) as the process of optimizing opportunities for health to enhance quality of life as people age. It applies to both individuals and population groups. A universal Active and Healthy Ageing definition is not available and it may differ depending on the purpose of the definition and/or the questions raised. While the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) has had a major impact, a definition of Active and Healthy Ageing is urgently needed. A meeting was organised in Montpellier, France, October 20-21, 2014 as the annual conference of the EIP on AHA Reference Site MACVIA-LR (Contre les Maladies Chroniques pour un Vieillissement Actif en Languedoc Roussillon) to propose an operational definition of Active and Healthy Ageing including tools that may be used for this. The current paper describes the rationale and the process by which the aims of the meeting will be reached.

Working Memory and Recollection Contribute to Academic Achievement

The contributions of working memory and recollection to academic achievement are typically examined separately and most often with children who have learning difficulties. This study is the first to observe both types of memory in the same study and in typically developing children. Academic achievement focused on standardized assessments of math fluency, calculation, reading fluency, and passage comprehension. As noted in previous studies, working memory was associated with each assessed measure of academic achievement. Recollection, however, specifically contributed to math fluency and passage comprehension. Thus, recollection should be considered alongside working memory in studies of academic achievement.

An Analog Filter Approach to Frequency Domain Fluorescence Spectroscopy

The rate equations found in frequency domain fluorescence spectroscopy are the same as those found in electronics under analog filter theory. Laplace transform methods are a natural way to solve the equations, and the methods can provide solutions for arbitrary excitation functions. The fluorescence terms can be modelled as circuit components and cascaded with drive and detection electronics to produce a global transfer function. Electronics design tools such as SPICE can be used to model fluorescence problems. In applications, such as remote sensing, where detection electronics are operated at high gain and limited bandwidth, a global modelling of the entire system is important, since the filter terms of the drive and detection electronics affect the measured response of the fluorescence signals. The techniques described here can be used to separate signals from fast and slow fluorophores emitting into the same spectral band, and data collection can be greatly accelerated by means of a frequency comb driver waveform and appropriate signal processing of the response. The simplification of the analysis mathematics, and the ability to model the entire detection chain, make it possible to develop more compact instruments for remote sensing applications.

A phase II RCT and economic analysis of three exercise delivery methods in men with prostate cancer on androgen deprivation therapy

BACKGROUND

Androgen deprivation therapy is commonly used to treat prostate cancer, the most common visceral cancer in men. However, various side effects often worsen physical functioning and reduce well-being among men on this treatment. Based on existing evidence, both resistance and aerobic training provide benefits for this population yet adherence rates are often low. The method of exercise delivery (supervised in-center or home-based) may be important, yet few studies have compared different models. Additionally, long-term exercise adherence is critical to achieve sustained benefits but long-term adherence data and predictors of adherence are lacking. The primary aim of this phase II, non-inferiority randomized controlled trial is to determine whether three exercise training delivery models are equivalent in terms of benefits in quality of life and physical fitness in this population. Secondary aims include examination of long-term adherence and cost-effectiveness.

DESIGN

Men diagnosed with prostate cancer, starting or continuing on androgen deprivation therapy for at least 6 months, fluent in English, and living close to one of two experienced Canadian study centers are eligible. Participants complete five assessments over one year, including a fitness assessment and self-report questionnaires. Socio-demographic and clinical data collection occur at baseline, bone mineral density testing at two time points, and blood work is performed at three time points. Participants are randomized in a 1:1:1 fashion to supervised personal training, supervised group training, or home-based smartphone- and health coach-supported training. Each participant receives a detailed exercise manual, including illustrations of exercises and safety precautions. Participants are asked to complete 4 to 5 exercise sessions per week, incorporating aerobic, resistance and flexibility training. Participant intensity levels will be monitored. The intervention duration is 6 months, with 6 months additional follow-up. Outcomes include: body composition, fitness testing, quality of life and fatigue, biological outcomes, and program adherence. Cost information will be obtained using patient diary-based self-report.

DISCUSSION

The goals of this study are to gain a better understanding of health benefits and costs associated with commonly used yet currently not compared exercise delivery models as well as an increased understanding of adherence to exercise.

TRIAL REGISTRATION

The trial has been registered at clinicaltrials.gov (Registration # NCT02046837), registered January 20(th), 2014.