Endoscopic and Histological Assessment, Correlation, and Relapse in Clinically Quiescent Ulcerative Colitis (MARQUEE)

OBJECTIVE

It is difficult to predict relapse in quiescent ulcerative colitis (UC), but newer endoscopic and histological indices could improve this. This study aimed to determine in UC patients in clinical remission (1) the prevalence of active endoscopic and histological disease; (2) the correlation between endoscopic and histological scores; and (3) the predictive power of these scores for clinical relapse.

DESIGN

This multicenter prospective cohort study conducted by the Crohn's and Colitis Foundation Clinical Research Alliance included 100 adults with UC in clinical remission undergoing surveillance colonoscopy for dysplasia. Endoscopic activity was assessed using the Mayo endoscopic score (MES), ulcerative colitis endoscopic index of severity (UCEIS), and ulcerative colitis colonoscopic index of severity (UCCIS). Histology was assessed with the Riley index subcomponents, total Riley score, and basal plasmacytosis.

RESULTS

Only 5% of patients had an MES of 0, whereas 38% had a score of 2 to 3; using the UCEIS, the majority of patients had at least mild activity, and 15% had more severe activity. Many patients also had evidence of histological disease activity. The correlations among endoscopic indices, histological subcomponents, and total score were low; the highest correlations occurred with the subcomponent architectural irregularity (ρ = 0.43-0.44), total Riley score (ρ = 0.35-0.37), and basal plasmacytosis (ρ = 0.35-0.36). Nineteen patients relapsed clinically over 1 year, with the subcomponent architectural irregularity being the most predictive factor (P = 0.0076).

CONCLUSIONS

This multicenter prospective study found a high prevalence of both endoscopic and histological disease activity in clinically quiescent UC. The correlations between endoscopy and histology were low, and the power to predict clinical relapse was moderate.

Autism Spectrum Social Stories In Schools Trial 2 (ASSSIST2): study protocol for a randomised controlled trial analysing clinical and cost-effectiveness of Social Stories™ in primary schools

Background

Interventions designed to support children with a diagnosis of Autism Spectrum Conditions (ASC) can be time consuming, needing involvement of outside experts. Social Stories™ are a highly personalised intervention aiming to give children with ASC social information or describing an otherwise difficult situation or skill. This can be delivered daily by staff in education settings. Studies examining Social Story™ use have yielded mostly positive results but have largely been single case studies with a lack of randomised controlled trials (RCTs). Despite this numerous schools are utilising Social Stories™, and a fully powered RCT is timely.

Methods

A multi-site pragmatic cluster RCT comparing care as usual with Social Stories™ and care as usual. This study will recruit 278 participants (aged 4–11) with a clinical diagnosis of ASC, currently attending primary school in the North of England. Approximately 278 school based staff will be recruited to provide school based information about participating children with approximately 140 recruited to deliver the intervention. The study will be cluster randomised by school. Potential participants will be screened for eligibility prior to giving informed consent. Follow up data will be collected at 6 weeks and 6 months post randomisation and will assess changes in participants’ social responsiveness, goal based outcomes, social and emotional health. The primary outcome measure is the Social Responsiveness Scale Second Edition (SRS-2) completed by school based staff at 6 months. Approvals have been obtained from the University of York’s Research Governance Committee, Research Ethics Committee and the Health Research Authority. Study results will be submitted for publication in peer-reviewed journals and disseminated to participating families, educational staff, local authority representatives, community groups and Patient and Participant Involvement representatives. Suggestions will be made to NICE about treatment evidence dependent on findings.

Discussion

This study addresses a much used but currently under researched intervention and results will inform school based support for primary school children with a diagnosis of ASC.

Trial registration

The trial is registered on the ISRCTN registry (registration number: ISRCTN11634810). The trial was retrospectively registered on 23rd April 2019.

AESOPS: a randomised controlled trial of the clinical effectiveness and cost-effectiveness of opportunistic screening and stepped care interventions for older hazardous alcohol users in primary care

BACKGROUND

There is clear evidence of the detrimental impact of hazardous alcohol consumption on the physical and mental health of the population. Estimates suggest that hazardous alcohol consumption annually accounts for 150,000 hospital admissions and between 15,000 and 22,000 deaths in the UK. In the older population, hazardous alcohol consumption is associated with a wide range of physical, psychological and social problems. There is evidence of an association between increased alcohol consumption and increased risk of coronary heart disease, hypertension and haemorrhagic and ischaemic stroke, increased rates of alcohol-related liver disease and increased risk of a range of cancers. Alcohol is identified as one of the three main risk factors for falls. Excessive alcohol consumption in older age can also contribute to the onset of dementia and other age-related cognitive deficits and is implicated in one-third of all suicides in the older population.

OBJECTIVE

To compare the clinical effectiveness and cost-effectiveness of a stepped care intervention against a minimal intervention in the treatment of older hazardous alcohol users in primary care.

DESIGN

A multicentre, pragmatic, two-armed randomised controlled trial with an economic evaluation.

SETTING

General practices in primary care in England and Scotland between April 2008 and October 2010.

PARTICIPANTS

Adults aged ≥ 55 years scoring ≥ 8 on the Alcohol Use Disorders Identification Test (10-item) (AUDIT) were eligible. In total, 529 patients were randomised in the study.

INTERVENTIONS

The minimal intervention group received a 5-minute brief advice intervention with the practice or research nurse involving feedback of the screening results and discussion regarding the health consequences of continued hazardous alcohol consumption. Those in the stepped care arm initially received a 20-minute session of behavioural change counselling, with referral to step 2 (motivational enhancement therapy) and step 3 (local specialist alcohol services) if indicated. Sessions were recorded and rated to ensure treatment fidelity.

MAIN OUTCOME MEASURES

The primary outcome was average drinks per day (ADD) derived from extended AUDIT--Consumption (3-item) (AUDIT-C) at 12 months. Secondary outcomes were AUDIT-C score at 6 and 12 months; alcohol-related problems assessed using the Drinking Problems Index (DPI) at 6 and 12 months; health-related quality of life assessed using the Short Form Questionnaire-12 items (SF-12) at 6 and 12 months; ADD at 6 months; quality-adjusted life-years (QALYs) (for cost-utility analysis derived from European Quality of Life-5 Dimensions); and health and social care resource use associated with the two groups.

RESULTS

Both groups reduced alcohol consumption between baseline and 12 months. The difference between groups in log-transformed ADD at 12 months was very small, at 0.025 [95% confidence interval (CI)--0.060 to 0.119], and not statistically significant. At month 6 the stepped care group had a lower ADD, but again the difference was not statistically significant. At months 6 and 12, the stepped care group had a lower DPI score, but this difference was not statistically significant at the 5% level. The stepped care group had a lower SF-12 mental component score and lower physical component score at month 6 and month 12, but these differences were not statistically significant at the 5% level. The overall average cost per patient, taking into account health and social care resource use, was £488 [standard deviation (SD) £826] in the stepped care group and £482 (SD £826) in the minimal intervention group at month 6. The mean QALY gains were slightly greater in the stepped care group than in the minimal intervention group, with a mean difference of 0.0058 (95% CI -0.0018 to 0.0133), generating an incremental cost-effectiveness ratio (ICER) of £1100 per QALY gained. At month 12, participants in the stepped care group incurred fewer costs, with a mean difference of -£194 (95% CI -£585 to £198), and had gained 0.0117 more QALYs (95% CI -0.0084 to 0.0318) than the control group. Therefore, from an economic perspective the minimal intervention was dominated by stepped care but, as would be expected given the effectiveness results, the difference was small and not statistically significant.

CONCLUSIONS

Stepped care does not confer an advantage over minimal intervention in terms of reduction in alcohol consumption at 12 months post intervention when compared with a 5-minute brief (minimal) intervention.

TRIAL REGISTRATION

This trial is registered as ISRCTN52557360.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 25. See the HTA programme website for further project information.

Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial

OBJECTIVES

To investigate the effectiveness of the systematic default provision of smoking cessation support to all adult smokers admitted to hospital, relative to usual care.

DESIGN

Open, cluster randomised controlled trial.

SETTING

Acute medical wards in one large teaching hospital in the United Kingdom.

PARTICIPANTS

264 patients randomised to intervention and 229 to usual care; primary outcome data were available at four weeks for 260 and 224 patients, respectively. All adult smokers and recent ex-smokers able to give informed consent were eligible for entry into the study.

INTERVENTIONS

The intervention comprised systematic smoking ascertainment and default provision of behavioural support and cessation pharmacotherapy for the duration of the hospital stay for all smokers and recent ex-smokers, with follow-up and referral to community services after discharge. Usual care comprised cessation support delivered at the initiative and discretion of clinical staff. All staff and patients were aware of group assignment.

MAIN OUTCOME MEASURES

Smoking cessation at four weeks, validated by measuring exhaled carbon monoxide. Secondary outcomes were uptake of inpatient behavioural support, use of cessation pharmacotherapy, referral to and uptake of community support after discharge, and validated smoking cessation at six months. Participants lost to follow-up were assumed to have reverted to smoking.

RESULTS

All patients in the intervention group received at least brief advice to quit smoking, compared to 106 (46%) patients in the usual care group. Cessation at four weeks was achieved by 38% (n=98) of intervention patients and 17% (n=37) of usual care patients (adjusted odds ratio 2.10 (95% confidence interval 0.96 to 4.61), P=0.06, number of patients needed to treat 8). Uptake of inpatient behavioural support, use of pharmacotherapy, and referral to and uptake of community support after discharge were all substantially and statistically significantly higher in the intervention group than in the usual care group. Cessation at six months was achieved by 19% (n=47) of intervention and 9% (n=19) of usual care patients, although this difference was not significant (adjusted odds ratio 1.53 (95% confidence interval 0.60 to 3.91); P=0.37).

CONCLUSIONS

Substantial improvements in smoking cessation among smokers admitted to hospital can be achieved by systematic ascertainment and delivery of cessation support in secondary care.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ISRCTN25441641.

SETTING STANDARDS FOR TRAINING AND COMPETENCE: THE UK ALCOHOL TREATMENT TRIAL

AIMS

To examine factors that influence the recruitment and training of therapists and their achievement of competence to practise two psychological therapies for alcohol dependence, and the resources required to deliver this.

METHODS

The protocol for the UK Alcohol Treatment Trial required trial therapists to be competent in one of the two trial treatments: Social Behaviour and Network Therapy (SBNT) or Motivational Enhancement Therapy (MET). Therapists were randomised to practise one or other type of therapy. To ensure standardisation and consistent delivery of treatment in the trial, the trial training centre trained and supervised all therapists.

RESULTS

Of 76 therapists recruited and randomised, 72 commenced training and 52 achieved competence to practise in the trial. Length of prior experience did not predict completion of training. However, therapists with a university higher qualification, and medical practitioners compared to other professionals, were more likely to complete. The average number of clients needed to be treated before the trainee achieved competence was greater for MET than SBNT, and there was a longer duration of training for MET.

CONCLUSIONS

Training therapists of differing professional backgrounds, randomised to provide a specific therapy type, is feasible. Supervision after initial training is important, and adds to the training costs.

Cost effectiveness of ward based non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease: economic analysis of randomised controlled trial

OBJECTIVE

To evaluate the cost effectiveness of standard treatment with and without the addition of ward based non-invasive ventilation in patients admitted to hospital with an acute exacerbation of chronic obstructive pulmonary disease.

DESIGN

Incremental cost effectiveness analysis of a randomised controlled trial.

SETTING

Medical wards in 14 hospitals in the United Kingdom.

PARTICIPANTS

The trial comprised 236 patients admitted to hospital with an acute exacerbation of chronic obstructive pulmonary disease and mild to moderate acidosis (pH 7.25-7.35) secondary to respiratory failure. The economic analysis compared the costs of treatment that these patients received after randomisation.

MAIN OUTCOME MEASURE

Incremental cost per in-hospital death.

RESULTS

24/118 died in the group receiving standard treatment and 12/118 in the group receiving non-invasive ventilation (P=0.05). Allocation to the group receiving non-invasive ventilation was associated with a reduction in costs of 49362 pounds sterling (78741 dollars; 73109 euros), mainly through reduced use of intensive care units. The incremental cost effectiveness ratio was -645 pounds sterling per death avoided (95% confidence interval -2310 pounds sterling to 386 pounds sterling), indicating a dominant (more effective and less costly) strategy. Modelling of these data indicates that a typical UK hospital providing a non-invasive ventilation service will avoid six deaths and three to nine admissions to intensive care units per year, with an associated cost reduction of 12000-53000 pounds sterling per year.

CONCLUSIONS

Non-invasive ventilation is a highly cost effective treatment that both reduced total costs and improved mortality in hospital.

Costs of employee smoking in the workplace in Scotland

BACKGROUND

Employers have responded to new regulations on the effects of passive smoking by introducing a range of workplace policies. Few policies include provision of smoking cessation intervention.

OBJECTIVE

To estimate the cost to employers of smoking in the workplace in Scotland to illustrate the potential gains from smoking cessation provision. Costs vary with type of smoking policy in place; therefore, to estimate these costs results from a survey were combined with evidence drawn from a literature review.

STUDY DESIGN

A telephone survey of 200 Scottish workplaces, based on a stratified random sample of workplaces with 50 or more employees, was conducted in 1996. Additional evidence was compiled from a review of the literature of smoking related costs and specific smoking related effects.

RESULTS

167 completed responses were received, of which 156 employers (93%) operated a smoking policy, 57 (34%) operated smoke free buildings, and 89 (53%) restricted smoking to a "smoke room". The research literature shows absenteeism to be higher among smokers when compared to non-smokers. The estimated cost of smoking related absence in Scotland is pound40 million per annum. Total productivity losses are estimated at approximately pound450 million per annum. In addition, the resource cost in terms of losses from fires caused by smoking materials is estimated at approximately pound4 million per annum. In addition, there are costs from smoking related deaths and smoking related damage to premises.

CONCLUSION

This study shows how smoking cessation interventions in the workplace can yield positive cost savings for employers, resulting in gains in productivity and workplace attendance which may outweigh the cost of any smoking cessation programme.

In vitro formation of a catabolic plasmid carrying Klebsiella pneumoniae DNA that allows growth of Escherichia coli K-12 on 3-hydroxybenzoate

The four enzymes needed to convert 3-hydroxybenzoate to pyruvate and fumarate via the gentisate pathway, as well as a putative positive regulator protein, were encoded on an 8 kb Sphl fragment of Klebsiella pneumoniae DNA. The five genes were clustered in the order regulator-gentisate dioxygenase-fumarylpyruvate hydrolase-3-hydroxybenzoate monooxygenase-maleylpyruvate isomerase (mhbRDHMI), with the catabolic genes transcribed in the dioxygenase to isomerase direction. 2-Hydroxybenzoate was found to be a non-metabolizable inducer analogue for the mhb genes, supporting the view that gentisate rather than maleylpyruvate was the physiological inducer. The plasmid pNDR20 encoding the full gentisate catabolic pathway endowed Escherichia coli with the ability to grow on 3-hydroxybenzoate but the host cell appeared to be responsible for substrate uptake.

Comprehensive surgical radiation oncology

Surgical radiation oncology uses surgical procedures to deliver or assist in the delivery of radiation to a tumor or tumor bed after resection. Intraoperative radiation therapy (IORT) bypasses radiosensitive skin and superficial structures and allows radiation to be delivered directly to the surgically exposed tumor. Removable brachytherapy places radioactive material inside or close to a tumor through hollow catheters positioned inside the tumor. Permanent brachytherapy inserts encapsulated radioactive seeds through needles attached to a mechanical gun directly into the tumor during surgery. This article discusses radiation precautions associated with each type of therapy and describes the nursing care needed by patients undergoing liver transplant radiation therapy.

2-Phenylethylamine catabolism by Escherichia coli K12

Escherichia coli K12 grows on 2-phenylethylamine as sole carbon and energy source by converting it, via phenylacetaldehyde, to phenylacetic acid. Phenylacetaldehyde was formed by the action of an inducible amine oxidase and catalase activity was increased sixfold, presumably to ensure removal of the H2O2 that was expected to be a product of the amine oxidation. The phenylacetaldehyde was oxidized to phenylacetic acid by an inducible NAD+-dependent dehydrogenase. Mutants defective in phenylacetaldehyde dehydrogenase cannot grow on 2-phenylethylamine as carbon and energy source but can still use it as a nitrogen source.

Isolation and mapping of Escherichia coli K12 mutants defective in phenylacetate degradation

Mutants of Escherichia coli K12 unable to grow on phenylacetate have been isolated and mapped. The mutations were located in the relatively 'silent' region of the E. coli K12 chromosome at min 30.4 on the genetic map, with the gene order rac pac-1 pac-2 trg.