Ethnicity and paediatric healthcare utilisation: Improving the quality of quantitative research

Background

The COVID-19 pandemic highlighted the stark health inequities affecting minority ethnic populations in Europe. However, research on ethnic inequities and healthcare utilisation in children has seldom entered the policy discourse. A scoping review was conducted in the UK, summarising and appraising the quantitative evidence on ethnic differences (unequal) and inequities (unequal and unfair or disproportionate to healthcare needs) in paediatric healthcare utilisation.

Methods

Embase, Medline and grey literature sources were searched for studies published 2001-2021. Studies that found differences and inequities were mapped by ethnic group and healthcare utilisation outcome. They were appraised using the National Institute for Health and Care Excellence appraisal checklists. The distribution of studies was described across various methodological parameters.

Results

Of the 61 included studies, most found evidence of ethnic variations in healthcare utilisation (n = 54, 89%). Less than half attempted to distinguish between ethnic differences and inequities (n = 27, 44%). Studies were concentrated on primary and preventive care and hospitalisation, with minimal evidence on emergency and outpatient care. The quality of studies was often limited by a lack of theory underpinning analytical decisions, resulting in conflation of difference and inequity, and heterogeneity in ethnic classification. The majority of studies examined children's ethnicity but overlooked parent/caregiver ethnicity, and also didn't investigate patterns across age, year or location.

Conclusions

To improve the validity, generalisability and comparability of research on ethnicity and paediatric healthcare utilisation, findings from this scoping review were used to develop recommendations for future research. These lessons could be applied more broadly across the European context to improve evidence generation and evidence-based policy-making to reduce inequities in healthcare.

Key messages

• Quantitative studies of ethnicity and paediatric healthcare utilisation in the UK lack the use of sound theoretical frameworks, and often do not distinguish between ethnic differences and inequities.

• The quality of future studies can be improved with greater attention to how ethnicity is classified and analysed, alongside specific considerations for examining healthcare utilisation in children.

1266 Digital Rectal Examination: Do You Still Put Your Foot in It If You Don’t Put Your Finger in It?

Introduction

Most surgical trainees are familiar with the aphorism ‘if you don’t put your finger in it, you put your foot in it’, with regards to digital rectal examination (DRE). This commonly taught maxim, attributed to Bailey and Love in their Short Practice of Surgery, was coined to highlight the folly of neglecting DRE in patients with histories suggestive of malignant anorectal pathology. However, data are lacking on the diagnostic yield of DRE for detecting anorectal cancer in patients with lower gastrointestinal bleeding (LGIB), whilst advances in biomarker and imaging technology beg the question: is there still a role for DRE in the assessment of patients with LGIB?

Method

We designed a clinical coding search strategy to identify all adult patients with acute LGIB referred to general surgery at a UK university hospital from January to July 2020. Electronic patient records were interrogated to identify history and examination findings, diagnoses and clinical outcomes.

Results

169 patients (median age 63 (16-94) years, 54.4% male) were identified, 74.6% (126/169) with bright red bleeding, 23.7% (40/169) with altered blood and 1.8% (3/169) with melaena. DRE was performed in 91.1% (154/169) of patients, identifying blood in 42.9% (66/154) of cases and suspicious lesions, which were subsequently confirmed as anorectal malignancy, in 1.3% (2/154).

Conclusions

DRE represents a possibly stigmatising and uncomfortable examination for patients and clinicians alike. These data support the utility of DRE in patients with LGIB and may inform the discussion at the bedside to facilitate the timely diagnosis of anorectal malignancy.

Descriptive data on cardiovascular and metabolic risk factors in ambulatory and non-ambulatory adults with cerebral palsy

Forty-two participants with cerebral palsy were recruited for a study examining traditional and novel indicators of cardiovascular risk (McPhee et al., 2015 [1]). Data pertaining to the prevalence of obesity, smoking, hypertension, and metabolic risk are provided. These data are presented along with the scoring methods used in evaluation of the study participants. Percentages are included for comparative purposes with the existing literature.

Effect of the 12-gene colon cancer assay results on adjuvant treatment recommendations in patients with stage II colon cancer

INTRODUCTION

The 12-gene colon cancer Recurrence Score assay is a clinically validated predictor of recurrence risk in stage II colon cancer patients. A survey was performed characterizing the assay's impact on treatment recommendations for these patients.

METHODS

US medical oncologists (n = 346) who ordered the assay for ≥3 stage II colon cancer patients were asked to complete a web-based survey regarding their most recent such patient. Physicians surveyed represented users of the assay within the first 2 years of commercial availability which may include 'early adopters'.

RESULTS

Most of 116 eligible physicians were in community practice (86%), with median 14.5 years' experience (range = 2-40). Mean patient age was 61 years (range = 32-85); 81% had T3 disease, and 38% had comorbidities. Of 76 patients tested for mismatch-repair/microsatellite-instability (MMR/MSI), 13 (17%) were MMR-deficient/MSI-high; 46 (61%) MMR-proficient/MSI-low; and 17 (22%) unknown. Most patients (84%) had ≥12 nodes examined. Median Recurrence Score result was 20 (range = 1-77). Before assay, treatment recommendations were specified for 92 (79%) patients, with no recommendation for 24 (21%). Of the 92 with pre-assay recommendations, chemotherapy was planned for 52 (57%) and observation for 40 (43%); the assay changed recommendations for 27 (29%). Treatment intensity decreased for 18 (67%) and increased for nine (33%) patients; it was more likely to decrease for lower Recurrence Score values and increase for higher values (p < 0.001).

CONCLUSION

For stage II colon cancer patients receiving Recurrence Score testing, 29% of treatment recommendations were changed. Use of the assay may lead to reductions in treatment intensity. Study limitations include retrospective design, data gathering during the first 2 years of assay availability only, and potential non-representativeness of respondents.

Characterization of a resistance locus (Pfs-1) to the spinach downy mildew pathogen (Peronospora farinosa f. sp. spinaciae) and development of a molecular marker linked to Pfs-1

Downy mildew is a destructive disease of spinach worldwide. There have been 10 races described since 1824, six of which have been identified in the past 10 years. Race identification is based on qualitative disease reactions on a set of diverse host differentials which include open-pollinated cultivars, contemporary hybrid cultivars, and older hybrid cultivars that are no longer produced. The development of a set of near-isogenic open-pollinated spinach lines (NILs), having different resistance loci in a susceptible and otherwise common genetic background, would facilitate identification of races of the downy mildew pathogen, provide a tool to better understand the genetics of resistance, and expedite the development of molecular markers linked to these disease resistance loci. To achieve this objective, the spinach cv. Viroflay, susceptible to race 6 of Peronospora farinosa f. sp. spinaciae, was used as the recurrent susceptible parent in crosses with the hybrid spinach cv. Lion, resistant to race 6. Resistant F(1) progeny were subsequently backcrossed to Viroflay four times with selection for race 6 resistance each time. Analysis of the segregation data showed that resistance was controlled by a single dominant gene, and the resistance locus was designated Pfs-1. By bulk segregant analysis, an amplified fragment length polymorphism (AFLP) marker (E-ACT/M-CTG) linked to Pfs-1 was identified and used to develop a co-dominant Sequence characterized amplified region (SCAR) marker. This SCAR marker, designated Dm-1, was closely linked ( approximately 1.7 cM) to the Pfs-1 locus and could discriminate among spinach genotypes that were homozygous resistant (Pfs-1Pfs-1), heterozygous resistant (Pfs-1pfs-1), or homozygous susceptible (pfs-1pfs-1) to race 6 within the original mapping population. Evaluation of a wide range of commercial spinach lines outside of the mapping population indicated that Dm-1 could effectively identify Pfs-1 resistant genotypes; the Dm-1 marker correctly predicted the disease resistance phenotype in 120 out of 123 lines tested. In addition, the NIL containing the Pfs-1 locus (Pfs-1Pfs-1) was resistant to multiple races of the downy mildew pathogen indicating Pfs-1 locus may contain a cluster of resistance genes.

How safe is adventure tourism in New Zealand? An exploratory analysis

The paper reports findings from a multidisciplinary programme of research, the major aims of which were to determine the nature and extent of the New Zealand adventure tourism injury problem. Analysis of hospital discharge and mortality data for a 15-year period identified adventure tourism-related activities as contributing to approximately 20% of overseas visitor injuries, and 22% of fatalities. Activities that commonly involve independent-unguided adventure tourism, notably mountaineering, skiing and tramping, contributed most to injury and fatality incidence. Horse riding and cycling activities were identified from hospital discharge data and adventure tourism operators' reported client injury-incidence, as the commercial adventure tourism activities most frequently involved in client injuries. Falls were the most common injury events, and a range of client, equipment, environmental and organisational risk factors were identified. Possible interventions to reduce injury risk among overseas and domestic adventure tourists are discussed.

Mapping between SNOMED RT and Clinical terms version 3: a key component of the SNOMED CT development process

SNOMED RT and Clinical Terms Version 3 are two large, controlled medical terminologies that are being merged to form a new work titled SNOMED Clinical Terms (SNOMED CT). One of the first steps in this process was to create maps between semantically equivalent and proximate concepts in the two terminologies. Same-as and is-a relationships were used to map the descriptions from one terminology to concepts in the other terminology. The objectives were to identify semantically equivalent concepts in the two terminologies, to find the most semantically proximate is-a relationships for non-equivalent concepts, and to evaluate the synonymy in the source terminologies. The results suggest that the rate of semantic overlap between descriptions in SNOMED RT and CTV3 is approximately 28%. This article discusses the methodology, issues, and findings of the description mapping process.

The sleep of older people in hospital and nursing homes

Disturbed sleep can affect personal wellbeing and impede the rehabilitation and recovery of older people from illness. This paper reports the findings of a pilot study which included examination of sleep quality and sleep patterns of older people in community hospital and nursing home settings. A marked proportion of older people reported sleeping well in nursing care settings, and those in nursing homes slept better than those in the community hospital. The main causes of sleep disturbance in both settings were: needing to go to the toilet, noise, pain, and discomfort; a similar pattern was seen across the different settings. No discernible difference was found in quality of sleep and whether patients felt rested or not between those patients on hypnotic medication and those who were not. The implications of the findings for practice and future research are discussed.

The geniculohypothalamic pathway in a congenitally anophthalmic mouse

In a previous study we described abnormalities in cytoarchitecture and vasoactive intestinal polypeptide distribution in the suprachiasmatic nucleus (SCN) of anophthalmic mice. However, the effect of anophthalmia on the geniculohypothalamic pathway, an important pathway for relay of photic information to the SCN, is not known. The present study examined the geniculohypothalamic pathway in congenitally anophthalmic and sighted control mice. The data demonstrate that the development of an intergeniculate leaflet (IGL), the expression of neuropeptide Y (NPY) by IGL neurons and the formation of NPY terminal fields in the SCN proceed in the absence of retinal input. Although the cytoarchitectural organization of the anophthalmic IGL differs from that of the control mouse, the distribution of NPY plexuses in the suprachiasmatic nucleus is remarkably similar.

Control of IgG/Fc glycosylation: a comparison of oligosaccharides from chimeric human/mouse and mouse subclass immunoglobulin Gs

Oligosaccharide profiles were obtained for chimeric mouse-human antibodies corresponding to each of the human IgG subclasses 1-4, and mouse IgG2b antibodies each expressed in the mouse J558L cell line. These antibodies have specificity for the NIP hapten and form a matched set of IgGs. An IgG4 chimeric antibody (B72.3) produced in the chinese hamster ovary (CHO-K1) cell line was also analysed for carbohydrate. Additionally aglycosylated mutants of this IgG4 (B72.3) and anti-NIP mouse IgG2b were analysed. The total lack of carbohydrate found in the aglycosylated site-directed mutants human chimeric IgG4 B72.3 (Asn 297-->Gln) and mouse IgG2b (Asn 297-->Ala) demonstrates that there are no N-glycosylation sites other than Asn 297. Therefore glycosylation profiles for all the IgGs analysed reflect carbohydrate attached to this site. Factors such as cell type (A), template direction by the IgG heavy chains (B) and culture conditions (C) are shown to influence IgG glycosylation profiles. (A) The anti-NIP IgG antibodies expressed by the J558L cell line may have one or two Gal (alpha 1-->3) Gal residues per oligosaccharide unit, indicative of the presence of (alpha 1-->3) galactosyl transferase in the J558L mouse cell line. (B) The galactosylation profiles obtained for the IgG heavy chains, in particular the preference for galactosylation of the Man (alpha 1-->6) arm rather than the Man (alpha 1-->3) arm, contrary to the beta-galactosyltransferase specificity, suggest that the polypeptide chain may act as a template to influence the extent of galactosylation and hence the proportions of each oligosaccharide incorporated. The IgG2 antibody does not display this galactosylation preference. (C) The extent of galactosylation appears to be influenced by the growth conditions, with the highest levels of galactosylation being found for IgG produced by cells grown in still cultures, rather than cells grown as ascites or in hollow fibre bioreactors. It is concluded that though the profile of glycosylation is controlled predominantly by the glycosylation activity of the cell in which the IgG is expressed, differences between the IgG heavy chain templates of the various subclasses and culture conditions can also influence glycosylation.

Multiple binding sites on the CH2 domain of IgG for mouse Fc gamma R11

Important mammalian defensive functions such as phagocytosis are triggered in leukocytes by the interaction of the Fc region of IgG with cell surface receptors (Fc gamma R). The CH2 domain of IgG has been implicated previously as the site of interaction with human and mouse Fc gamma R. This domain was mapped for interaction with mouse Fc gamma R11 expressed by the macrophage-like cell line P388D1, using two panels of a total of 32 site-directed mutants of mouse IgG2b and chimeric human IgG3 monoclonal antibodies. Two potential binding sites have been identified: one in or within the vicinity of the lower hinge site on IgG for human Fc gamma R1, and one within the binding site on IgG for Clq. The three mutant IgGs (Gly 237----Ala, Asn 297----Ala, and Glu 318----Ala) which do not interact in complexed form also fail to bind as monomers. A 1H NMR study of the three non-binding monomeric mutants suggests that the mutations are largely site-specific, indicating that IgG interacts with mouse Fc gamma R11 at two regions within the CH2 domain. This interaction dictates phagocytosis mediated by Fc gamma R11 of the P388D1 cell line.