Explaining local variation in referrals from health services to children's social care in England 2013-16: a study using 'children in need' administrative data

Background

Referral rates from Health service to Children’s Social Care (CSC) services vary across England. In 2019, the National Audit Office (re)iterated the urgent need to understand the drivers of such variation.

Methods

Using administrative data (Children in Need Census, 2013–16), we calculated annual referral rates from Health to CSC services (Health referral rate) by Local Authority (LA) areas. We used multilevel linear regression to investigate the relationship between age-adjusted Health referral rates and local need (demand factors) and local practice/systems (supply factors). We present a tool to compare unadjusted and adjusted LA rates.

Results

There was high LA variation in Health referral rates, particularly for infants (mean = 29.0/1000 children < 1 y; range = 6.5–101.8; sd = 12.4). LA variation persisted after age-adjustment. Child poverty (local need) and overall referral rate (local practice/systems) explained 60% of variation in age-adjusted Health referral rates. Overall referral rate was the strongest predictor. Adjusted referral rates were substantially different from unadjusted rates. After adjustment, 57.7% of LAs had higher/lower Health referral rates than expected.

Conclusions

While higher levels of local need are associated with higher Health referrals, some areas have high Health referrals irrespective of local need. Our tool demonstrates the benefits of using adjusted rates to compare LAs.

Folic acid supplementation in postmenopausal women with hot flushes: phase III randomised double-blind placebo-controlled trial

OBJECTIVE

To assess whether folic acid supplementation ameliorates hot flushes.

DESIGN

Double-blind, placebo-controlled randomised trial.

SETTING

Nine hospitals in England.

POPULATION

Postmenopausal women experiencing ≥50 hot flushes weekly.

METHODS

Women (n = 164) were randomly assigned in a 1:1 ratio to receive folic acid 5 mg tablet or placebo daily for 12 weeks. Participants recorded frequency and severity of hot flushes in a Sloan Diary daily and completed Greene Climacteric and Utian Quality of Life (UQoL) Scales at 4-week intervals.

MAIN OUTCOME MEASURES

The change in daily Hot Flush Score at week 12 from randomisation based on Sloan Diary Composite Score B calculation.

RESULTS

Data of 143 (87%) women were available for the primary outcome. The mean change (SD) in Hot Flush Score at week 12 was -6.98 (10.30) and -4.57 (9.46) for folic acid and placebo group, respectively. The difference between groups in the mean change was -2.41 (95% CI -5.68 to 0.87) (P = 0.149) and in the adjusted mean change -2.61 (95% CI -5.72 to 0.49) (P = 0.098). Analysis of secondary outcomes indicated an increased benefit in the folic acid group regarding changes in total and emotional UQoL scores at week 8 when compared with placebo. The difference in the mean change from baseline was 5.22 (95% CI 1.16-9.28) and 1.88 (95% CI 0.23-3.52) for total and emotional score, respectively.

CONCLUSIONS

The study was not able to demonstrate that folic acid had a statistically significant greater benefit in reducing Hot Flush Score over 12 weeks in postmenopausal women when compared with placebo.

TWEETABLE ABSTRACT

Folic acid may ameliorate hot flushes in postmenopausal women but confirmation is required from a larger study.

Abstract P1-16-08: Response to subsequent therapy after dual immune checkpoint blockade in metastatic breast cancer

Introduction: While initial studies have found that combining chemotherapy with immune checkpoint blockade (ICB) can augment responses, additional toxicity has been observed. The optimal sequencing of chemotherapy and ICB has not yet been described. Sequential responses to chemotherapy after ICB have been reported in various tumor types; however, data is limited, and this has not been described in breast cancer to date.

Methods: We identified patients (pts) from a small pilot study in HER2-negative metastatic breast cancer (MBC) who received at least 1 cycle of durvalumab (PD-L1 inhibitor) and tremelimumab (CTLA-4 inhibitor). We excluded pts without follow up data or if they did not receive subsequent systemic therapy. Comparison of differences between subgroups was calculated by Fisher's exact test for categorical variables and Wilcoxon rank-sum test for continuous variables. Time to treatment failure (TTF) of subsequent therapy and overall survival (OS) were assessed by the Kaplan-Meier method and differences between breast cancer subtype were compared by log-rank tests.

Results: Twenty-three pts received at least 1 cycle of ICB of whom 14 pts were eligible for this analysis. Nine had estrogen receptor positive (ER+) BC and 5 had triple negative (TN) BC. There were no statistically significant differences between the ER+ and TN subgroups in age, race, ethnicity, ECOG performance status (PS) at end of ICB, or sites of metastatic disease except for more lymph node metastases in the TN cohort (p=0.003). Overall response rates to ICB in this cohort was higher in TN vs ER+ (40% vs 0%, p=0.11). Pts received a median of 4 lines of systemic therapy for MBC prior to ICB. Subsequent therapy after ICB was eribulin in 29%, carboplatin/gemcitabine in 21%, palbociclib + endocrine therapy (ET) in 14%, anthracycline in 14%, ixabepilone +/- capecitabine in 14%, and paclitaxel in 7%. Clinical response was seen in 8 pts (57%), of whom 5 had ER+ BC and 3 had TNBC. The median TTF of subsequent therapy was 3.0 mo (1.9, 5.5), which compared to a median TTF for therapy prior to ICB of 2.5 mo. The median OS was 12.3 mo (2.3-13.3). There were no significant differences between the ER+ and TN cohorts (log-rank test p=0.74 and 0.90 for TTF and OS, respectively. Subsequent therapy was discontinued due to progressive disease in 44%, decline in PS in 19%, liver failure in 6%, treatment related adverse event in 6%, and unknown cause in 13%. Two pts remain on subsequent therapy with palbociclib + ET beyond 6 mo without disease progression. There were no statistically significant differences between TTF &gt;3 mo (n=5) and TTF &lt;3 mo (n=9) subgroups. Pts with TTF &gt;3 mo were numerically more likely to have a PS 0-1 (100 vs 78%), liver metastases (80 vs 56%), and ER+ BC (80 vs 56%). Pts with TTF &lt;3 mo had more lymphopenia (66% vs 20%) and more lines of prior systemic therapy for MBC (median 6 vs 4).

Conclusions: While median duration of response on subsequent therapy was short, a subset of pts had significant clinical responses. These findings provide rationale for prospective validation as they provide strategies for sequencing ICB with standard therapies.

Citation Format: Shah AN, Yalamanchili A, Helenowski I, Bhole S, Woodman J, Gradishar WJ, Cristofanilli M, Santa-Maria CA. Response to subsequent therapy after dual immune checkpoint blockade in metastatic breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-16-08.

Effect of Dexamethasone on Resting Blood Lactate Concentrations in Horses

Background

Blood lactate concentration is a marker of tissue perfusion and helps guide therapeutic interventions in critically ill horses. In both humans and dogs, administration of corticosteroids can increase blood lactate concentration, leading to type B hyperlactatemia. This effect could be a consequence of the impact of corticosteroids on glucose metabolism.

Objectives

To investigate the effects of daily IM dexamethasone administration on blood lactate and glucose concentrations in horses.

Animals

Nine healthy adult horses.

Methods

A randomized, blinded, controlled, cross‐over study design was used. Horses were randomly assigned to 1 of 2 groups, either receiving 0.05 mg/kg of dexamethasone IM or an equivalent volume of saline, daily for 7 days. Blood was collected to determine lactate and glucose concentrations at baseline, 2 hours after the daily injections and 24 hours after the last injection.

Results

Dexamethasone treatment had a statistically significant effect on lactate (P = .006) and glucose (P = .033) concentrations. The least squares mean lactate concentration was 0.93 mmol/L (95% CI: 0.87–0.99) in the dexamethasone group compared to 0.71 mmol/L (95% CI: 0.70–0.73) for the saline group. A positive relationship between blood lactate and glucose concentrations was identified, with a 0.07 mmol/L (95% CI: 0.05–0.09) increase in lactate concentration per unit increase in glucose (P < .0001) concentration.

Conclusions and Clinical Importance

Dexamethasone induces statistically significant increases in blood lactate and glucose concentrations in healthy horses. Awareness of the potential for corticosteroids to induce type B hyperlactatemia might be important in the management of critically ill horses receiving dexamethasone.

Teachers of the Alexander Technique in the UK and the people who take their lessons: A national cross-sectional survey

OBJECTIVES

Given the rising profile of the Alexander Technique in the UK, there is a need for a comprehensive description of its teachers and of those who currently take lessons. In a national survey of Alexander teachers, we set out to address this information gap.

DESIGN

A cross-sectional survey of 871 UK members of three main Alexander Technique teachers' professional associations was conducted. A questionnaire requested information about their professional background, teaching practice and methods, and about the people who attend lessons and their reasons for seeking help.

RESULTS

With an overall response rate of 61%, 534 teachers responded; 74% were female with median age of 58 years, 60% had a higher education qualification, and 95% were self-employed, many with additional non-Alexander paid employment. The majority (87%) offered lessons on their own premises or in a privately rented room, and 19% provided home visits; both individual and group lessons were provided. People who took lessons were predominantly female (66%) with a median age of 48 years, and 91% paid for their lessons privately. Nearly two-thirds (62%) began lessons for reasons related to musculoskeletal conditions, including back symptoms, posture, neck pain, and shoulder pain. Other reasons were general (18%, including well-being), performance-related (10%, including voice-, music-, and sport-related), psychological (5%) and neurological (3%). We estimate that Alexander teachers in the UK provide approximately 400,000 lessons per year.

CONCLUSIONS

This study provides an overview of Alexander Technique teaching in the UK today and data that may be useful when planning future research.

Acute respiratory failure in a 35-year-old woman following preterm vaginal delivery

A 35-year-old woman, a non-smoker with a normal body mass index, 'felt wheezy' and developed profound hypoxia 30 min after preterm vaginal delivery at 24+ weeks of gestation. She denied other symptoms, had no fever but was tachycardic and tachypnoeic with normal blood pressure. Pulmonary embolism, amniotic fluid embolism, cardiomyopathy, arrhythmias, sepsis and non-cardiogenic pulmonary oedema were considered as differential diagnoses. Chest X-ray showed an increased pulmonary vasculature, but the blood tests, ECG, echocardiogram and CT pulmonary angiogram were essentially normal. She was managed on a high dependency area with high-flow oxygen and intravenous antibiotics. She improved dramatically and the oxygen requirements dropped to 2 L over the next 4 h. It is plausible that this woman had acute non-cardiogenic pulmonary oedema secondary to a combination of risk factors. This case highlights the importance of a methodical and multidisciplinary approach for a prompt diagnosis and successful treatment of an acutely ill parturient.

Screening injured children for physical abuse or neglect in emergency departments: a systematic review

BACKGROUND

Screening markers are used in emergency departments (EDs) to identify children who should be assessed for possible physical abuse and neglect. We conducted three systematic reviews evaluating age, repeat attendance and injury type as markers for physical abuse or neglect in injured children attending EDs.

METHODS

We included studies comparing markers in physically abused or neglected children and non-abused injured children attending ED or hospital. We calculated likelihood ratios (LRs) for age group, repeat attendance and injury type (head injury, bruises, fractures, burns or other). Given the low prevalence of abuse or neglect, we considered that an LR of 10 or more would be clinically useful.

RESULTS

All studies were poor quality. Infancy increased the risk of physical abuse or neglect in severely injured or admitted children (LRs 7.7-13.0, 2 studies) but was not strongly associated in children attending the ED (LR 1.5, 95% CI: 0.9, 2.8; one study). Repeat attendance did not substantially increase the risk of abuse or neglect and may be confounded by chronic disease and socio-economic status (LRs 0.8-3.9, 3 studies). One study showed no evidence that the type of injury substantially increased the risk of physical abuse or neglect in severely injured children.

CONCLUSIONS

There was no evidence that any of the markers (infancy, type of injury, repeated attendance) were sufficiently accurate (i.e. LR >or= 10) to screen injured children in the ED to identify those requiring paediatric assessment for possible physical abuse or neglect. Clinicians should be aware that among injured children at ED a high proportion of abused children will present without these characteristics and a high proportion of non-abused children will present with them. Information about age, injury type and repeat attendances should be interpreted in this context.

Use made by patients of chronic disease surveillance consultations in general practice

A prospective, observational study of chronic disease surveillance consultations over a six-month period was performed in one semi-rural general practice in order to determine the content of the consultations, including incidental items not relevant to the chronic disease. At least one incidental item was recorded during 43% of consultations. There was substantial clinical content in these items: 23% of items required a prescription to be issued and 7% referral to a specialist. It is concluded that chronic disease surveillance consultations in general practice are frequently extended by patients who are anxious to discuss issues which may not be relevant to their chronic diseases. General practitioners must be sensitive to such patient expectations when they instigate chronic disease management clinics.