The economic and resource burden of e-scooter-related orthopaedic injuries: A district general hospital's experience

PURPOSE

Electric scooters (e-scooters) are an increasingly popular method of transportation worldwide. However, there are concerns regarding their safety, specifically with regards to orthopaedic injuries. We aimed to investigate the overall burden and financial impact on orthopaedic services as a result of e-scooter-related orthopaedic injuries.

METHODS

We retrospectively identified all e-scooter-related injuries requiring orthopaedic admission or surgical intervention in a large District General Hospital in England over a 16-month period between September 2020 and December 2021. Injuries sustained, surgical management, inpatient stay and resources used were calculated.

RESULTS

Seventy-nine patients presented with orthopaedic injuries as a result of e-scooter transportation with a mean age of 30.1 years (SD 11.6), of which 62 were males and 17 were females. A total of 86 individual orthopaedic injuries were sustained, with fractures being the most common type of injury. Of these, 23 patients required 28 individual surgical procedures. The combined theatre and recovery time of these procedures was 5500 min, while isolated operating time was 2088 min. The total cost of theatre running time for these patients was estimated at £77,000. A total of 17 patients required hospital admission under Trauma and Orthopaedics, which accounted for total combined stay of 99 days with a mean length of stay of 5.8 days.

CONCLUSION

While there are potential environmental benefits to e-scooters, we demonstrate the risks of injury associated with their use and the associated increased burden to the healthcare system through additional emergency attendances, frequent outpatient clinic appointments, surgical procedures, and hospital inpatient admissions.

Preliminary findings from a risk stratification, quality of life and burden of illness in pulmonary arterial hypertension pilot study

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Janssen Australia and New Zealand (Janssen-Cilag Pty Ltd)

Pulmonary Arterial Hypertension (PAH) management strategies focus on lowering mortality risk, extending the patient’s life span through the control and alleviation of disease symptoms, improving Quality of Life (QoL) and decreasing the burden of illness.

This paper describes preliminary results of an Investigator Initiated pilot study exploring the relationship between PRO measures (PAH-SYMPACT, EQ5D5L); Burden of Illness assessment; and the ESC/ERS Risk Stratification.

Findings

Measures of PAH risk and QoL were assessed in 42 patients presenting to the IPAH clinic for management; mean age 69.2 [range 39, 84]; females 35 (83.3%), males 7 (16.7%). Tools analysed and compared included: PAH-SYMPACT and EQ-5D-5L as PRO and QoL measures; and ESC-ERS PAH risk stratification criteria to assess mortality risk. Health utility scores were derived from existing value sets: there was a 20% median reduction in QALYs for our patient population, with detrimental effects being more marked in those patients with greater impairment of EQ-5D-5L physical and cognitive-emotional domains (respectively: r = -0.92, p<0.001; and r = -0.85, p<0.001), PAH-SYMPACT physical domain reduction (r = -0.59, p<0.01), and PAH-SYMPACT cardiovascular symptoms (r = 0.64), p<0.01) and cardiorespiratory (r = 0.64, p<0.01) involvement. Physical domain scores were highly correlated for the two PROs studied (r = 0.74, p<0.001), but an unexpected poor correlation was seen in the cognitive/emotional domain (non-significant negative correlation) which requires further exploration. Unsurprisingly, EQ-5D-5L Visual Analogue Score for well-being was inversely correlated with physical domain impairment (r = -0.59, p<0.01), although it was noted that this did not apply for the cognitive/emotional domain. The agreement between tools was variable, with highest concordance seen for assessment of the physical domain (r = 0.74, p<0.001), and this raises the need to further define the merits of disease-specific (PAH-SYMPACT) vs generic (EQ-5D-5L) PRO analytic approaches. Tools examined in this study were well-correlated with symptomatic impairment, but neither PRO tool correlated with established risk markers as characterized in compound prognostic guides such as ESC-ERS criteria.

Conclusions

The fact that PRO indices showed little correlation with established risk stratification markers implies that the information provided by PROs is not redundant, and it is yet be assessed whether the incorporation of PRO’s may add further to the precision of risk assessment, a little-studied area which this group is further exploring. There should be more widespread and uniform use of PRO measures as part of standard PAH management.

Implementing an eHealth tool to improve referral services for obstetric emergencies in Sierra Leone

Background

Maternal health remains a major issue of concern in Sierra Leone. In the main referral maternity institution, Princess Christian Maternity Hospital (PCMH), up to 25% of maternal deaths occur during or shortly after transit from another health facility. There is an urgent need to improve referral systems between peripheral health units (PHUs) and PCMH. Our aim was to pilot and evaluate an eHealth tool facilitating referral of obstetric emergency cases through effective teleconsultation between PHUs and PCMH.

Methods

A web application was designed to capture unclear or complicated delivery cases at PHUs and request respective telemedical counselling from the referral institution PCMH. The eHealth tool was piloted at 10 PHUs in Western area urban and rural in August 2021. Necessary devices were provided and delivery staff was trained to use the app. In December 2021, we conducted focus group discussion with 3-6 delivery staff at five PHUs and at PCMH to evaluate utilization and outcomes of the tool.

Results

All participants perceived the eHealth tool as an improvement of referral procedures. Response time from PCMH after a request for counselling from a PHU was mostly <30 minutes. The main perceived advantage of the tool was the systematic documentation of obstetric complications and procedures. This relieved staff from fear of wrong treatment accusations, and recorded communication with PCMH made processes and responsibilities transparent. Another important benefit was PCMH staff being already prepared to receive a specific emergency case after use of the app, thus reducing the ‘third delay’ within the referral facility. As a major obstacle to smooth referral despite the eHealth tool, a lacking ambulance system was mentioned as a critical gap.

Conclusions

Exceedingly positive user experiences with this simple tool seem to make an expansion to more PHUs worthwhile. Benefits of using the app in more remote districts in Sierra Leone should be further investigated.

Key messages

• Delivery staff in Sierra Leone was capable of using a web app for telemedical counselling in a useful and effective manner.

• The eHealth tool was perceived as very helpful in systematically and transparently documenting emergency delivery cases and treatment procedures.

145 Best Medical Therapy for Patients with Peripheral Arterial Disease: A Quality Improvement Project in Vascular Surgery, Aberdeen Royal Infirmary

Introduction

Peripheral arterial disease (PAD) is the leading cause of limb amputation and cardiovascular morbidity. The National Institute for Health and Care Excellence (NICE) advocates best medical therapy (BMT) with high-dose statin (atorvastatin 80mg) and antiplatelets (clopidogrel or aspirin) for secondary prevention in patients with PAD. We assessed compliance to BMT prescribing in our vascular department.

Method

Retrospective data were collected for all patients admitted with symptomatic PAD in our vascular department over a 2-week period. Criteria for BMT were as per NICE guidelines with a standard set to 100%. Following cycle 1, a new admission document prompting antiplatelet and statin review was designed and departmental teaching on BMT delivered. Standard compliance was re-audited after 3 months.

Results

Twenty-five patients were admitted with PAD during cycle 1 with 28% of patients (n = 7) on BMT on admission. This increased to 40% (n = 10) on discharge with 100% (n = 25) on an antiplatelet and 28% (n = 7) on high-dose statin. Overall, there were twenty patients in cycle 2 with 25% of patients (n = 5) on BMT on admission. This increased to 80% (n = 16) on discharge with 100% (n = 20) on an antiplatelet and 80% (n = 16) on high-dose statin.

Conclusions

Our data demonstrated poor implementation of BMT for patients with PAD managed in primary care suggesting a need for primary care education. Adaption of our admission proforma to prompt BMT prescribing as well as departmental teaching was associated with drastic improvement of BMT prescription on discharge and standard adherence.

Sensitivity of RT-PCR testing of upper respiratory tract samples for SARS-CoV-2 in hospitalised patients: a retrospective cohort study

Background: This study aimed to determine the sensitivity and specificity of reverse transcription PCR (RT-PCR) testing of upper respiratory tract samples from hospitalised patients with coronavirus disease 2019 (COVID-19), compared to the gold standard of a clinical diagnosis. Methods: All RT-PCR testing for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in NHS Lothian, Scotland, United Kingdom between the 7 th of February and 19 th April 2020 (inclusive) was reviewed, and hospitalised patients were identified. All upper respiratory tract RT-PCR tests were analysed for each patient to determine the sequence of negative and positive results. For those who were tested twice or more but never received a positive result, case records were reviewed, and a clinical diagnosis of COVID-19 allocated based on clinical features, discharge diagnosis, and radiology and haematology results. For those who had a negative RT-PCR test but a clinical diagnosis of COVID-19, respiratory samples were retested using a multiplex respiratory panel, a second SARS-CoV-2 RT-PCR assay, and a human RNase P control. Results: Compared to the gold standard of a clinical diagnosis of COVID-19, the sensitivity of a single upper respiratory tract RT-PCR for COVID-19 was 82.2% (95% confidence interval 79.0-85.1%).   The sensitivity of two upper respiratory tract RT-PCR tests increased sensitivity to 90.6% (CI 88.0-92.7%). A further 2.2% and 0.9% of patients who received a clinical diagnosis of COVID-19 were positive on a third and fourth test; this may be an underestimate of the value of further testing as the majority of patients 93.0% (2999/3226) only had one or two RT-PCR tests. Conclusions: The sensitivity of a single RT-PCR test of upper respiratory tract samples in hospitalised patients is 82.2%. Sensitivity increases to 90.6% when patients are tested twice.  A proportion of cases with clinically defined COVID-19 never test positive on RT-PCR despite repeat testing.

Development of a novel micro-bead force spectroscopy approach to measure the ability of a thermo-active polymer to remove bacteria from a corneal model

Microbial keratitis occurs from the infection of the cornea by fungi and or bacteria. It remains one of the most common global causes of irreversible blindness accounting for 3.5% (36 million) of blind people as of 2015. This paper looks at the use of a bacteria binding polymer designed to bind Staphylococcus aureus and remove it from the corneal surface. Mechanical unbinding measurements were used to probe the interactions of a thermo-active bacteria-binding polymer, highly-branched poly(N-isopropyl acrylamide), functionalised with modified vancomycin end groups (HB-PNIPAM-Van) to bacteria placed on rabbit corneal surfaces studied ex-vivo. This was conducted during sequential temperature phase transitions of HB-PNIPAM-Van-S. aureus below, above and below the lower critical solution temperature (LCST) in 3 stages, in-vitro, using a novel micro-bead force spectroscopy (MBFS) approach via atomic force microscopy (AFM). The effect of temperature on the functionality of HB-PNIPAM-Van-S. aureus showed that the polymer-bacteria complex reduced the work done in removing bacterial aggregates at T > LCST (p < 0.05), exhibiting reversibility at T < LCST (p < 0.05). At T < LCST, the breaking force, number of unbinding events, percentage fitted segments in the short and long range, and the percentage of unbinding events occurring in the long range (> 2.5 µm) increased (p < 0.05). Furthermore, the LCST phase transition temperature showed 100 × more unbinding events in the long-range z-length (> 2.5 µm) compared to S. aureus aggregates only. Here, we present the first study using AFM to assess the reversible mechanical impact of a thermo-active polymer-binding bacteria on a natural corneal surface.

Risk factors for preeclampsia and eclampsia at a main referral maternity hospital in Freetown, Sierra Leone: a case-control study

BACKGROUND

In the African region, 5.6% of pregnancies are estimated to be complicated by preeclampsia and 2.9% by eclampsia, with almost one in ten maternal deaths being associated with hypertensive disorders. In Sierra Leone, representing one of the countries with the highest maternal mortality rates in the world, 16% of maternal deaths were caused by pregnancy-induced hypertension in 2016. In the light of the high burden of preeclampsia and eclampsia (PrE/E) in Sierra Leone, we aimed at assessing population-based risk factors for PrE/E to offer improved management for women at risk.

METHODS

A facility-based, unmatched observational case-control study was conducted in Princess Christian Maternity Hospital (PCMH). PCMH is situated in Freetown and is the only health care facility providing 'Comprehensive Emergency Obstetric and Neonatal Care services' throughout the entire country. Cases were defined as pregnant or postpartum women diagnosed with PrE/E, and controls as normotensive postpartum women. Data collection was performed with a questionnaire assessing a wide spectrum of factors influencing pregnant women's health. Statistical analysis was performed by estimating a binary logistic regression model.

RESULTS

We analyzed data of 672 women, 214 cases and 458 controls. The analysis yielded several independent predictors for PrE/E, including family predisposition for PrE/E (AOR = 2.72, 95% CI: 1.46-5.07), preexisting hypertension (AOR = 3.64, 95% CI: 1.32-10.06), a high mid-upper arm circumflex (AOR = 3.09, 95% CI: 1.83-5.22), presence of urinary tract infection during pregnancy (AOR = 2.02, 95% CI: 1.28-3.19), presence of prolonged diarrhoea during pregnancy (AOR = 2.81, 95% CI: 1.63-4.86), low maternal assets (AOR = 2.56, 95% CI: 1.63-4.02), inadequate fruit intake (AOR = 2.58, 95% CI: 1.64-4.06), well or borehole water as the main source of drinking water (AOR = 2.05, 95% CI: 1.31-3.23) and living close to a waste deposit (AOR = 1.94, 95% CI: 1.15-3.25).

CONCLUSION

Our findings suggest that systematic assessment of identified PrE/E risk factors, including a family predisposition for PrE/E, preexisting hypertension, or obesity, should be performed early on in ANC, followed by continued close monitoring of first signs and symptoms of PrE/E. Additionally, counseling on nutrition, exercise, and water safety is needed throughout pregnancy as well as education on improved hygiene behavior. Further research on sources of environmental pollution in Freetown is urgently required.

A sensitive and affordable multiplex RT-qPCR assay for SARS-CoV-2 detection

With the ongoing COVID-19 (Coronavirus Disease 2019) pandemic, caused by the novel coronavirus SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2), there is a need for sensitive, specific, and affordable diagnostic tests to identify infected individuals, not all of whom are symptomatic. The most sensitive test involves the detection of viral RNA using RT-qPCR (quantitative reverse transcription PCR), with many commercial kits now available for this purpose. However, these are expensive, and supply of such kits in sufficient numbers cannot always be guaranteed. We therefore developed a multiplex assay using well-established SARS-CoV-2 targets alongside a human cellular control (RPP30) and a viral spike-in control (Phocine Herpes Virus 1 [PhHV-1]), which monitor sample quality and nucleic acid extraction efficiency, respectively. Here, we establish that this test performs as well as widely used commercial assays, but at substantially reduced cost. Furthermore, we demonstrate >1,000-fold variability in material routinely collected by combined nose and throat swabbing and establish a statistically significant correlation between the detected level of human and SARS-CoV-2 nucleic acids. The inclusion of the human control probe in our assay therefore provides a quantitative measure of sample quality that could help reduce false-negative rates. We demonstrate the feasibility of establishing a robust RT-qPCR assay at approximately 10% of the cost of equivalent commercial assays, which could benefit low-resource environments and make high-volume testing affordable.

Evaluation of the molecular detection of ciprofloxacin resistance in Neisseria gonorrhoeae by the ResistancePlus GC assay (SpeeDx)

There is growing concern due to the emergence of multidrug resistance in Neisseria gonorrhoeae. A rapid molecular test which guides and provides antimicrobial susceptibility knowledge prior to start of treatment is needed. This study evaluated the clinical performance of the ResistancePlus GC assay compared to in-house PCR and antimicrobial susceptibility results for ciprofloxacin resistance. Samples were selected from a range of sites with corresponding cultures isolated from the same patient episode. The ResistancePlus GC assay displayed high sensitivity for N. gonorrhoeae detection (98.5%) and gyrA detection (97.1%). There was high agreement (98.9%) between the ResistancePlus GC assay and culture phenotype. Mixed population testing showed that the assay was able to detect resistance in a sample containing a minority variant of 27% resistant. The ResistancePlus GC assay performed well and could be used to provide a clinically relevant indication of ciprofloxacin susceptibility for the treatment of gonorrhoea.

Sensitivity of RT-PCR testing of upper respiratory tract samples for SARS-CoV-2 in hospitalised patients: a retrospective cohort study

Background: This study aimed to determine the sensitivity and specificity of reverse transcription PCR (RT-PCR) testing of upper respiratory tract (URT) samples from hospitalised patients with coronavirus disease 2019 (COVID-19), compared to the gold standard of a clinical diagnosis. Methods: All URT RT-PCR testing for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in NHS Lothian, Scotland, United Kingdom between the 7 th of February and 19 th April 2020 (inclusive) was reviewed, and hospitalised patients were identified. All URT RT-PCR tests were analysed for each patient to determine the sequence of negative and positive results. For those who were tested twice or more but never received a positive result, case records were reviewed, and a clinical diagnosis of COVID-19 allocated based on clinical features, discharge diagnosis, and radiology and haematology results. For those who had a negative RT-PCR test but a clinical diagnosis of COVID-19, respiratory samples were retested using a multiplex respiratory panel, a second SARS-CoV-2 RT-PCR assay, and a human RNase P control. Results: Compared to the gold standard of a clinical diagnosis of COVID-19, the sensitivity of a single upper respiratory tract RT-PCR for COVID-19 was 82.2% (95% confidence interval 79.0-85.1%).   The sensitivity of two upper respiratory tract RT-PCR tests increased sensitivity to 90.6% (CI 88.0-92.7%). A further 2.2% and 0.9% of patients who received a clinical diagnosis of COVID-19 were positive on a third and fourth test; this may be an underestimate of the value of further testing as the majority of patients 93.0% (2999/3226) only had one or two URT RT-PCR tests. Conclusions: The sensitivity of a single RT-PCR test of URT samples in hospitalised patients is 82.2%. Sensitivity increases to 90.6% when patients are tested twice.  A proportion of cases with clinically defined COVID-19 never test positive on URT RT-PCR despite repeat testing.

Evidence into action: implementing alcohol screening and brief interventions in the UK Armed Forces

Introduction

Alcohol-related harm continues to represent a major public health problem and previous evidence suggests that alcohol misuse within the UK Armed Forces is higher than in the general population. The aim was to introduce a population-level primary care intervention with an existing evidence base to identify and support Service Personnel whose drinking places them at greater risk of harm.

Implementation

Following successful piloting, the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) brief screening tool was introduced as part of routine dental inspections by Defence Primary Healthcare (DPHC) dentists. Alcohol brief intervention (ABI) advice and signposting to support services was offered to personnel identified as being at increased risk and recorded in the patient’s electronic health record.

Achievements to date

Patients attending DPHC Dental Centres are now routinely offered AUDIT-C with 74% (109 459) personnel screened in the first 12 months rising to over 276 000 at 24 months, representing the single largest use of AUDIT-C and ABIs in a military population to date.

Discussion

Introduction of AUDIT-C has seen Defence successfully deliver a whole population alcohol initiative, overcoming implementation barriers to demonstrate the flexibility of a dental workforce to deliver a public health intervention at scale and contributing towards promoting positive attitudes towards alcohol use. The initiative represents a first step towards the goal of a standardised alcohol screening and treatment pathway across DPHC while recognising that the Defence Medical Services are only one aspect of the broader public health approach required to tackle alcohol-related harm in Service Personnel.

Ten years of external quality assessment (EQA) of Neisseria gonorrhoeae antimicrobial susceptibility testing in Europe elucidate high reliability of data

Background

Confidence in any diagnostic and antimicrobial susceptibility testing data is provided by appropriate and regular quality assurance (QA) procedures. In Europe, the European Gonococcal Antimicrobial Susceptibility Programme (Euro-GASP) has been monitoring the antimicrobial susceptibility in Neisseria gonorrhoeae since 2004. Euro-GASP includes an external quality assessment (EQA) scheme as an essential component for a quality-assured laboratory-based surveillance programme. Participation in the EQA scheme enables any problems with the performed antimicrobial susceptibility testing to be identified and addressed, feeds into the curricula of laboratory training organised by the Euro-GASP network, and assesses the capacity of individual laboratories to detect emerging new, rare and increasing antimicrobial resistance phenotypes. Participant performance in the Euro-GASP EQA scheme over a 10 year period (2007 to 2016, no EQA in 2013) was evaluated.

Methods

Antimicrobial susceptibility category and MIC results from the first 5 years (2007–2011) of the Euro-GASP EQA were compared with the latter 5 years (2012–2016). These time periods were selected to assess the impact of the 2012 European Union case definitions for the reporting of antimicrobial susceptibility.

Results

Antimicrobial susceptibility category agreement in each year was ≥91%. Discrepancies in susceptibility categories were generally because the MICs for EQA panel isolates were on or very close to the susceptibility or resistance breakpoints. A high proportion of isolates tested over the 10 years were within one (≥90%) or two (≥97%) MIC log₂ dilutions of the modal MIC, respectively. The most common method used was Etest on GC agar base. There was a shift to using breakpoints published by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) in the latter 5 years, however overall impact on the validity of results was limited, as the percentage categorical agreement and MIC concordance changed very little between the two five-year periods.

Conclusions

The high level of comparability of results in this EQA scheme indicates that high quality data are produced by the Euro-GASP participants and gives confidence in susceptibility and resistance data generated by laboratories performing decentralised testing.

Ascertaining the epidemiology, patient flow and disease management for Dravet syndrome in Spain

INTRODUCTION

Dravet syndrome (DS) is a rare, drug resistant epilepsy that starts very early in life with febrile seizures followed by cognitive impairment and diverse seizure types.

AIM

To generate evidence on the epidemiology of DS, its diagnosis, patient-flow, treatment and unmet needs from the perspective of Spanish experts.

DEVELOPMENT

A two-round Delphi study involving 19 physicians was conducted. Questionnaires were based on literature review and validated by clinical experts. Consensus was reached when topics were subject to routine clinical practice and individual experience, or the coefficient of variation among answers was <= 0.3. The estimated number of new DS patients is 73 per year. Prevalence is estimated to be between 348-540 patients. DS is mostly diagnosed in children. Survival varies from 5 to 60 years. There is no standardised follow-up of patients beyond the age of 18 and mortality rates are uncertain. No standard guidelines exist for diagnosing or treating DS. It takes 9 to 15 months to confirm the diagnosis and genetic testing is unevenly available. Valproic acid, clobazam, stiripentol and topiramate are commonly used. Poor efficacy and safety are the main reasons for treatment switch.

CONCLUSIONS

The epidemiology of DS in Spain is not well known and several areas of unmet needs still exist. Experts' views offer a starting point for further research into the reality of DS in Spain. Epidemiological studies, consensus criteria, easy access to genetic testing, treatment options, training and research into quality of life aspects are highly needed.

Links between deprivation and risk of violence-related injury: a qualitative study to identify potential causal mechanisms

Background

Deprivation has been shown to have a greater effect on risk of violent injury among adolescent girls than boys, but the mechanisms underlying this association have not been identified.

Methods

In this qualitative study designed to identify causal mechanisms, focus groups involving girls aged 14-16 years attending secondary schools in South Wales, UK, were convened. Schools were recruited based on a measure of area-level deprivation. Discussions were audio-recorded and transcripts analysed thematically.

Results

Girls from more deprived areas tended not to participate in organized activities, obtained alcohol from multiple sources, consumed alcoholic drinks of varying strengths in both supervised and unsupervised settings, and tended not to feel trusted by their parents; this led to poor adolescent-parent communication. Girls from less deprived areas tended to participate in organized activities, obtain alcohol from parents, consume low strength alcohol in supervised settings, and have a trusting and communicative relationship with their parents.

Conclusion

Deprivation may increase risk of adolescent girls sustaining violence-related injury by increasing their time spent in unsupervised environments, with alcohol and without parental knowledge.

Radiolabelled Stripped Mucin, SM3, Monoclonal Antibody for Immunoscintigraphy of Ovarian Tumours

A new monoclonal antibody, SM3, against stripped mucin core protein has been evaluated for the radioimmunoscintigraphy of ovarian cancer. It was radiolabelled with In-111, I-123 and Tc-99m and results showed a sensitivity of 95%, 100% and 100% and an accuracy of 73%, 86% and 100% for malignancy; respectively.

Abstract P3-07-07: Inhibition of death-associated protein kinase 1 enhances chemotherapy action against triple-negative breast cancer

Background: Triple negative breast cancers (TNBCs) are the most aggressive ER negative breast cancers with limited therapy strategies and poor prognosis. P53 gene is frequently mutated in approximately 80% of TNBCs. To identify novel molecular targets for ER negative breast cancer, particularly the more aggressive TNBC, we conducted a human kinome screen and identified death-associated protein kinase 1 (DAPK1) as one of the kinases that are highly expressed in ER negative breast cancer. Deletion or inhibition of DAPK1 suppresses growth of p53-mutant but not p53-wildtype breast cancer cells. Here we investigate whether DAPK1 inhibition will enhance chemotherapy action against p53-mutant TNBCs.

Experimental design and methods: We performed experiments to test cell growth of p53-mutant TNBCs that were treated with DAPK1 siRNA or DAPK1 inhibitors in combination with different doses of chemotherapy drugs including 5-FU (5-Fluorouracil), doxorubicin, cisplatin, PARP inhibitor (BMN673), paclitaxel, gemcitabine and vinorelbine.

Results: Our results show that DAPK1 inhibitors enhance the growth inhibitory effects of cisplatin and PARP inhibitor in p53-mutant TNBCs. Furthermore, combined DAPK1 inhibition (via siRNA knockdown) with cisplatin synergistically inhibits cell growth of p53-mutant TNBCs.

Conclusion: DAPK1 is a novel, promising target for the treatment of triple-negative p53-mutant breast cancer. Our studies demonstrate that DAPK1 inhibition sensitizes TNBCs to the cytotoxic effects of cisplatin or the PARP inhibitor. We are now conducting studies to determine whether DAPK1 inhibition will sensitize TNBC tumors and patient-derived TNBC xenografts to the effects of cisplatin and PARP inhibition. These studies suggest that the combination of DAPK1 inhibition with drugs that interfere with DNA repair will be useful for the treatment of the most aggressive form of breast cancer, triple-negative breast cancer.

Funding: This study was funded by a Susan G. Komen Promise grant (SAB12-00006 to P.H. Brown), a MD Anderson Knowledge Gap Moonshot grant (to P.H. Brown) and a Breast Cancer Research Foundation grant (BCRF 15101807, 2015–2016 to P.H. Brown).

Citation Format: Zhao D, Zhao J, Mazumadar A, Bollu L, Shepherd J, Ma Y, Zhang Y, Hill JL, Savage MI, Brown PH. Inhibition of death-associated protein kinase 1 enhances chemotherapy action against triple-negative breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-07-07.

Abstract P1-08-04: SOX9 is a critical regulator of triple-negative breast cancer cell growth and invasion

Background: SRY (Sex Determining Region Y)-related HMG-box (SOX) genes belong to a super-family of genes, which is characterized by a homologous sequence called the HMG-box residing on the Y-chromosome. There are 20 SOX genes present in humans and mice. We performed a siRNA screen of SOX transcription factors, and found that SOX9 was essential for breast cancer cell growth. The SOX9 protein recognizes the sequence CCTTGAG along with other members of the HMG-box class DNA-binding proteins and has been shown to be required for development, differentiation and lineage commitment. Moreover, SOX9 is expressed in adenocarcinomas, and is highly expressed in the most aggressive cancers. Our previous data shows SOX9 is highly expressed in “triple negative breast cancer” (TNBC) than in non-TNBC. Thus, we hypothesized that the SOX9 transcription factor acts as an essential molecule regulating TNBC growth and invasion. To test the hypothesis, we used SOX9-overexpressed, or SOX9-knockdown/knockout breast cancer cell models to determine whether SOX9 is necessary and/or sufficient to regulate TNBC cell proliferation, migration and invasion.

Methods: We measured the cell growth using an automated cell counting assay. Cell migration and invasion were detected by transwell migration & invasion assays in ER-positive (MCF7 and ZR75-1) and ER-negative (MDA231 and MDA468) breast cancer cells. DOX-inducible SOX9-knockout cell lines were established in MDA231, MDA468, and LM2 cell lines using an inducible Cas9-CRISPR system. A SOX9 expressing lentivirus was used to overexpress SOX9, and siRNAs was used to knockdown SOXs in the different breast cancer cells. Protein and mRNA levels of SOX9 in TNBC, non-TNBC, immortalized human breast epithelial cell lines were examined by western blotting and qRT-PCR assay.

Results: Knockdown of SOXs by siRNA caused decreased cell proliferation of MDA231 by ≥50% and of MDA468 by 30%-50% in siSOX4, siSOX6, siSOX9, siSOX10 and siSOX11 treatment groups (but not in siSOX8 and siSOX17 treatment groups). However, in MCF7 and T47D cell lines, treatment with siRNA to these SOX factors did not cause significant cell growth reduction. We demonstrated that SOX9 is more highly expressed in TNBC cells at both the mRNA and protein levels. Knockdown of SOX9 decreased cell migration and invasion of MDA231 to 25% and 50% respectively. The same effect also was observed in MDA468 cells, with approximately a 50% decline in migration and invasion. In SOX9-knockout MDA231, MDA468, and LM2 cells, cell proliferation, migration, and invasion were significantly reduced. In contrast, overexpression of SOX9 in MCF7 and ZR75-1 cells increased cell migration and invasion. We are now conducting in vivo studies to determine the effect of SOX9 on breast cancer cell metastasis.

Conclusion: SOX9 is a critical regulator of TNBC cell proliferation, migration and invasion. These studies suggest that regulating SOX9 transcription factor and its signaling pathway will be a promising therapeutic strategy to treat TNBC and prevent metastasis.

This work was supported by a Susan G. Komen Scientific Advisory Board Grant, SAB1600006 (PB), and a grant from the Breast Cancer Research Foundation 2015-2016 BCRF grant(PB), and by the Charles Cain Endowment (PB).

Citation Format: Ma Y, Shepherd J, Mazumdar A, Zhao D, Bollu L, Hill J, Zhang Y, Brown P. SOX9 is a critical regulator of triple-negative breast cancer cell growth and invasion [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-08-04.

Social-Class Differences in a Sample of Nonelite Marathon Runners

In this study the reasons for starting to run, starting to run marathons and the psychosocial benefits and costs derived from an involvement in running were compared for blue collar and for white collar nonelite runners. Extrinsic rewards were more important to the blue collar runners than to the white collar runners. No class differences were found for the importance of intrinsic rewards or in the benefits/costs associated with an involvement in running.

Stability of creatinine with delayed separation of whole blood and implications for eGFR

Background: The stability of creatinine in whole blood is unclear: it is not known if analysis of creatinine in samples with delayed separation could lead to misclassification of chronic kidney disease (CKD) using estimated glomerular filtration rate (eGFR).

Methods: Multiple blood samples were taken at a single time-point from five individuals and subject to varying time delays prior to centrifugation, after which serum was separated and analysed for creatinine by five different methods. The effect of time delay on eGFR was further investigated by measuring creatinine on duplicate patient samples arriving in the laboratory after immediate and delayed centrifugation.

Results: A significant increase in creatinine was seen by 24 h using kinetic Jaffe methods ( P<0.025). Over a period of 31 h creatinine concentration was stable using enzymatic creatinine assays. Using duplicate patient samples, four of 21 patients where specimens were delayed in the laboratory by more than 10 h showed a misclassification of CKD.

Conclusion: Delays in sample receipt can lead to significant increases in measured creatinine and misclassification of CKD. Enzymatic creatinine assays are reliable with respect to delayed sample receipt over the time course studied.

Exploring Constraints on Developing Knowledge

This article explores some of the constraints on the development of knowledge through a multi-perspective examination of a project where there was an intention, and enacted process, to develop knowledge. Building on prior work in the fields of knowledge and knowledge management, the article is engaged with the generic question of what the conditions that facilitate knowledge creation in organizations are. However, the approach adopted here is not to focus on success stories, but to develop an understanding of constraining factors through an examination of an example of apparent failure and the absence of new knowledge. A detailed multi-perspective exploration of a particular organizational episode is provided. Data from this episode are considered from three theoretical perspectives: psychodynamics, social construction and complexity theory. This multi-perspective exploration highlights the need for conflict in organizational settings where new knowledge is at least supposed to be being developed.

Increase in anti-tuberculosis drug resistance in Botswana: results from the fourth National Drug Resistance Survey

SETTING

Although approximately 0.5 million cases of multidrug-resistant tuberculosis (MDR-TB) occur globally each year, surveillance data are limited. Botswana is one of the few high TB burden countries to have carried out multiple anti-tuberculosis drug resistance surveys (in 1995-1996, 1999 and 2002).

OBJECTIVE

In 2007-2008, we conducted the fourth national survey of anti-tuberculosis drug resistance in Botswana to assess anti-tuberculosis drug resistance, including trends over time. In the previous survey, 0.8% (95%CI 0.4-1.5) of new patients and 10.4% (95%CI 5.6-17.3) of previously treated patients had MDR-TB.

DESIGN

During the survey period, eligible specimens from all new sputum-smear positive TB patients and from all TB patients with history of previous anti-tuberculosis treatment underwent mycobacterial culture and anti-tuberculosis drug susceptibility testing (DST).

RESULTS

Of 924 new TB patients and 137 with previous anti-tuberculosis treatment with DST results, respectively 23 (2.5%, 95%CI 1.6-3.7) and 9 (6.6%, 95%CI 3.3-11.7) had MDR-TB. The proportion of new TB patients with MDR-TB has tripled in Botswana since the previous survey.

CONCLUSION

Combatting drug-resistant TB will require the scale-up of MDR-TB diagnosis and treatment to prevent the transmission of MDR-TB and strengthening of general TB control to prevent the emergence of resistance.

Protocol for a population-based molecular epidemiology study of tuberculosis transmission in a high HIV-burden setting: the Botswana Kopanyo study

INTRODUCTION

Mycobacterium tuberculosis (Mtb) is transmitted from person to person via airborne droplet nuclei. At the community level, Mtb transmission depends on the exposure venue, infectiousness of the tuberculosis (TB) index case and the susceptibility of the index case's social network. People living with HIV infection are at high risk of TB, yet the factors associated with TB transmission within communities with high rates of TB and HIV are largely undocumented. The primary aim of the Kopanyo study is to better understand the demographic, clinical, social and geospatial factors associated with TB and multidrug-resistant TB transmission in 2 communities in Botswana, a country where 60% of all patients with TB are also infected with HIV. This manuscript describes the methods used in the Kopanyo study.

METHODS AND ANALYSIS

The study will be conducted in greater Gaborone, which has high rates of HIV and a mobile population; and in Ghanzi, a rural community with lower prevalence of HIV infection and home to the native San population. Kopanyo aims to enrol all persons diagnosed with TB during a 4-year study period. From each participant, sputum will be cultured, and for all Mtb isolates, molecular genotyping (24-locus mycobacterial interspersed repetitive units-variable number of tandem repeats) will be performed. Patients with matching genotype results will be considered members of a genotype cluster, a proxy for recent transmission. Demographic, behavioural, clinical and social information will be collected by interview. Participant residence, work place, healthcare facilities visited and social gathering venues will be geocoded. We will assess relationships between these factors and cluster involvement to better plan interventions for reducing TB transmission.

ETHICS

Ethical approval from the Independent Review Boards at the University of Pennsylvania, US Centers for Disease Control and Prevention, Botswana Ministry of Health and University of Botswana has been obtained.

Effect of high-dose atorvastatin on the cardiovascular risk associated with individual components of metabolic syndrome: a subanalysis of the Treating to New Targets (TNT) study

AIMS

To investigate the impact of intensive lipid-lowering with high-dose atorvastatin on the cardiovascular risk associated with individual metabolic syndrome components [high body mass index (BMI), elevated triglycerides, low high-density lipoprotein (HDL) cholesterol, hypertension and elevated fasting glucose] in patients with coronary heart disease (CHD).

METHODS

Patients with clinically evident, stable CHD and low-density lipoprotein (LDL) cholesterol <3.4 mmol/l (130 mg/dl) were randomized to double-blind therapy with atorvastatin 10 mg/day (n = 5006) or 80 mg/day (n = 4995) after an 8-week open-label run-in with atorvastatin 10 mg. The median follow-up was 4.9 years. The impact of individual metabolic syndrome risk factors was tested on the primary endpoint, which was the occurrence of a first major cardiovascular event.

RESULTS

On-treatment LDL cholesterol was 2.6 mmol/l (101 mg/dl) with atorvastatin 10 mg and 2.0 mmol/l (77 mg/dl) with atorvastatin 80 mg. Among patients receiving atorvastatin 10 mg, the presence of each individual metabolic syndrome component significantly increased the risk of major cardiovascular events compared with the absence of each (BMI, p = 0.014; triglycerides, p = 0.006; HDL cholesterol, p = 0.0006; hypertension, p < 0.0001; and fasting glucose p < 0.0001). In patients receiving atorvastatin 80 mg, elevated triglycerides and fasting glucose were no longer significant predictors of major cardiovascular events. The predictive power of hypertension on the risk of major cardiovascular events was reduced in patients treated with atorvastatin 80 mg, although it remained a significant predictor.

CONCLUSIONS

Treatment with high-dose atorvastatin to a mean LDL cholesterol level of 2.0 mmol/l (77 mg/dl) considerably attenuated the predictive power associated with three metabolic syndrome components.

Usefulness of Ki-67, Mitoses, and Tumor Size for Predicting Metastasis in Carcinoid Tumors of the Lung: A Study of 48 Cases at a Tertiary Care Centre in Canada

Background. Evaluation of Ki-67 index in lung carcinoid tumors (LCTs) has been of interest in order to identify high risk subsets. Our objectives are (1) to evaluate the usefulness of Ki-67 index, mitoses, and tumor size in predicting metastasis and (2) to compare the Manual Conventional Method (MCM) and the Computer Assisted Image Analysis Method (CIAM) for Ki-67 calculation. Methods. We studied 48 patients with LCTs from two academic centres in Canada. For Ki-67 calculation, digital images of 5000 cells were counted using an image processing software and 2000 cells by MCM. Mitoses/10 HPF was counted. Results. We had 37 typical carcinoids (TCs) and 11 atypical carcinoids (ACs). 7/48 patients developed metastasis. There was a positive relationship between metastasis and carcinoid type (P = 0.039) and metastasis and mitoses (≥2) (P = 0.017). Although not statistically significant, the mean Ki-67 index for ACs was higher than for TCs (0.95% versus 0.72%, CIAM, P = 0.299). Similarly, although not statistically significant, the mean Ki-67 index for metastatic group (MG) was higher than for nonmetastatic group (NMG) (1.01% versus 0.71% by CIAM, P = 0.281). However when Ki-67 index data was categorized at various levels, there is suggestion of a useful cutoff (≥0.50%) to predict metastasis (P = 0.106, CIAM). A significantly higher proportion of patients with mitosis ≥2 and Ki-67 index ≥0.50% had metastasis (P = 0.033) compared to other patients. Similarly patients with tumor size ≥3 cm and Ki-67 ≥0.50% had a greater percentage of metastases than others (P = 0.039). Although there was a strong correlation between two (MCM versus CIAM) counting methods (r = 0.929, P = 0.001), overall the calculated Ki-67 index was slightly higher by MCM (range 0 to 6.4, mean 1.5) compared to CIAM (range 0 to 2.9, mean 0.75). Conclusion. This study confirms that mitoses ≥2 is a powerful predictor of metastasis in LCTs. Although this is a small sample size, there is suggestion that analysis of Ki-67 index along with mitoses and tumor size may be a useful adjunct for predicting metastasis in LCTs.

The Effect of Weight Change on Volumetric Measures of Mammographic Density

The association between changing body mass index (BMI) and mammographic breast density is important to better evaluate how to adjust for BMI gain/loss in longitudinal studies of density and breast cancer risk. Increasing BMI has been associated with decreasing percent dense area but the effect on absolute dense area is unclear. No studies have explored a longitudinal association using volumetric density measurement. Methods: We examined the association between change in BMI and change in volumetric breast density among 24,556 women who received breast imaging at the San Francisco Mammography Registry from 2007–2013. Height and weight were self-reported at the time of mammography. Breast density was assessed using single x-ray absorptiometry (SXA) volumetric measurement. The cross-sectional and longitudinal associations between BMI and absolute dense volume (DV) and percent dense volume (PDV) were assessed using multivariable adjusted regression. Results: Women were primarily Caucasian (66%) or Asian (25%) and most were postmenopausal (64%) at time of first mammogram. In cross-sectional analysis, BMI was positively associated with DV (β = 2.95 cm3, 95% CI, 2.69–3.21) and inversely associated with PDV (β = −2.03%, 95% CI, −2.09–−1.98). In longitudinal analysis, an annual increase in BMI was associated with an annual decrease in both DV (β = −1.01 cm3/year, 95% CI, −1.59–−0.42) and PDV (β = −1.17%/year, 95% CI, −1.31–−1.04). Findings were consistent between pre- and postmenopausal women. The annual decrease in DV was strongest among premenopausal women who were initially overweight or obese (P &lt; 0.01 for interaction by initial BMI). Conclusion: Our findings support an inverse association between change in BMI and change in PDV. Longitudinal studies of PDV and breast cancer risk, or those using PDV as an indicator of breast cancer risk, should consider adjusting for change in BMI. The association between increasing BMI and decreasing DV is unexpected and will require confirmation using volumetric methods.

Using process data to understand outcomes in sexual health promotion: an example from a review of school-based programmes to prevent sexually transmitted infections

This article discusses how process indicators can complement outcomes as part of a comprehensive explanatory evaluation framework, using the example of skills-based behavioural interventions to prevent sexually transmitted infections and promote sexual health among young people in schools. A systematic review was conducted, yielding 12 eligible outcome evaluations, 9 of which included a process evaluation. There were few statistically significant effects in terms of changes in sexual behaviour outcomes, but statistically significant effects were more common for knowledge and self-efficacy. Synthesis of the findings of the process evaluations identified a range of factors that might explain outcomes, and these were organized into two overarching categories: the implementation of interventions, and student engagement and intervention acceptability. Factors which supported implementation and engagement and acceptability included good quality teacher training, involvement and motivation of key school stakeholders and relevance and appeal to young people. Factors which had a negative impact included teachers' failure to comprehend the theoretical basis for behaviour change, school logistical problems and omission of topics that young people considered important. It is recommended that process indicators such as these be assessed in future evaluations of school-based sexual health behavioural interventions, as part of a logic model.

Clinical effectiveness and cost-effectiveness of depth of anaesthesia monitoring (E-Entropy, Bispectral Index and Narcotrend): a systematic review and economic evaluation

BACKGROUND

It is important that the level of general anaesthesia (GA) is appropriate for the individual patient undergoing surgery. If anaesthesia is deeper than required to keep a patient unconscious, there might be increased risk of anaesthetic-related morbidity, such as postoperative nausea, vomiting and cognitive dysfunction. This may also prolong recovery times, potentially increasing health-care costs. If anaesthesia is too light, patients may not be fully unconscious and could be at risk of intraoperative awareness.

OBJECTIVE

The objective of this report is to assess the clinical effectiveness and cost-effectiveness of Bispectral Index (BIS), E-Entropy and Narcotrend technologies, each compared with standard clinical monitoring, to monitor the depth of anaesthesia in surgical patients undergoing GA.

DATA SOURCES

A search strategy was developed and run on a number of bibliographic electronic databases including MEDLINE, EMBASE, The Cochrane Library and the Health Technology Assessment (HTA) database. For the systematic review of patient outcomes, databases were searched from the beginning of 2009 to November 2011 for studies of BIS (and then updated in February 2012), and from 1995 to November 2011 (and then updated in February 2012) for studies of E-Entropy and Narcotrend. For the systematic review of cost-effectiveness, searches were from database inception to November 2011 (an update search was performed in February 2012).

REVIEW METHODS

The systematic review of patient outcomes followed standard methodology for evidence synthesis. A decision-analytic model was developed to assess the cost-effectiveness of depth of anaesthesia monitoring compared with standard clinical observation. A simple decision tree was developed, which accounted for patients' risk of experiencing short-term anaesthetic-related complications in addition to risk of experiencing intraoperative awareness.

RESULTS

Twenty-two randomised controlled trials comparing BIS, E-Entropy and Narcotrend with standard clinical monitoring were included in the systematic review of patient outcomes, alongside evidence from a recent Cochrane review. Six trials of patients classified with risk factors for intraoperative awareness were combined in a fixed-effect meta-analysis. The overall pooled Peto's odds ratio was 0.45 (95% confidence interval 0.25 to 0.81) in favour of BIS. However, there was statistically significant heterogeneity. The base-case cost per quality-adjusted life-year (QALY) for BIS compared with standard clinical monitoring ranged from £22,339 to £44,198 depending on patient subgroups (type of GA received; level of risk for awareness). For E-Entropy, base-case estimates ranged from £14,421 to £31,430. For Narcotrend, estimates varied from a cost per QALY of £8033 to Narcotrend dominating standard clinical monitoring.

LIMITATIONS

The analysis was limited by lack of clinical effectiveness data, particularly for E-Entropy and Narcotrend.

CONCLUSIONS

The available evidence on the impact of the technologies on reducing the likelihood of intraoperative awareness is limited. However, there were reductions in general anaesthetic consumption and anaesthetic recovery times. The cost-effectiveness of depth of anaesthesia monitoring appears to be highly dependent on a number of factors, including probability of awareness.

STUDY REGISTRATION

PROSPERO registration number CRD42011001834.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Integration-free induced pluripotent stem cells model genetic and neural developmental features of down syndrome etiology

Down syndrome (DS) is the most frequent cause of human congenital mental retardation. Cognitive deficits in DS result from perturbations of normal cellular processes both during development and in adult tissues, but the mechanisms underlying DS etiology remain poorly understood. To assess the ability of induced pluripotent stem cells (iPSCs) to model DS phenotypes, as a prototypical complex human disease, we generated bona fide DS and wild-type (WT) nonviral iPSCs by episomal reprogramming. DS iPSCs selectively overexpressed chromosome 21 genes, consistent with gene dosage, which was associated with deregulation of thousands of genes throughout the genome. DS and WT iPSCs were neurally converted at >95% efficiency and had remarkably similar lineage potency, differentiation kinetics, proliferation, and axon extension at early time points. However, at later time points DS cultures showed a twofold bias toward glial lineages. Moreover, DS neural cultures were up to two times more sensitive to oxidative stress-induced apoptosis, and this could be prevented by the antioxidant N-acetylcysteine. Our results reveal a striking complexity in the genetic alterations caused by trisomy 21 that are likely to underlie DS developmental phenotypes, and indicate a central role for defective early glial development in establishing developmental defects in DS brains. Furthermore, oxidative stress sensitivity is likely to contribute to the accelerated neurodegeneration seen in DS, and we provide proof of concept for screening corrective therapeutics using DS iPSCs and their derivatives. Nonviral DS iPSCs can therefore model features of complex human disease in vitro and provide a renewable and ethically unencumbered discovery platform.

Are educational interventions to prevent catheter-related bloodstream infections in intensive care unit cost-effective?

BACKGROUND

There is increasing interest in evidence-based educational interventions in central venous catheter care. It is unclear how effective these are at reducing the risk of bloodstream infections from the use of intravascular catheters (catheter-BSIs) and the associated costs and health benefits.

AIM

To estimate the additional costs and health benefits from introducing such interventions and the costs associated with catheter-BSIs.

METHODS

A comprehensive epidemiological and economic review was performed to develop the parameters for an economic model to assess the cost-effectiveness of introducing an educational intervention compared with clinical practice without the intervention. The model follows the clinical pathway of cohorts of patients from their admission to an intensive care unit (ICU), where some may acquire catheter-BSI, and estimates the associated costs, mortality and life expectancy.

FINDINGS

The additional cost per catheter-BSI episode was £3940. The results of this model demonstrate that introducing an additional educational intervention to prevent catheter-BSI improved patient life expectancy and reduced overall costs.

CONCLUSION

Introducing evidence-based education is likely to reduce the incidence of catheter-BSI and the model results suggest that the cost of introducing the interventions will be outweighed by savings related to reduced ICU bed occupancy costs.

Factors facilitating and constraining the delivery of effective teacher training to promote health and well-being in schools: a survey of current practice and systematic review

Background

Schools are an important setting for health promotion and teachers have an integral role to play in promoting children and young people’s health and well-being. Adequate initial teacher training (ITT) and continuing professional development in health is therefore important.

Objectives

To conduct a survey of initial teacher training providers in England and a systematic review of effectiveness to assess how health and well-being is covered on courses, and to identify barriers and facilitators to effective training.

Methods

Methods included an online questionnaire survey with a sample of 220 ITT course managers in England; interviews with a purposive sample of 19 of the course managers responding to the questionnaire; and a two-stage systematic review comprising a descriptive map of the characteristics of international research studies of health teacher training and a detailed synthesis of a subset of studies specifically on pre-service training. Databases (including MEDLINE, EMBASE, The Campbell Library and PsycINFO) were searched from the period of database inception up to May 2011.

Results

The overall response rate for the survey was 34%. The majority (89%) of respondents agreed that it was either important or very important to cover health within the ITT curriculum. The most commonly covered topics on courses wereEvery Child Matters(100%), child protection (100%), emotional health (99%) and antibullying (97%). Fewer course managers reported covering healthy eating (63%), sex and relationships (62%), drugs (56%), alcohol (41%) and smoking (34%). Many interviewees expressed a holistic view of education and believed that health was important in the ITT curriculum. However, there was variability in how health was addressed across and within institutions. Trainee teachers' experience of addressing child health on school placement was also variable. Facilitators to covering health included interests and backgrounds of ITT staff; staff health-related professional experience; availability of health expertise from external agencies; supportive government policy frameworks; and interprofessional and interdepartmental working. The main barriers were limited curriculum time; health being perceived to be a lower priority than other aspects of training; health no longer a high government priority in education; and lack of funding. A total of 170 studies met the eligibility criteria for the descriptive map. The majority covered teacher training in relation to sexual and reproductive health, drugs and alcohol or mental and emotional health. A total of 21 publications (20 studies) were prioritised for the synthesis. All were evaluations of health training for pre-service teachers, and just under half were from the UK. Twelve studies reported outcomes (impact of training on teachers, but not pupils), many of which were single cohort before-and-after studies. Sixteen studies reported processes. Following training there were some increases in trainee teachers' factual knowledge of health and a general increase in their confidence to address health issues. In general, training was acceptable and well received by trainees. Evidence suggested that effective training should include practical experience and skills and be personally relevant and take into account individual needs. Barriers to health training identified from the studies included lack of time, balancing breadth and depth, and variation in training provision.

Conclusions

Among those surveyed there appears to be general support for health and well-being in ITT. However, further research on the longer-term impact of ITT around health and well-being is needed, particularly in the early career period. The main limitation of this research was the low response rate (34%) to the survey.

Study registration

PROSPERO number CRD42012001977.

Funding

The National Institute for Health Research Public Health Research programme.

The effect of atorvastatin and simvastatin on vitamin D, oxidative stress and inflammatory marker concentrations in patients with type 2 diabetes: a crossover study

The pleiotropic effect of statins may be mediated in part through raising 25 hydroxy vitamin D (25OHD) concentrations. It has also been shown that an increase in oxidative stress and inflammatory markers are a feature of the patients with type 2 diabetes (T2DM). A cross-over study of 26 patients with T2DM taking either simvastatin 40 mg or atorvastatin 10 mg was undertaken. After 3 months on one statin, lipids, C-reactive protein (hsCRP), 25OHD and malondialdehyde (MDA) were measured repeatedly. The same procedure was then followed taking the other statin. Despite similar lipid-lowering, the mean 25OHD was higher on atorvastatin compared with simvastatin and the mean MDA and hsCRP levels lower, irrespective of which statin the patients were taking before crossover. The changes in 25OHD predicted changes in CRP and MDA levels. Thus, compared with simvastatin, atorvastatin shows apparently beneficial pleiotropic effects with respect to 25OHD concentrations as well as markers of oxidative stress and inflammation in patients with T2DM.