Fit for Purpose? The Suitability of Oral Health Outcome Measures to Inform Policy

KNOWLEDGE TRANSFER STATEMENT

Oral health research and program evaluation should consider alternative outcome measures for population oral health other than the DMFT index.

Perspectives of Healthcare Professionals on the Management and Treatment of Advanced Ovarian Cancer in the UK: Results From the KNOW-OC Survey

AIMS

New treatment options for advanced ovarian cancer have the potential to significantly change the treatment pathway in the UK. Understanding the structures and responsibilities of multidisciplinary teams/tumour boards (MDT) and regional variations will enable services to adapt more effectively to these changes.

MATERIALS AND METHODS

The KNOW-OC survey was conducted in 2020 to understand the views of a selected group of 66 healthcare professionals (HCPs) involved in advanced ovarian cancer care in UK hospitals.

RESULTS

The results showed that MDT involvement in the management of advanced ovarian cancer varied depending on pathway stage and line of relapse, with 98.5% of HCPs responding that the MDT was involved in decisions at initial presentation, but only 40.9% for patients with multiple relapses. The MDT was mostly responsible for determining whether the patients would undergo primary or interval cytoreductive surgery according to 75.8% of respondents, and most HCPs (80.3%) stated that tumour dissemination patterns were the most important factor influencing this decision. The most commonly assessed biomarkers at the time of the survey were CA125, gBRCA and tBRCA. Homologous recombination deficiency was viewed as the second most important factor for determining prognosis, but few centres had access to testing at the time of survey completion. The use of active surveillance was expected to decrease in favour of first-line targeted therapies. Nearly all (98.5%) HCPs agreed there is a role for secondary cytoreductive surgery for the treatment of recurrence (for carefully selected patients).

CONCLUSIONS

The results highlighted UK-specific geographical variation in the views of HCPs on MDT involvement and specific practices, such as molecular biomarker testing, and the overall treatment approach. Together, these findings improve the understanding of reported clinical practice across the UK for ovarian cancer and provide insight into decision-making associated with updates to recommendations for best practice (e.g. European Society for Medical Oncology/European Society of Gynaecological Oncology consensus statements) and the introduction of new treatment options.

A content review of state tobacco pre-emption laws in the US

OBJECTIVES

State ceiling pre-emption laws effectively limit the authority of local governments to regulate numerous public health issues, including tobacco. While general trends in the number of state tobacco pre-emption laws have been well-documented, less is known about the specific content of these laws. This study provides a comprehensive analysis of the content of current state tobacco pre-emption laws and captures the salient features of these laws.

STUDY DESIGN

This was a comparative analysis of tobacco pre-emption laws in the United States.

METHODS

The study team collected data about tobacco pre-emption laws from the Centers for Disease Control and Prevention's State Tobacco Activities Tracking and Evaluation System. Trained legal researchers further verified and reviewed each law's content using the Westlaw database. A coding scheme was developed to capture and analyse these laws' most salient features.

RESULTS

State tobacco pre-emption laws use various terms to indicate the pre-emption of a local authority, including supersede, pre-empt, uniform, exclusive, and consistent. State laws cover numerous general topics and vary widely in explicit terminology of authorities and fields pre-empted. Several state laws included grandfathering exceptions and a few allowed exceptions for particular local jurisdictions.

CONCLUSIONS

State laws that undermine local tobacco control efforts from implementing more stringent laws pose a threat to public health. These laws vary widely in their scope across the U.S., and local jurisdictions should be empowered to enact and maintain tobacco control measures that protect their communities from the harms of tobacco use and exposure.

Prioritizing population oral health through public policy in Australia: the Victorian experience

Dental caries, a non-communicable disease, is one of the most prevalent diseases globally and share common modifiable risk factors with obesity such as excess sugar intake. However, prioritization by governments to improve population oral health has been limited and is typically excluded from the discourse of public health policy development. Therefore, interventions that target dental caries can have other co-benefits including obesity prevention. In Victoria, Australia, local government authorities have a regulatory requirement to develop their Municipal Health and Wellbeing Plans. The aim of this paper is to identify whether prioritization for oral health by local government authorities in Victoria has changed through the subsequent renewal of the Victorian Public Health and Wellbeing Plans 2011-2015 and 2019-2023. Three desktop audits for all publicly available Municipal Health and Wellbeing Plans by local government authorities in Victoria were conducted between 2014 and 2022. Key terms related to oral health was searched within these policy documents and categorized into six indicators: (i) included oral health as a priority, (ii) linked healthy eating and oral health, (iii) supported the Achievement Program, (iv) included the Smiles 4 Miles program, (v) advocated for fluoridated drinking water, and (vi) included other strategies related to oral health. Overall, there was statistically significant reduction in five of the six indicators, with the exception for prioritization of other strategies related to oral health such as targeting excess sugar intake and smoking. A multi-sectoral approach, that includes oral health would be advantageous to address the growing burden of non-communicable diseases.

Dental Health Services Victoria value-based health care principles for oral health models of care

BACKGROUND

Efforts to progress oral healthcare reform can be challenging with competing interests of governments and service providers to achieve the intended outcomes. The value-based health care approach has been adopted in many areas of healthcare but has had limited applications to oral healthcare systems. Dental Health Services Victoria, an Australian state government funded entity, commenced its journey to value-based health care in 2016, to shift away from traditional dental service models that reward activity and volume towards a stronger emphasis on value and outcomes.

AIMS

To maintain the value-based health care agenda focus, Dental Health Services Victoria developed three key principles, which can be adopted by other organisations engaged in reforming oral healthcare, to improve the oral health for the population it serves.

MATERIALS & METHODS

In 2018, Dental Health Services Victoria developed a value-based health care framework, which has informed strategic organisation priorities for action. In 2023, the following three key principles are identified as being essential to support the operationalisation and development of effective models of oral healthcare: Principle 1 - Care is co-designed with the person or population Principle 2 - Prevention and early intervention are prioritised. Principle 3 - Consistent measurement of health outcomes and costs are embedded.

DISCUSSION

The exploration of the three key principles is an important communication tool to translate value-based health care into practice with key stakeholders. Further work is required to socialise them to within dental teams.

CONCLUSION

Organisations looking to commence the value-based health care agenda can apply Dental Health Services Victoria's three key principles as a first step.

Is value-based healthcare a strategy to achieve universal health coverage that includes oral health? An Australian case study

The 2021 Resolution on Oral Health by the 74th World Health Assembly supports an important health policy direction: inclusion of oral health in universal health coverage. Many healthcare systems worldwide have not yet addressed oral diseases effectively. The adoption of value-based healthcare (VBHC) reorients health services towards outcomes. Evidence indicates that VBHC initiatives are improving health outcomes, client experiences of healthcare, and reducing costs to healthcare systems. No comprehensive VBHC approach has been applied to the oral health context. Dental Health Services Victoria (DHSV), an Australian state government entity, commenced a VBHC agenda in 2016 and is continuing its efforts in oral healthcare reform. This paper explores a VBHC case study showing promise for achieving universal health coverage that includes oral health. DHSV applied the VBHC due to its flexibility in scope, consideration of a health workforce with a mix of skills, and alternative funding models other than fee-for-service.

<i>Corrigendum to</i>: Is Australia&#x2019;s lack of national clinical leadership hampering efforts with the oral health policy agenda?

The landmark 2021 Resolution on Oral Health by the 74th World Health Assembly has elevated the importance of oral health into the global health policy agenda. This has led to the development and adoption of the World Health Organization (WHO) Global Strategy on Oral Health in 2022. It acknowledged the need to integrate oral health as part of universal health coverage (UHC), which is supported by national clinical leadership for oral health. Although Australia is a signatory WHO member state, it is yet to appoint a Commonwealth Chief Dental Officer to provide national clinical leadership. This commentary provides a background on the current issues on population oral health in Australia, an insight into the Australian oral healthcare system, and explores some of the challenges and learnings related to previous Commonwealth dental programs. This paper highlights why expertise in dental public health is required to steer national oral health policy that is focused on prevention and early intervention. A population oral health approach for UHC should be informed by evidence, prioritise and address oral health inequities, and be co-ordinated by national clinical leadership for oral health.

Evaluating the benefit of early patient and public involvement for product development and testing with small companies

INTRODUCTION

There is a growing understanding of the benefits of patient and public involvement (PPI), and its evaluation, in research. An online version of the CUBE PPI evaluation framework has been developed. We sought to use the CUBE to evaluate the value of early PPI with two small healthcare companies during product development.

METHODS

Contributors were recruited online and had lived experience of either type 1 diabetes or obesity. Two 1-h sessions were run with a company developing a smartphone application to manage diabetes (DEE-EM): one with young people (YP; n = 5) and one with parents (n = 7). Two 1-h sessions were run with a company developing a weight-loss product, both with adults (n = 7 in each session). Sessions were facilitated by an independent University researcher and attended by company representatives, who presented their product. One facilitator led the evaluation of the session by giving a demonstration of the CUBE and asking simple questions in the YP session.

RESULTS

A high proportion of contributors completed the CUBE (80.5% DEE-EM; 93% Oxford Medical Products). Responses were positive to all four CUBE dimensions (in italics). Contributors felt there were diverse ways to contribute to the sessions, and that they had a strong voice to add to the discussion. Balance was achieved regarding whose concerns (public or company) led the agenda, and contributors felt that both companies would make changes based on the discussion. The supportive attitude of both companies resulted in most contributors feeling comfortable participating in PPI sessions with the industry, while recognising the profit-making aspect of their work.

CONCLUSIONS

PPI with small healthcare companies is both feasible and worthwhile. The CUBE framework facilitated the evaluation of the interaction between experts in different knowledge spaces. We provide recommendations for future projects, including considerations of who should participate and the level of implicit endorsement of the product that participation implies.

PATIENT OR PUBLIC CONTRIBUTION

People with lived experience of type 1 diabetes or obesity were invited to contribute to one of four PPI sessions, which they then evaluated. One contributor agreed to contribute to the analysis of the evaluation data and interpretation and preparation of the manuscript.

Is Australia's lack of national clinical leadership hampering efforts with the oral health policy agenda?

The landmark 2021 Resolution on Oral Health by the 74th World Health Assembly has elevated the importance of oral health into the global health policy agenda. This has led to the development and adoption of the World Health Organization (WHO) Global Strategy on Oral Health in 2022. It acknowledged the need to integrate oral health as part of universal health coverage (UHC), which is supported by national clinical leadership for oral health. Although Australia is a signatory WHO member state, it is yet to appoint a Commonwealth Chief Dental Officer to provide national clinical leadership. This commentary provides a background on the current issues on population oral health in Australia, an insight into the Australian oral healthcare system, and explores some of the challenges and learnings related to previous Commonwealth dental programs. This paper highlights why expertise in dental public health is required to steer national oral health policy that is focused on prevention and early intervention. A population oral health approach for UHC should be informed by evidence, prioritise and address oral health inequities, and be co-ordinated by national clinical leadership for oral health.

The time is now: making the case for a UK registry of deployment of radiology artificial intelligence applications

Artificial intelligence (AI)-based healthcare applications (apps) are rapidly evolving, and radiology is a target specialty for their implementation. In this paper, we put the case for a national deployment registry to track the spread of AI apps into clinical use in radiology in the UK. By gathering data on the specific locations, purposes, and people associated with AI app deployment, such a registry would provide greater transparency on their spread in the radiology field. In combination with other regulatory and audit mechanisms, it would provide radiologists and patients with greater confidence and trust in AI apps. At the same time, coordination of this information would reduce costs for the National Health Service (NHS) by preventing duplication of piloting activities. This commentary discusses the need for a UK-wide registry for such apps, its benefits and risks, and critical success factors for its establishment. We conclude by noting that a critical window of opportunity has opened up for the development of a deployment registry, before the current pattern of localised clusters of activity turns into the widespread proliferation of AI apps across clinical practice.

Cost-effectiveness analysis of silver diamine fluoride to divert dental general anaesthesia compared to standard care

BACKGROUND

The aim is to perform a model-based cost-effectiveness analysis of a silver diamine fluoride (SDF) protocol intervention to divert dental general anaesthesia (DGA) among Victorian children aged 2- 10 years.

METHODS

Data inputs was based on an Australian single-cohort 2017/18 study. Intervention costs for standard care were derived from two subgroups of children: 1) children who received standard care without DGA, and 2) children who received standard care with DGA. Two scenarios were modelled due to limited post-follow-up data: 1) children receiving SDF had standard care without DGA (base-case scenario), and 2) children receiving SDF did not receive standard care without DGA (alternative scenario). A simple decision-tree model with probabilistic sensitivity analysis (PSA) estimated the incremental costs per diverted DGA.

RESULTS

The probability of children requiring specialist referral and offered SDF, but the primary carer opted for DGA is 0.124 (SD 0.034), and the probability of children requiring DGA in standard care is 0.346 (SD 0.036). For both the base-case and alternative scenario, the incremental cost-effectiveness ratio outcome is dominant and their cost-effectiveness being either 74.8% or 100%, respectively.

CONCLUSIONS

The SDF protocol intervention is cost-effective dental caries management option for young children where referral for DGA is considered. © 2022 Australian Dental Association.

POS1521-HPR UNDERSTANDING AND IDENTIFYING KEY CONTEXTUAL FACTORS THAT INFLUENCE THE PRACTITIONER-PATIENT ENCOUNTER IN THE MANAGEMENT OF OSTEOARTHRITIS: A QUALITATIVE SYSTEMATIC REVIEW

Background

Contextual factors (CFs) related to the patient, healthcare practitioners, and their therapeutic relationship are integral to the overall treatment effect of any given intervention (1). In osteoarthritis (OA), around 75% of the treatment effect is directly attributable to CFs (2). Identifying and understanding the role of CFs may encourage healthcare practitioners to develop and enhance the contextual aspects of care.

Objectives

To explore and understand the experience and perspectives of patients and health practitioners regarding CFs in consultations for OA.

Methods

A systematic search was conducted between March 15 and May 18, 2020, on the following databases: MEDLINE via Ovid, EMBASE, AMED, PsycINFO and CINAHL. The search for unpublished studies included ProQuest Dissertations and Google Scholar. The search was not limited to any language or publication year. The Joanna Briggs Institute (JBI) methodology for quality assessment, study selection, data extraction and synthesis were used. Findings were assessed for credibility, categorised based on similarity in meaning and subjected to a meta-aggregation. The ConQual approach was used to assess the confidence of the synthesised findings (3).

Results

Of 1808 records generated from the systematic search of databases and grey literature, eight studies were included in the meta-aggregation (Figure 1). All included papers were moderate to high quality based on the JBI qualitative critical appraisal tool. Meta-aggregation generated three synthesised findings. According to the ConQual criteria, all the synthesised findings’ level of evidence was rated as moderate (Table 1). The key, potentially modifiable, factors identified were positive communication; clear and relevant information provided by the health practitioner; patient expectation concerning their outcome and the consultation experience; sufficient consultation time; and easy access to consultations.

Table 1.

ConQual summary of findings

Synthesized findingType of researchDependabilityCredibilityConQual scoreI. People with OA will likely experience comprehensive and satisfactory management of their condition if the key contextual enhancers are implemented.QualitativeUnchanged*Downgrade 1 level**ModerateII. Health providers acknowledged that information provision and efficient communication skills are likely to enhance management during consultations for OA.QualitativeUnchanged*Downgrade 1 level**ModerateIII. Effective consultations are affected by an intersection of organizational challenges and patient and provider characteristics. Limited experience with OA of some practitioners, unrealistic patients’ expectations, and short consultation duration are barriers that need to be adjusted for better management.QualitativeUnchanged*Downgrade 1 level**Moderate

* The average score was (4/5) for dependability.

** Downgraded one level due to a mix of unequivocal and credible findings.

Figure 1.

PRISMA flowchart of the study selection and inclusion process

Conclusion

This qualitative systematic review has defined three synthesized findings. Identification of modifiable CFs that are deemed important by both patients and health practitioners can inform the development of a training package for healthcare professional.

References

[1]Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. The Lancet. 2001;357(9258):757-762.

[2]Zou K, Wong J, Abdullah N, Chen X, Smith T, Doherty M et al. Examination of overall treatment effect and the proportion attributable to contextual effect in osteoarthritis: meta-analysis of randomised controlled trials. Annals of the Rheumatic Diseases. 2016;75(11):1964-1970.

[3]Munn, Z., Porritt, K., Lockwood, C., Aromataris, E. & Pearson, A. 2014. Establishing confidence in the output of qualitative research synthesis: the ConQual approach. BMC medical research methodology, 14, 1-7.

Disclosure of Interests

None declared

Walking-related knee contact forces and associations with knee pain across people with mild, moderate and severe radiographic knee osteoarthritis: a cross-sectional study

OBJECTIVE

To investigate knee contact forces (KCFs), and their relationships with knee pain, across grades of radiographic knee osteoarthritis (OA) severity.

DESIGN

Cross-sectional exploratory analysis of 164 participants with medial knee OA. Radiographic severity was classified as mild (grade 2), moderate (grade 3) or severe (grade 4) using the Kellgren & Lawrence (KL) scale. Walking knee pain was assessed using an 11-point numerical rating scale. External knee adduction moment (external KAM) and internal muscle forces were used to calculate medial, lateral and total KCFs using a musculoskeletal computational model. Force-time series across stance phase of gait were compared across KL grades using Statistical Parametric Mapping. Associations between KCFs and pain across KL grades were assessed using linear models.

RESULTS

Medial KCFs during early and middle stance were higher in participants with KL3 and KL4 compared to those with KL2. In contrast, lateral KCFs were higher in those with KL2 compared to KL3 and KL4 in middle to late stance. The external loading component (i.e., KAM) of the medial KCF during middle to late stance was also greater in participants with KL3 and KL4 compared to those with KL2, whereas the internal (i.e., muscle) component was greater in those with KL3 and KL4 compared to KL3 during early stance. There were no associations between medial KCF and knee pain in any KL grade.

CONCLUSIONS

Medial and lateral KCFs differ between mild, moderate and severe radiographic knee OA but are not associated with knee pain severity for any radiographic OA grade.

Differentiating border-zone tissue from post-infarct scar using ripple mapping during VT ablation

Funding Acknowledgements

Type of funding sources: None.

Background

Areas of post-infarct ventricular scar and border-zone slow conduction are often highlighted on a bipolar voltage map with generalized values 0.5mV–1.5mV. The true voltage that differentiates regions of conducting from non-conducting tissue is unknown. Ripple Mapping (RM)displays allows conducting tissue to be seen as areas supporting Ripple activation, and non-conducting tissue as areas devoid of Ripple activation.

Purpose

We describe application of Ripple Maps to differentiate areas of scar from conducting tissue during ischemic VT ablation.

Methods

Dense bipolar voltage maps were created (Pentaray catheter, pacing 80-100bpm) and presented as a single value (e.g. 0.5mV-0.5mV) to binarize the color display (red and purple). RMs were superimposed on the voltage map and played above a pre-set noise threshold (&gt;0.05mV). The voltage map mV limit was sequentially reduced ("border-zone threshold") until only those areas devoid of Ripple bars appeared red. The surrounding border-zone supporting ripple activation thus appeared purple. We performed off-line analysis of border-zone voltage thresholds from a series of RM guided VT ablations.

Results

10 consecutive patients (LVEF 32.3±7.5%) with remote myocardial infarction underwent VT ablation (median 19days (IQR 8-33) since last VT). Bipolar voltage mapping (5873±2841 points, median shell area 224cm2), revealed voltages&lt;0.5mV covered a median 11% (IQR 7-17%) of the shell. The border-zone voltage threshold was median 0.2mV (range 0.12mV - 0.3mV). Non-conducting tissue below this value covered only median 5% (IQR 3-7%) of the entire shell. VT was mappable in 4 patients, and the isthmus was bordered by tissue below the same border-zone threshold as found in normal rhythm. The border-zone was homogenized with ablation(40-50W, median 29 mins (IQR 22-33), and clinical VT was non-inducible in all, and 9 pts (91%) remain sustained VT-free at median 90-day follow-up (IQR 23-139), 2-weeks blanking period).

Picture 1 presents an infero-lateral LV infarct collected in an RV paced rhythm (7340points) and displayed at conventional bipolar voltage settings 0.5-1.5mV. Tissue with voltages&lt;0.5mV appear red and cover 30% of the total area. In this case, this border-zone voltage threshold was defined as 0.25mV. Non-conducting tissue, seen as areas devoid of ripple bars below this value, now appeared as red, and covered only 11% of the total area. Picture 2 demonstrates the morphologies of 4 poorly tolerated induced VTs during this case. Each had near perfect pacemaps to the exit sites of border-zone tissue defined using this approach, and were targets for ablation resulting in complete non-inducibility and no VT recurrence in early follow-up.

Conclusion

The bipolar voltage that differentiates putative scar from bordering conducting tissue is unique to each patient, and far lower than 0.5mV-1.5mV. RM presents a practical approach to visualize the border-zone activation to guide ablation.

How does hip osteoarthritis differ from knee osteoarthritis?

Hip and knee osteoarthritis (OA) are leading causes of global disability. Most research to date has focused on the knee, with results often extrapolated to the hip, and this extends to treatment recommendations in clinical guidelines. Extrapolating results from research on knee OA may limit our understanding of disease characteristics specific to hip OA, thereby constraining development and implementation of effective treatments. This review highlights differences between hip and knee OA with respect to prevalence, prognosis, epigenetics, pathophysiology, anatomical and biomechanical factors, clinical presentation, pain and non-surgical treatment recommendations and management.

Maintenance therapy of patients with recurrent epithelial ovarian carcinoma with the anti-tumor-associated-mucin-1 antibody gatipotuzumab: results from a double-blind, placebo-controlled, randomized, phase II study

BACKGROUND

Gatipotuzumab is a humanized monoclonal antibody recognizing the carbohydrate-induced epitope of the tumor-associated mucin-1 (TA-MUC1). This study aimed to evaluate the efficacy and safety of switch maintenance therapy with gatipotuzumab in patients with TA-MUC1-positive recurrent ovarian, fallopian tube, or primary high-grade serous peritoneal cancer.

PATIENTS AND METHODS

In this double-blind, randomized, placebo-controlled, phase II trial, patients with at least stable disease (SD) following chemotherapy were randomized 2:1 to receive intravenous gatipotuzumab (500 mg followed by 1700 mg 1 week later) or placebo every 3 weeks until tumor progression or unacceptable toxicity occurred. Stratification factors were the number of prior chemotherapy lines (2 versus 3-5), response versus SD after the most recent chemotherapy, and progression-free survival (PFS) <6 versus 6-12 months following the prior therapy. Primary endpoint was PFS according to modified immune-related RECIST 1.1 response criteria. Secondary endpoints were PFS at 6 months, safety, overall response rate, CA-125 progression, overall survival, quality of life, and pharmacokinetics.

RESULTS

Overall, 216 patients were randomized to gatipotuzumab (n  =  151) or placebo (n  =  65). Median PFS with gatipotuzumab was 3.5 months as compared with 3.5 months with placebo (hazard ratio 0.96, 95% confidence interval 0.69-1.33, P  =  0.80). No advantage for gatipotuzumab over placebo was seen in the secondary efficacy endpoints or in any stratified subgroups. Gatipotuzumab was well tolerated, with mild to moderate infusion-related reactions being the most common adverse events.

CONCLUSIONS

Gatipotuzumab switch maintenance therapy does not improve outcome in TA-MUC1-positive ovarian cancer patients.

TRIAL REGISTRATION

ClinicalTrials.govNCT01899599; https://clinicaltrials.gov/ct2/show/NCT01899599.

Perceived barriers to mental health and substance use treatment among US childbearing-aged women: NSDUH 2008-2014

This study compared and contrasted perceived barriers to mental health and substance use treatment among pregnant and non-pregnant women from 2008-2010 to 2011-2014. A trend study was conducted using secondary data from the National Survey on Drug Use and Health 2008-2014 from a propensity score-matched sample of pregnant (n = 5,520) and nonpregnant women (n = 11,040) aged 18 to 44 years. The most frequently perceived barriers to mental health treatment among all women ranked similarly in 2008-2010 compared to 2011-2014: cost (45.2% vs. 50.6%), opposition to treatment (41.9% vs. 41.4%), and stigma (28.2% vs. 24.7%). The rank order of barriers to substance use treatment in 2008-2010 among all women was cost (38.7%), stigma (18.2%), and time/transportation limitations (17%), whereas in 2011-2014, stigma ranked first (35.5%), followed by cost (25.9%) and time/transportation limitations (22.2%). In 2011-2014, the women were significantly more likely than women in 2008-2010 to report not knowing where to go (8.2% vs. .9%, p = .003) and a lack of substance use treatment programs (17.7% vs. 3.0%, p = .014). Perceived barriers to mental health treatment did not change overtime; however, there was a decrease in reported availability of substance use treatment programs between 2008-2010 and 2011-2014.

Association of multimorbidity and changes in health-related quality of life following myocardial infarction: a UK multicentre longitudinal patient-reported outcomes study

BACKGROUND

Multimorbidity is prevalent for people with myocardial infarction (MI), yet previous studies investigated single-health conditions in isolation. We identified patterns of multimorbidity in MI survivors and their associations with changes in HRQoL.

METHODS

In this national longitudinal cohort study, we analysed data from 9566 admissions with MI from 77 National Health Service hospitals in England between 2011 and 2015. HRQoL was measured using EuroQol 5 dimension (EQ5D) instrument and visual analogue scale (EQVAS) at hospitalisation, 6, and 12 months following MI. Latent class analysis (LCA) of pre-existing long-term health conditions at baseline was used to identify clusters of multimorbidity and associations with changes in HRQoL quantified using mixed effects regression analysis.

RESULTS

Of 9566 admissions with MI (mean age of 64.1 years [SD 11.9], 7154 [75%] men), over half (5119 [53.5%] had multimorbidities. LCA identified 3 multimorbidity clusters which were severe multimorbidity (591; 6.5%) with low HRQoL at baseline (EQVAS 59.39 and EQ5D 0.62) which did not improve significantly at 6 months (EQVAS 59.92, EQ5D 0.60); moderate multimorbidity (4301; 47.6%) with medium HRQoL at baseline (EQVAS 63.08, EQ5D 0.71) and who improved at 6 months (EQVAS 71.38, EQ5D 0.76); and mild multimorbidity (4147, 45.9%) at baseline (EQVAS 64.57, EQ5D 0.75) and improved at 6 months (EQVAS 76.39, EQ5D 0.82). Patients in the severe and moderate groups were more likely to be older, women, and presented with NSTEMI. Compared with the mild group, increased multimorbidity was associated with lower EQ-VAS scores (adjusted coefficient: -5.12 [95% CI -7.04 to -3.19] and -0.98 [-1.93 to -0.04] for severe and moderate multimorbidity, respectively. The severe class was more likely than the mild class to report problems in mobility, OR 9.62 (95% confidence interval: 6.44 to 14.36), self-care 7.87 (4.78 to 12.97), activities 2.41 (1.79 to 3.26), pain 2.04 (1.50 to 2.77), and anxiety/depression 1.97 (1.42 to 2.74).

CONCLUSIONS

Among MI survivors, multimorbidity clustered into three distinct patterns and was inversely associated with HRQoL. The identified multimorbidity patterns and HRQoL domains that are mostly affected may help to identify patients at risk of poor HRQoL for which clinical interventions could be beneficial to improve the HRQoL of MI survivors.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01808027 and NCT01819103.

Fed-batch production assessment of a tetravalent bispecific antibody: A case study on piggyBac stably transfected HEK293 cells

The transition from preclinical biological drug development into clinical trials requires an efficient upscaling process. In this context, bispecific antibody drugs are particularly challenging due to their propensity to form aggregates and generally produce low titers. Here, the upscaling process for a tetravalent bispecific antibody expressed by a piggyBac transposon-mediated stable HEK293 cell pool has been evaluated. The project was performed as a case study at Testa Center, a non-GMP facility for scale-up testing of biologics in Sweden, and encompassed media adaptation strategies, fed-batch optimization and a novel antibody purification technology. The cell pool was adapted to different culture media for evaluation in terms of cell viability and titers compared to its original Expi293 Expression Medium. These parameters were assessed in both sequential stepwise adaption and direct media exchanges. By this, a more affordable medium was identified that did not require stepwise adaptation and with similar titers and viability as in the Expi293 Expression Medium. Fed-batch optimizations resulted in culture densities reaching up to 20 × 10⁶ viable cells/mL with over 90 % viability 12 days post-inoculum, and antibody titers three times higher than corresponding batch cultures. By implementing a novel high-speed protein A fiber technology (Fibro PrismA) with a capture residence time of only 7.5 s, 8 L of supernatant could be purified in 4.5 h without compromising the purity, structural integrity and function of the bispecific antibody. Results from this study related to medium adaptation and design of fed-batch protocols will be highly beneficial during the forthcoming scale-up of this therapeutic antibody.

OP0302-HPR IDENTIFYING THE CONTEXTUAL FACTORS IN THE PATIENT-PRACTITIONER ENCOUNTER THAT HAVE THERAPEUTIC EFFECT: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background:

Placebo or contextual effect is an integral part of the treatment effect (1). The factors related to this effect are “contextual factors” (CFs) (2). CFs may be categorised into five groups as factors related to practitioner, patient, practitioner-patient interaction, treatment and therapeutic environment (3). Several CFs have demonstrated their therapeutic effect, whereas others not (4). The majority of musculoskeletal pain relief result from CFs (5). Identifying the key CFs may encourage health practitioners to optimize the contextual aspects of care.

Objectives:

To identify the modifiable CFs that can improve clinical outcomes in published randomised controlled trials (RCTs).

Methods:

A systematic search was carried out, up until April 18th 2019, on the following databases: MEDLINE via Ovid, EMBASE, AMED, PsycINFO and Cochrane library. RCTs comparing contextual enhanced interventions versus non-enhanced control in adults for any health conditions were searched. The outcomes included both self-reported outcomes and objectively measured outcomes. The effect size and 95%confidence interval were calculated using the standard mean difference. Risk of bias was evaluated using the modified Cochrane tool. The random effects model was used to pool the results.

Results:

Of 3900 records generated from the systematic search, 15 trials (4615 participants) met the inclusion criteria, and 13 were included in this meta-analysis (Figure 1). Conditions studied included musculoskeletal [4], cardiovascular [2], irritable bowel syndrome [1], diabetes [1], asthma [1], GP or hospital patients [6]. Three CFs have been identified from these trials, including empathy, patient involvement and positive communication. All were found to be effective for patient experience i.e. satisfaction. Positive communication was also effective for symptoms but not objective outcomes (Table 1).

Table 1.

Summary of results.

OutcomeInterventionNumber of studies (Number of participants) SMD (95% CI)I2Patient experience outcomes,e.g. satisfactionEmpathy2 (137)0.45 (0.11, 0.79)42.2 %Patient involvement4 (1596)0.31 (0.21, 0.41)93.0 %Positive communication3 (793)0.38 (0.24, 0.52)93.9 %Symptomatic outcomes,e.g. painEmpathy1 (221)-0.18 (-0.45, 0.08)0.0 %Patient involvement1 (314)-0.05 (-0.27, 0.17)0.0 %Positive communication3 (658)0.20 (0.05, 0.35)64.8 %Objective outcomes,e.g. peak expiratory flowPositive communication2 (266)0.10 (-0.14, 0.34)66.6 %

Positive SMD favours intervention group. SMD= Standard mean difference, CI= Confidence interval, I2= heterogeneity.

Figure 1.

Summary of screening process.

Conclusion:

This systematic review has identified three CFs (empathy, patient involvement and positive communication) that have therapeutic effects for different conditions in trials, especially for self-reported outcomes. More research is needed to examine the clinical outcomes of CFs and to understand the influence of health practitioners on disease processes.

References:

[1]Zou K, Wong J, Abdullah N, Chen X, Smith T, Doherty M et al. Examination of overall treatment effect and the proportion attributable to contextual effect in osteoarthritis: meta-analysis of randomised controlled trials. Annals of the Rheumatic Diseases. 2016;75(11):1964-1970.

[2]Miller F, Kaptchuk T. The power of context: reconceptualizing the placebo effect. Journal of the Royal Society of Medicine. 2008;101(5):222-225.

[3]Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. The Lancet. 2001;357(9258):757-762.

[4]Howick J, Moscrop A, Mebius A, R Fanshawe T, Lewith G, L Bishop F et al. Effects of empathic and positive communication in healthcare consultations: a systematic review and meta-analysis. Journal of the Royal Society of Medicine. 2018;111(7):240–252.

[5]Rossettini G, Carlino E, Testa M. Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain. BMC Musculoskeletal Disorders. 2018;19(1).

Disclosure of Interests:

None declared.

Assessing atrial fibrillation ablation priority during COVID-19 -does use of patient questionnaires help in stratification above physician assessment?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Catheter ablation for atrial fibrillation (AF) is largely offered for symptomatic relief. The ORBIT registry has shown that patients with a higher EHRA class and lower quality of life (QoL) scores (AFEQT score <65.7) are more likely to suffer emergency hospital admissions. To help prevent unplanned AF admissions and to best utilise the reduced capacity for elective work during the COVID-19 pandemic, it has become even more important to prioritise the most symptomatic AF patients for ablation. Purpose: To evaluate the accuracy of a subjective symptom-based clinician prioritisation schema compared to objective patient-completed quality of life (QoL) scores. Methods: In July 2020, all elective cases awaiting AF ablation at our institution were categorised by their cardiologist as either category 1 (C1-urgent), category 2 (C2–priority, procedure to be done during the ongoing COVID-19 pandemic) or category 3 (C3–routine, procedure may be delayed until post pandemic). This categorisation was based on review of clinic letters where EHRA AF symptom class or PROMS are not routinely recorded.  All patients in C2 and C3 were then posted an AF specific (AFEQT) and a generic (EQ5D) QoL questionnaire to complete. Physicians were blinded to patient responses on the QoL questionnaires. Results: Details of physician prioritisation and completed questionnaires were available for 85 patients (62 ± 10 years, PAF in 61%, males 66%). The 18 patients that had been categorised in C2 (priority) group were found to have a significantly lower AFEQT score (30.4, IQR 17.2-51.9) compared to the 67 patients classed in C3 (routine) group (56.5, IQR 32.1-74.1; p < 0.01)(Figure 1a). EQ5D scores also tended to be lower in the C2 patients (0.7, IQR 0.4-0.8) compared to C3 (0.8, IQR 0.6-0.9; p = 0.056) (Figure 1c). 16 (89%) patients in C2 had significant AF-related impact on QoL (as defined as AFEQT score <65.7) compared to 42 (63%) of patients in C3.  However, there was significant overlap between groups (Figure 1b). 4 patients in C3 had unplanned AF related hospital admissions while awaiting ablation, as compared to none in C2. The median AFEQT score of these 4 patients was 23.3, indicating that they were highly symptomatic despite being classified in C3 by their cardiologist. Conclusion : Physician assessments are moderately accurate in prioritising patients awaiting AF ablation. The addition of formal patient-completed QoL assessment such as with AFEQT, helps to identify the most symptomatic patients at risk of emergency hospital admission, and physicians should consider using these as part of routine assessment, especially during the COVID pandemic.

Spatio-temporal distribution of spinetail devil ray Mobula mobular in the eastern tropical Atlantic Ocean

The distribution of the spinetail devil ray Mobula mobular in the eastern tropical Atlantic remains poorly known compared to the Pacific and Indian Oceans. We used fishery-dependent data and generalized additive models to examine the environmental characteristics associated with the presence of M. mobular in the eastern Atlantic Ocean. Results revealed that the distribution of M. mobular is significantly associated with seasonal upwelling systems in coastal and pelagic areas. Our model predicted the presence of the species in areas where there is evidence of its occurrence, such as the Angolan upwelling system and the coast of Ghana. In addition, our model predicted new hotspot areas, including locations around the Mauritanian upwelling system, the Guinea coast, offshore Ghana and the south coast of Angola and Brazil, where sample sizes are limited. Those areas, as well as the environmental preferences depicted by the model, provide valuable information about the habitat and ecology of the spinetail devil ray. Future research lines derived from this study, as well as its limitations, are discussed. Furthermore, in light of our results we discuss the improvements that are needed to contribute to the conservation and management of this vulnerable species.

Effect of exercise on pain processing and motor output in people with knee osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

Guidelines recommend exercise as a core treatment for knee osteoarthritis. However, it is unclear how exercise affects measures of pain processing and motor function. The aim was to evaluate the effect of exercise on measures of pain processing and motor function in people with knee osteoarthritis.

METHODS

We searched five electronic databases (MEDLINE, EMBASE, CINAHL, SCOPUS and Cochrane Central Register of Controlled Trials) for studies on knee osteoarthritis, of any design, evaluating pain processing and motor function before and after exercise. Data were pooled with random-effects meta-analysis. Study quality was assessed using the Downs and Black and quality of evidence was assessed using the GRADE.

RESULTS

Eighteen studies were eligible and 16 were included. Following acute exercise, pressure pain threshold increased local to the study limb (standardised mean difference [95% confidence interval (CI)] 0.26, [0.02, 0.51], n = 159 from 5 studies), but there was no statistically significant change remote from the study limb (0.09, [-0.11, 0.29], n = 90 from 4 studies). Following an exercise program (range 5-12 weeks) there were no statistically significant changes in pressure pain threshold (local 0.23, [-0.01, 0.47], n = 218 from 8 studies; remote 0.33 [-0.13, 0.79], n = 76 from 4 studies), temporal pain summation (0.38 [-0.08, 0.85], n = 122 from 3 studies) or voluntary quadriceps muscle activation (4.23% [-1.84 to 10.30], n = 139 from 4 studies).

CONCLUSION

Very-low quality evidence suggests that pressure pain threshold increases following acute exercise. Very-low quality evidence suggests that pressure pain threshold, temporal pain summation or voluntary quadriceps activation do not change statistically significantly following exercise programs.

Prescription of oral anticoagulation for stroke prophylaxis in atrial fibrillation according to frailty status: a national study of 536,995 primary care records

Background

At least 10 million people in Europe have a diagnosis of atrial fibrillation (AF). People with AF commonly have concomitant frailty, rendering them vulnerable to various adverse outcomes. Whilst appropriate prescription of oral anticoagulation (OAC) is associated with reduced risk of stroke and mortality, there are fears of iatrogenic harm in older people with frailty.

Purpose

Previous studies give conflicting evidence of the association between frailty and OAC prescription and are based on small samples from select cohorts. Therefore, we provide data of the association between OAC prescription and frailty for a large representative cohort of patients with AF.

Methods

This cross-sectional study used EHR for 536,955 patients in England aged ≥65 years on 31/12/2015. Clinical Terms Version 3 (CTV-3) codes were used to identify AF and relevant past medical history (PMH, including: cancer, varices, intracranial or gastrointestinal haemorrhage). Frailty was determined according to the validated electronic frailty index (eFI, a cumulative deficit score of 36 possible deficits), and categorised into robust (0–0.12), mild (&gt;0.12–0.24), moderate (&gt;0.24–0.36) or severe (&gt;0.36) frailty.

Patients with a CHA2DS2-VASc score of ≥2 were considered eligible for OAC prescription. Prescription of OAC among those eligible (warfarin or direct oral anticoagulant [DOAC]) or not was established using prescribing data within the EHR.

Poisson regression modelling was used to determine the odds of OAC prescription for each frailty category compared with non-frail (robust) individuals. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported with and without adjustment for sex, deprivation, PMH, concomitant prescription of medications that increase bleeding risk (including antiplatelets, steroids, non-steroidal anti-inflammatories).

Results

Of the cohort, 61,177 (11.4%) had AF. Of these, 58,204 (95.1%) were eligible for OAC, which was prescribed in 30,916 (53.1%) people. Individuals prescribed OAC were on average 5 months younger than those not prescribed OAC (80.1 vs 80.5 years, p&lt;0.001), and had a slightly higher CHA2DS2-VASc score (4.0 vs 3.8, p&lt;0.001). Frailty was identified in 54,734 (89.5%) patients with AF.

OAC was prescribed in 2,028 of 4,863 (41.7%) patients in the robust category; 10,221 of 19,198 (53.2%) with mild; 11,167 of 20,099 (55.6%) with moderate; and 7,500 of 14,044 (53.4%) with severe frailty. In comparison to the robust category, frailty was associated with higher odds of OAC prescription: mild frailty OR 1.6 (95% CI 1.5 to 1.7); moderate 1.7 (1.6 to 1.9); severe 1.6 (1.5 to 1.7). Adjustment for confounding variables increased the magnitude of the association (Figure 1).

Conclusion

People with AF and advancing frailty were more likely to be prescribed an anticoagulant than those with AF who are robust. Specific safety and efficacy data for OAC are needed in people with AF and frailty to better inform clinical decision-making.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): CW was funded by the Hull-York Medical School. He is now an NIHR clinical lecturer.

First Direct Measurement of ^{22}Mg(α,p)^{25}Al and Implications for X-Ray Burst Model-Observation Comparisons

Type-I x-ray bursts can reveal the properties of an accreting neutron star system when compared with astrophysics model calculations. However, model results are sensitive to a handful of uncertain nuclear reaction rates, such as ^{22}Mg(α,p). We report the first direct measurement of ^{22}Mg(α,p), performed with the Active Target Time Projection Chamber. The corresponding astrophysical reaction rate is orders of magnitude larger than determined from a previous indirect measurement in a broad temperature range. Our new measurement suggests a less-compact neutron star in the source GS1826-24.

Sex differences in health-related quality of life among acute myocardial infarction survivors: an inverse weighted propensity score analysis

Background

Over 800,000 women in the UK are living with coronary heart disease, which is the main cause of acute myocardial infarction (AMI). Marked improvements have been noted in clinical outcomes following AMI due to improved use of evidence-based treatments. However, sex differences in outcomes following AMI persist, with limited evidence in the literature concerning patient reported outcomes such as health related quality of life (HRQoL).

Purpose

To investigate sex differences in HRQoL following AMI.

Methods

Data on HRQoL among 9,566 survivors of AMI were collected from 77 National Health Service hospitals in England between 1 November 2011 and 24 June 2015. HRQoL at time of hospitalisation with an AMI as well as at 1, 6 and 12 months post discharge were collected using the self-reported EuroQol five dimension questionnaire which contains a descriptive system (EQ-5D ranging from −0.5 “worse than death” to 1 “full health”) and a visual analogue scale (EQ-VAS ranging from 0 “worst imaginable health state” to 100 “best imaginable health state”). Multilevel regression modelling coupled with inverse probability weighting propensity score analysis was used to investigate longitudinal trajectories of sex differences in perceived HRQoL following AMI.

Results

Overall, there were 2,397 (25%) women in the study. HRQoL improved over time, however, women had a lower baseline HRQoL compared with men (EQ-VAS mean (SD) 59.8 (20.4) vs. 64.5 (20.9), and EQ-5D median (IQR) 0.73 (0.52 to 0.88) vs. 0.81 (0.62 to 1.00). Sex differences in HRQoL over time persisted, with women having a reduced HRQoL (EQ-VAS coefficient: −4.41, 95% CI: −5.16 to −3.66 and EQ-5D coefficient: −0.07, −0.08 to −0.06) and across the individual EQ-5D dimensions women were more likely to report problems with anxiety (odds ratio 2.03, 95% CI: 1.80 to 2.29), mobility (1.82, 1.58 to 2.09), self-care (1.75, 1.47 to 2.08), usual activities (1.70, 1.52 to 1.89) and pain (1.59, 1.45 to 1.75).

Conclusion

Although quality of life improves for AMI survivors, women have a lower baseline and worse recovery compared with men.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation, Wellcome Trust, Sir Henry Wellcome Postdoctoral Fellowship

The optimal timing for the interval to surgery after short course preoperative radiotherapy (5 ×5 Gy) in rectal cancer - are we too eager for surgery?

BACKGROUND

The improved overall survival (OS) after short course preoperative radiotherapy (SCPRT) using 5 × 5 Gy reported in the early rectal cancer trials could not be replicated in subsequent phase III trials. This original survival advantage is attributed to poor quality of surgery and the large differential in local recurrence rates, with and without SCPRT. Immuno-modulation during and after SCPRT and its clinical implications have been poorly investigated. We propose an alternative explanation for this survival benefit in terms of immunological mechanisms induced by SCPRT and the timing of surgery, which may validate the concept of consolidation chemotherapy.

MATERIAL AND METHODS

We reviewed randomized controlled trials (RCTs) and studies of SCPRT from 1985 to 2019. We aimed to examine the precise timing of surgery in days following SCPRT and identify evidence for immune modulation, neo-antigens and memory cell induction by radiation.

RESULTS

Considerable variability is reported in randomised trials for median overall treatment time (OTT) from start of SCPRT to surgery (8-14 days). Only three early trials showed a benefit in terms of OS from SCPRT, although the level of benefit in preventing local recurrence was consistent across all trials. Different patterns of immune effects are observed within days after SCPRT depending on the OTT, but human leukocyte antigen (HLA)-1 expression was not upregulated.

CONCLUSIONS

SCPRT has a substantial immune-stimulatory potential. The importance of the timing of surgery after SCPRT may have been underestimated. An optimal interval for surgery after 5 × 5 Gy may lead to better outcomes, which is possibly exploited in total neoadjuvant therapy schedules using consolidation chemotherapy. Individual patient meta-analyses from appropriate SCPRT trials examining outcomes for each day and prospective trials are needed to clarify the validity of this hypothesis. The interaction of SCPRT with tumour adaptive immunology, in particular the kinetics and timing, should be examined further.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

FRI0637-HPR INDIVIDUALISED EXERCISE INTERVENTION FOR HIP AND KNEE OSTEOARTHRITIS: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMISED CONTROLLED TRIALS

Background:

Osteoarthritis (OA) is a leading cause of disability worldwide. Currently, exercise is recognised to be one of the core treatments for OA (NICE, 2014). Convincing evidence shows that exercise can have positive effects on pain and function in people with OA (Fransen et al., 2015). However, a standardised exercise regimen may not suit all patients and adherence to exercise is always an issue. Therefore, several international guidelines recommended individualisation of the exercise regimen according to individual patient characteristics (e.g. pain severity, personal goals and co-morbidities), as this may enhance take up and adherence, hence treatment effect of the intervention (Fernandes et al., 2013).

Objectives:

The aims of this systematic review were: (1) to evaluate the current evidence for efficacy in randomised controlled trials (RCTs) of individualised exercise (IE) interventions for people with hip or knee OA; and (2) compare this to the efficacy of non-individualised exercise (NIE).

Methods:

A systematic search was carried out, up until March 6th2018, on the following databases: MEDLINE, CINAHL, AMED, PsycINFO and EMBASE. RCTs of IE interventions, or with subgroup analysis based on specific patient characteristics, were searched. Standardised mean difference and 95% confidence interval (CI) were calculated using random effects model. Risk of bias was evaluated using the modified Cochrane tool. Pain was the primary outcome of interest. Results of IE interventions were then compared to the NIE interventions identified from a previous systematic review (Goh et al., 2019).

Results:

We reviewed titles of 1,766 records in the systematic search. The screening process (Figure) identified 15 studies (1,826 participants) that met the inclusion criteria, of which 7 were included in a meta-analysis. Most included studies had high risk of bias. Blinding was a consistent problem due to the nature of the intervention. Within the trials exercise was individualised according to factors including severity of symptoms, exercise performance, lower limb muscle strength and presence of co-morbidities (e.g. heart failure, chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM) type 2).

The analysis showed that IE significantly improved pain, physical function, performance and quality of life outcomes (Table). When compared to NIE interventions, IE showed greater effect size for all outcomes but their 95% CIs were overlapping.

Figure showing Summary of screening process

Table 1.

Summary of results

OutcomeType of exercise programES95% CINumber of studies (Number of patients)PainIE1.040.32 - 1.777 (991)NIE0.570.44 - 0.6965 (4,723)FunctionIE1.370.50 - 2.247 (991)NIE0.510.38 - 0.6463 (4,829)PerformanceIE2.000.07 - 3.932 (291)NIE0.51038 - 0.6366 (4,889)QoLIE1.30-0.52 - 3.122 (226)NIE0.320.15 - 0.4934 (2,545)

ES= Effect size. CI= Confidence Interval. IE= Individualised Exercise. NIE= Non-Individualised Exercise. QoL= Quality of Life

Conclusion:

The results of this review show that IE may have better outcomes on people with hip or knee OA compared to NIE. However, the small study effect may inflate the estimates of the individualised exercise group, and further head to head comparisons are required.

References:

[1] FERNANDES L., HAGEN K. B., BIJLSMA J. W., ANDREASSEN O., CHRISTENSEN P., CONAGHAN P. G., DOHERTY M., GEENEN R., HAMMOND A. & KJEKEN I. 2013. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.Annals of the rheumatic diseases,72, 1125-1135.

[2] FRANSEN M., MCCONNELL S., HARMER A. R., VAN DER ESCH M., SIMIC M. & BENNELL K. L. 2015. Exercise for osteoarthritis of the knee.The Cochrane Library.

[3] GOH S.-L., PERSSON M. S., STOCKS J., HOU Y., WELTON N. J., LIN J., HALL M. C., DOHERTY M. & ZHANG, W. 2019. Relative efficacy of different exercises for pain, function, performance and quality of life in knee and hip osteoarthritis: Systematic review and network meta-analysis.Sports Medicine,49, 743-761.

[4] NICE 2014. Osteoarthritis: care and management in adults.https://www.nice.org.uk/guidance/cg177/chapter/1-Recommendations#non-pharmacological-management-2[Accessed 02/12 2019]

Disclosure of Interests:

Khalid Yaseen: None declared, Burak Kundakci: None declared, Siew Li Goh: None declared, Michael Doherty Grant/research support from: AstraZeneca funded the Nottingham Sons of Gout study, Consultant of: Advisory borads on gout for Grunenthal and Mallinckrodt, Weiya Zhang Consultant of: Grunenthal for advice on gout management, Speakers bureau: Bioiberica as an invited speaker for EULAR 2016 satellite symposium, Abhishek Abhishek Grant/research support from: AstraZeneca and OxfordImmunotech, Speakers bureau: Menarini pharmaceuticals, Michelle Hall: None declared

THU0461 THE COMPARATIVE EFFICACY OF NON-PHARMACOLOGICAL INTERVENTIONS FOR FIBROMYALGIA: A SYSTEMATIC REVIEW WITH BAYESIAN NETWORK META-ANALYSIS

Background:

Non-pharmacological interventions are recommended as first-line treatment options in the management of fibromyalgia (FM)1. However, whether one intervention is more effective than another for specific patient-centred outcomes in FM is unknown.

Objectives:

To compare the relative efficacy of non-pharmacological interventions on FM impact questionnaire (FIQ), pain, fatigue, sleep and depression in people with FM.

Methods:

A Bayesian network meta-analysis was conducted. Randomised controlled trials (RCTs) assessing any non-pharmacological intervention versus usual care, placebo or active controls in patients with FM aged >16 years were searched for in seven databases. A common comparator was identified between interventions to develop a network (Figure 1). Standardised mean difference (SMD) and 95% credible interval (CrI) was estimated between interventions. Direct and indirect evidence were pooled using the random effect model. Modified Cochrane‘s tool was used to assess risk of bias.

Figure 1.

Network map of different interventions evaluating FIQ

Results:

78 studies (n = 5,639 participants) met the inclusion criteria. There was a high risk of bias on blinding and most trials had small sample size (n<50).

While multidisciplinary treatment (MDT) was the best for improving pain [-1.28 (-1.84, -0.72)], sleep [-1.14 (-2.38, 0.07)] and depression [-1.20 (-1.99, -0.46)], balneotherapy and exercise were the most effective treatments for FIQ [-1.06 (1.51, -0.61)] and fatigue [-0.75 (-1.35, -0.25)], respectively (Figure 2).

Figure 2.

Standardised mean difference (SMD) versus usual care in descending order for different outcomes

Data from 47 exercise trials (n = 3,271 participants) were analysed to examine comparative efficacy of different exercise types. Strengthening showed the greatest benefits for FIQ [-0.76 (-1.39, -0.15)], pain [-0.94 (-1.58, -0.29)] and depression [-0.83 (-1.53, -0.14)], whereas aerobic exercise was the best for fatigue [-0.98 (-2.33, 0.18)] and sleep [-0.96 (-2.08, 0.13)] (Table 1).

Table 1.

Relative effect size between types of exercises

FIQAerobic-0.58(-1.13, -0.03)-0.09(-0.55, 0.36)0.18(-0.44, 0.80)0.12(-0.36, 0.57)-0.57(-0.95, -0.24)-0.60(-1.36, 0.18)Flexibility0.49(-0.23, 1.20)0.76(-0.07, 1.58)0.70(-0.04, 1.41)0.004(-0.67, 0.64)-0.10(-0.74, 0.53)0.49(-0.50, 1.49)Mind-body0.27(-0.37, 0.91)0.20(-0.24, 0.65)-0.49(-0.85, -0.15)0.05(-0.59, 0.70)0.65(-0.35, 1.63)0.16(-0.53, 0.85)Mixed-0.06(-0.73, 0.59)-0.69(-1.06, -0.34)0.21(-0.42, 0.84)0.80(-0.19, 1.79)0.31(-0.41, 1.02)-0.06(-0.73, 0.59)Strengthening-0.76(-1.39, -0.15)-0.73(-1.16, -0.30)-0.13(-1.02, 0.74)-0.62(-1.15, -0.11)-0.78(-1.31, -0.26)-0.94(-1.58, -0.29)Usual carePain

Data are standard mean difference (95% credible intervel) between exercises, pairwised from the top left to the bottom right. The negative value indicates that the first exercise is more effective than the second exercise. For example, aerobic is better than flexibility for FIQ -0.58 (-1.13, -0.13), but not pain -0.60 (-1.36, 0.18).

Conclusion:

Several non-pharmacological interventions are beneficial for FM. However, the effect size varies between interventions and outcomes. All types of exercises are effective for FIQ and pain apart from flexibility exercise. The results of this study may be used to guide the selection of the most effective non-pharmacological interventions according to the predominant symptom in individual patients.

References:

[1]Macfarlane GJ et al. Ann Rheum Dis 2017;76(2):3-8-28.

Disclosure of Interests: :

None declared

FRI0628-HPR EVALUATING A COMPLEX PACKAGE OF CARE IN THE EAST-MIDLANDS KNEE PAIN FEASIBILITY COHORT RANDOMISED CONTROLLED TRIAL

Background:

The role of nurses in managing painful knee OA has been advocated but whether nurses can deliver such interventions as a package of care is unknown.The overall aim of this research is to develop and test a nurse-led complex intervention for knee pain comprising non-pharmacological and pharmacological components. In the first study phase, we report on fidelity and acceptability of a non-pharmacological intervention, to resolve possible challenges to delivery.

Objectives:

To evaluate fidelity of delivery and acceptability of non-pharmacological components of a complex intervention.

Methods:

This was a mixed-methods study. Participants with chronic knee pain were recruited from the community to receive the intervention, delivered in 4-sessions over a 5-week period by a trained research nurse. The intervention consisted of holistic assessment, patient education and advice, aerobic and strengthening exercise and weight-loss advice if required. All sessions were video-recorded. Fidelity checklists were completed by the nurse (nurse-rated) and two researchers from the video-recordings (video-rated). Median fidelity scores (%) and interquartile ranges (IQR) were calculated for each component and each session. Semi-structured interviews were conducted with participants. These were audio recorded, transcribed and analysed following the framework approach.

Results:

18 participants (34% women), with a mean (SD) age and BMI of 68.7 (9.0) years and 31.2 (8.4) kg/m2, took part in the study. Of these, 14 completed all visits. In total, 62 intervention sessions were assessed for fidelity. Overall fidelity was rated high by both nurse-rated scores (97.7%) and video-rated scores (84.2%). The level of agreement between nurse-rated and video-recorded methods was 73.3% (CI 71.3, 75.3) and the inter-rater agreement was 65.5% (CI 60.3, 70.5). Fidelity of delivery was lower for advice on footwear modification and walking aids in all sessions and moderate for education in session 1 and for exercise in session 4 (Table 1).

Table 1.

Fidelity scores of the components of the intervention for each session,

Intervention componentsSession 1*Session 2*Session 3*Session 4*Education78.1 (74.1, 93.7)87.5 (50, 100)87.5 (50, 100)100 (93.7, 100)Exercise94.4 (88.9, 100)88.9 (75, 94)86.1 (72, 100)75 (67.6, 82.8)Adjunctive treatments50 (45.83, 100)0 (0, 50)50 (0, 100)-

*median (IQR)

17 participants were interviewed. Most found advice supplied straightforward. They were satisfied with the package, which changed their perception of managing knee pain, understanding it can be improved though self-management. However, too much information was provided in a short time-span and it was difficult to fit exercises into their daily routine.

Conclusion:

Delivery of a non-pharmacological intevention by a nurse is feasible within a research setting. Most components of the intervention were delivered as intended, except for advice about the use of adjunctive treatment.

Acknowledgments:

This research was funded by the NIHR Nottingham BRC and Pain Centre Versus Arthritis

Disclosure of Interests:

Polykarpos Angelos Nomikos: None declared, Amy Fuller: None declared, Michelle Hall: None declared, Bonnie Millar: None declared, Reuben Ogollah: None declared, Michael Doherty: None declared, Roshan Nair Speakers bureau: Financial support from pharmaceutical companies (Biogen and Novartis) to present lectures at events related to psychological support for people with multiple sclerosis (Speaker’s bureau)., David Walsh Grant/research support from: 2016: Investigator-led grant from Pfizer Ltd (ICRP) on Pain Phenotypes in RA; non-personal financial disclosure (payment to University)., Consultant of: DAW has undertaken paid consultancy to Pfizer Ltd, Eli Lilly and Company and GSK Consumer Healthcare., Paid instructor for: 2019: Consultancy to Love Productions; consultancy on programme design, contribution to programme content on self-management of chronic pain (payments to University)

2019: Consultancy to AbbVie Ltd; 13.06.19; presentation on RA pain at EULAR, Madrid, and webinar (payments to University).

2019: Consultancy to Eli Lilly and Company Ltd. 06.06.19 Centre for Collaborative Neuroscience, Windlesham, Surrey, UK (payment to University).

2019: Consultancy to Pfizer (payment to University).

2018: Consultancy to Pfizer. 07.12.18. USA. 1 day. Tanezumab (payment to University).

2018: Consultancy to Pfizer. 23.11.18. Manchester UK. 1 day. Tanezumab (payment to University).

2018: Consultancy to Pfizer. 1.11.18. Skype. 4h. Tanezumab (payment to University).

2018: Consultancy to GlaxoSmithKline Plc. 1 day. Pain in RA and anti-GM-CSF (payment to University).

2018: Consultancy to Pfizer Ltd; Presentation at OARSI; non-personal financial disclosure (payment to University)

2018: Consultancy to Pfizer Ltd; Patient preference study; non-personal financial disclosure (payment to University)

2017: Consultancy to Pfizer Ltd; personal financial disclosure

2017: Consultancy to Pfizer Ltd through Nottingham University; non-personal financial disclosure (payment to University).

2015: Consultancy to GSK Consumer Healthcare; personal financial disclosure., Speakers bureau: 2019: Irish Society of Rheumatology: speaker fees (personal pecuniary), Ana Valdes Grant/research support from: Awarded a grant from Pfizer, Abhishek Abhishek: None declared