Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Blood Lactate Responses of Male and Female Players Across an International Rugby Sevens Tournament

PURPOSE

This study investigated within- and between-matches blood lactate (La-) responses across an international Rugby Sevens tournament (5 matches over 2 d) in male and female players.

METHODS

Earlobe blood samples were taken from 25 professional players around matches: before warm-up (PRE), immediately upon finishing match participation (POST), and 30 minutes postmatch (30 min).

RESULTS

POST [La-] (mean [SD], range) for males was 10.3 (3.2; 2.9-20.2) mmol·L-1 and for females was 9.1 (2.3; 3.4-14.6) mmol·L-1. Linear mixed-effects models revealed a decrease in POST [La-] after match 5, compared to match 1. Increased PRE [La-] was found before match 2 (+0.8 [0.6-1.1] mmol·L-1), match 3 (+0.8 [0.5-1.1] mmol·L-1), and match 5 (+0.6 [0.4-0.9] mmol·L-1) compared to match 1 (all P < .001). The [La-] remained elevated at 30 min, compared to PRE (+1.7 [1.4-2.0] mmol·L-1, P < .001), with ∼20% of values persisting >4 mmol·L-1. Higher POST was observed in males compared to females (+1.6 [0.1-3.2] mmol·L-1, P = .042); however, no differences between sexes were found across 30 min or PRE [La-]. No [La-] differences between positions (backs and forwards) were identified.

CONCLUSIONS

Lactate concentrations above 10 mmol·L-1 are required to effectively simulate the anaerobic demands of international Rugby Sevens matches. Practitioners are advised to individualize anaerobic training prescription due to the substantial variability observed within positional groups. Additionally, improving athletes' metabolic recovery capacity through training, nutrition, and recovery interventions may enhance physical preparation for subsequent matches within a day, where incomplete lactate clearance was observed.

Association between psychological distress trajectories from adolescence to midlife and mental health during the pandemic: evidence from two British birth cohorts

BACKGROUND

This paper examined whether distinct life-course trajectories of psychological distress from adolescence to midlife were associated with poorer mental health outcomes during the pandemic.

METHODS

We present a secondary analysis of two nationally representative British birth cohorts, the 1958 National Child Development Study (NCDS) and 1970 British Cohort Study (BCS70). We used latent variable mixture models to identify pre-pandemic longitudinal trajectories of psychological distress and a modified Poisson model with robust standard errors to estimate associations with psychological distress, life satisfaction and loneliness at different points during the pandemic.

RESULTS

Our analysis identified five distinct pre-pandemic trajectories of psychological distress in both cohorts. All trajectories with prior symptoms of psychological distress irrespective of age of onset, severity and chronicity were associated with a greater relative risk of poorer mental health outcomes during the pandemic and the probability of poorer mental health associated with psychological distress trajectories remained fairly constant. The relationship was not fully attenuated when most recent pre-pandemic psychological distress and other midlife factors were controlled for.

CONCLUSIONS

Whilst life-course trajectories with any prior symptoms of psychological distress put individuals at greater risk of poor mental health outcomes during the pandemic, those with chronic and more recent occurrences were at highest risk. In addition, prior poor mental health during the adult life-course may mean individuals are less resilient to shocks, such as pandemics. Our findings show the importance of considering heterogeneous mental health trajectories across the life-course in the general population in addition to population average trends.

Do initiation rites hasten sexual debut among adolescent girls? A longitudinal analysis from Ghana

Many Ghanaians identify their country's most enduring female initiation rite as a risk factor for early sexual debut, claiming that initiates interpret the rite as a normative starting point for sexual activity as was standard in the past. However, the assumption that African initiation rites may hasten sexual debut has not been statistically substantiated. This study explores this association using three waves of longitudinal data collected between 2010 to 2013 from 690 girls and young women aged 12-19, about half of whom had participated in the rite. The results suggest that initiates typically participate in the rite at age 11 and begin having sex around age 16, about six months earlier than non-initiates. Results from survival analyses correspondingly indicate that initiates are 50% more likely to report sexual debut than their non-initiated counterparts. This relationship remains robust when accounting for confounding variables and reverse causality and is not moderated by socioeconomic status. Findings suggest that initiation rites should be understood as having potentially meaningful implications for adolescent sexual debut and sexual and reproductive health outcomes in sub-Saharan Africa. Capitalising on initiation rites for their role in sexual socialisation may be a valuable opportunity to promote sexual and reproductive health among youth.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Developing and testing a case-management intervention to support the return to work of health care workers with common mental health disorders

BACKGROUND

To assess the feasibility and acceptability of conducting a trial of the clinical effectiveness and cost-effectiveness of a new case-management intervention to facilitate the return to work of health care workers, on sick leave, having a common mental disorder (CMD).

METHODS

A mixed methods feasibility study.

RESULTS

Systematic review examined 40 articles and 2 guidelines. Forty-nine National Health Service Occupational Health (OH) providers completed a usual care survey. We trained six OH nurses as case managers and established six recruitment sites. Forty-two out of 1938 staff on sick leave with a CMD were screened for eligibility, and 24 participants were recruited. Out of them, 94% were female. Eleven participants received the intervention and 13 received usual care. Engagement with most intervention components was excellent. Return-to-work self-efficacy improved more in the intervention group than in the usual care group. Qualitative feedback showed the intervention was acceptable.

CONCLUSIONS

The intervention was acceptable, feasible and low cost to deliver, but it was not considered feasible to recommend a large-scale effectiveness trial unless an effective method could be devised to improve the early OH referral of staff sick with CMD. Alternatively, the intervention could be trialled as a new stand-alone OH intervention initiated at the time of usual OH referral.

Comparing health outcomes of care experienced children to children not in care in Scotland 2009-2016

Background

Internationally, there is little quantitative evidence on how the health of children who have experienced social care compares to children in the general population. Invariably, available evidence suggests that care experience is related to poorer health, but often this is based on small sample sizes or without comparison to children who have not been in care. The Children's Health in Care in Scotland (CHiCS) study provides the first Scotland-wide evidence on health outcomes of care experienced children (CEC) compared to children in the general population (CGP).

Methods

We undertook an individual level administrative data linkage of social care, morbidity, prescribing, death and birth records from August 2009 to July 2016. The CEC cohort was defined as all school-age children who were in social care in 2009/2010 (n = 13,831) and the CGP cohort includes school-age children who were not in care (n = 649,771). Age-standardized rates per 1000 person-years were calculated for hospitalisation by cause, prescription types and cause of death for both cohorts.

Results

Initial results show that CEC experienced higher average rates of mortality, prescriptions, and different types of hospitalisations during the study period (not adjusted). There are substantial differences in the types of prescriptions and reasons for hospital admission between the cohorts; CEC are more likely to be prescribed antidepressants (rate of 260.2 per 1000 person-years for CEC compared to 114.4 for GCP) and to attend psychiatric outpatient appointments (rate of 163.2 compared to 32.6). Care experienced young women have higher rates of medical abortions (rate of 11.3 compared to 6.1).

Conclusions

The results from this study indicate that CEC are more likely to contact the health services, particularly for mental and sexual/reproductive health reasons, and these problems may track into adulthood. Interventions to reduce inequalities in health for CEC should focus on these areas.

Key messages

CEC had higher rates of mortality, prescriptions, and hospitalisations during the study period. CEC are more likely to contact the health services for mental and sexual/reproductive health reasons.

Measuring bonding or attachment in the parent-infant-relationship: A systematic review of parent-report assessment measures, their psychometric properties and clinical utility

BACKGROUND

Meaningful, valid and reliable self-report measures can facilitate the identification of important parent-infant-relationship factors, relevant intervention development and subsequent evaluation in community and clinical contexts. We aimed at identifying all available parent-report measures of the parent-infant-relationship or bond and to appraise their psychometric and clinimetric properties.

METHOD

A systematic review (PROSPERO: CRD42017078512) was conducted using the, 2018 COSMIN criteria. Eight electronic databases were searched. Papers describing the development of self-report measures of the parent-infant-bond, attachment or relationship from pregnancy until two years postpartum or the assessment of their psychometric properties were included.

RESULTS

Sixty-five articles evaluating 17 original measures and 13 modified versions were identified and reviewed. The studies' methodological quality (risk of bias) varied between 'very good' and 'inadequate' depending on the measurement property assessed; however, scale development studies were mostly of 'inadequate' quality. Although most measures had good clinical utility, the psychometric evaluation of their properties was largely poor. The original or modified versions of the Postpartum Bonding Questionnaire collectively received the strongest psychometric evaluation ratings with high quality of evidence.

CONCLUSIONS

This novel review revealed that only a few antenatal and postnatal measures demonstrated adequate psychometric properties. Further studies are needed to determine the most robust perinatal measures for researchers and clinicians.

0180 Sleep, Sleepiness, and Sleep Hygiene Related to Nomophobia (No Mobile Phone Phobia)

Introduction

Previously, active phone use at bedtime has been implicated in disrupted sleep and related complaints. To improve sleep, a recommendation following such findings is limiting phone use before and during bedtime. However, for those with the characteristic of “nomophobia”, fear of being out of mobile phone contact, this recommendation could exacerbate anxiety at and around bedtime and disrupt, rather than improve, sleep. In 2012, an estimated 77% of 18-24-year-olds could be identified as nomophobic. Because of the prevalence of nomophobia and its possible interaction with sleep, we explored the existence of nomophobia in a college-age population and its relationship to sleep, sleepiness, and sleep hygiene behaviors.

Methods

327 university students (age: M=19.7 years, SD=3.78) recruited from introductory psychology courses and campus newsletters were given extra credit or a chance to win $25 gift cards for participation. Participants completed demographic information, the Nomophobia Questionnaire (NMP-Q), the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index, questions regarding associated features of inadequate sleep hygiene, and the Sleep Hygiene Index. Additional sleep hygiene questions assessed frequency of active and passive technology use during sleep time.

Results

89.4% of the participants had moderate or severe nomophobia. Greater nomophobia was significantly related to greater daytime sleepiness (ESS) (r(293)=.150, p&lt;.05), associated features of poor sleep (daytime sleepiness: r(297)=.097, p&lt;.05, and avolition: r(297)=.100, p&lt;.05), more maladaptive sleep hygiene behaviors including active technology use during sleep time (r(298)=.249, p&lt;.05), long daytime naps, inconsistent wake and bed times, using bed for non-sleep purposes, uncomfortable bed, and bedtime cognitive rumination (r’s=0.097 to 0.182).

Conclusion

Most participants experienced moderate to severe nomophobia with greater nomophobia associated with greater sleepiness, avolition, and poorer sleep hygiene. Nomophobia is likely to be an important consideration when treating sleep disorders and/or making any sleep hygiene recommendations.

Support

Hendrix College Charles Brewer Fund for Psychology

0194 Bedtime Technology Use and New Questions for the Sleep Hygiene Index

Introduction

We examined the relationship between bedtime active and passive social technology use (self and bedpartner) and daytime sleepiness/sleep. We generated questions to differentiate participants with and without bedpartners and updated passive personal, active bedpartner, and passive bedpartner social technology questions of the Sleep Hygiene Index.

Methods

327 students (age: M=19.7 years, SD=3.78) recruited through psychology courses and campus newsletters received extra credit or chances to win $25 gift cards. Participants completed demographic information, the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index, questions regarding associated features of inadequate sleep hygiene, and the Sleep Hygiene Index. Five questions assessed active and passive social technology use, presence of a bedpartner, and awareness of bedpartner active and passive social technology use during sleep time.

Results

61.8% and 62.7% of students reported frequently or always using active and passive bedtime social technology, respectively; and 23.5% and 29.1% reported noticing a partner’s active or passive use. More frequent active technology use was significantly related to greater daytime sleepiness (ESS) (r(305)=.193, p&lt;.05), sleep disturbances (PSQI-global: r(302)=.120, p&lt;.05), and associated features of inadequate sleep hygiene (daytime sleepiness, worry about sleep, mood disturbance, avolition, and reduced cognition (r(306)=.212, p&lt;.05)). Neither passive use nor passive or active partner use was significantly related to any sleep/sleepiness variables.

Conclusion

We continue to find students are frequent users of bedtime social technology which is related to daytime sleepiness, disrupted sleep, and related complaints. Passive and partner active/passive bedtime technology use may not have a significant impact on daytime sleepiness. It is possible younger participants are not good judges of passive or partner technology use or this younger population is resilient to these disruptions.

Support

none

Surveillance imaging with FDG-PET/CT in the post-operative follow-up of stage 3 melanoma

Background

As early detection of recurrent melanoma maximizes treatment options, patients usually undergo post-operative imaging surveillance, increasingly with FDG-PET/CT (PET). To assess this, we evaluated stage 3 melanoma patients who underwent prospectively applied and sub-stage-specific schedules of PET surveillance.

Patients and methods

From 2009, patients with stage 3 melanoma routinely underwent PET +/- MRI brain scans via defined schedules based on sub-stage-specific relapse probabilities. Data were collected regarding patient characteristics and outcomes. Contingency analyses were carried out of imaging outcomes.

Results

One hundred and seventy patients (stage 3A: 34; 3B: 93; 3C: 43) underwent radiological surveillance. Relapses were identified in 65 (38%) patients, of which 45 (69%) were asymptomatic. False-positive imaging findings occurred in 7%, and 6% had treatable second (non-melanoma) malignancies. Positive predictive values (PPV) of individual scans were 56%-83%. Negative scans had predictive values of 89%-96% for true non-recurrence [negative predictive values (NPV)] until the next scan. A negative PET at 18 months had NPVs of 80%-84% for true non-recurrence at any time in the 47-month (median) follow-up period. Sensitivity and specificity of the overall approach of sub-stage-specific PET surveillance were 70% and 87%, respectively. Of relapsed patients, 33 (52%) underwent potentially curative resection and 10 (16%) remained disease-free after 24 months (median).

Conclusions

Application of sub-stage-specific PET in stage 3 melanoma enables asymptomatic detection of most recurrences, has high NPVs that may provide patient reassurance, and is associated with a high rate of detection of resectable and potentially curable disease at relapse.

Longitudinal patterns of mental health service utilisation by those with mental-physical comorbidity in the community

OBJECTIVE

Successful healthcare integration demands an understanding of current service utilisation by people with comorbidity. Physical illness may impact on mental health service use (MHSU), but longitudinal studies of comorbidity and MHSU are rare. This study 1) estimated associations between mental-physical comorbidity and longitudinal MHSU patterns; 2) tested whether associations between comorbidity and continuous MHSU are driven by "need".

METHODS

Survey data from a South East London community cohort were used (N = 1052). Common mental disorder symptoms (CMDS) were measured using the Clinical Interview Schedule Revised and self-report of long-standing disorders. A checklist of common conditions measured chronic physical conditions. MHSU captured self-reported use of mental health services in the past year at two time points. "Need" indicators included CMDS at follow-up, suicidal ideation, somatic symptom severity, self-rated health, daily functioning problems and perceived functioning limitations due to emotional health. Analyses used logistic and multinomial regression.

RESULTS

Continuous MHSU (at both time-points) was twice as commonly reported by those with comorbidity than those without physical comorbidity (30.9% vs 12.3%). CMDS at follow-up, suicidal ideation, and perceived functioning limitations due to emotional health only partially explained the association between CMDS-physical comorbidity and continuous MHSU. In the adjusted model, comorbidity remained associated with continuous MHSU (RRR = 3.23, 95% CI: 1.39-7.51; p = .002), while the association for non-comorbid CMDS was fully attenuated (RRR = 1.08, 95% CI: 0.40-2.93; p = .85).

CONCLUSION

CMDS-physical comorbidity was strongly associated with continuous MHSU, and "need" did not account for this association, suggesting that comorbidity itself represents a "need" indicator.

Neighbourhoods and obesity: A prospective study of characteristics of the built environment and their association with adiposity outcomes in children in Montreal, Canada

This paper examined prospective associations between built environment features assessed at baseline using direct audits and adiposity outcomes two years later in Montreal, Canada. Data stem from the Quebec Adipose and Lifestyle Investigation in Youth study of 630 children aged 8-10 years with a parental history of obesity. Baseline measurements took place between 2005 and 2008. Follow-up took place between 2008 and 2011. Built environment features were assessed at baseline in up to 10 contiguous street segments around participants' residential addresses using on-site audits. Analyses were restricted to participants who reported the same address both at baseline and follow-up. Prospective associations between adiposity outcomes at follow-up (BMI z-score and waist-height ratio) and built environment features at baseline (traffic-calming features, pedestrian aids, disorder, physical activity facilities, convenience stores, and fast-food restaurants) were examined using multivariable regression models. 391 children were included in the analyses. In fully-adjusted models, children living in residential areas with presence of pedestrian aids had lower BMI z-score, and lower waist-height ratio. Also, children residing in residential areas with at least one convenience store had lower BMI z-score, and lower waist-height ratio at follow-up. Findings provide evidence of the potential role of street-level urban design features in shaping childhood adiposity. To better inform policy and intervention, future research should explore the possibility of reducing obesogenic neighbourhoods by enhancing street-level design features.

Screening for latent tuberculosis in UK health care workers

Background

Active tuberculosis (TB) infection was diagnosed in two health care workers (HCWs) originally from high-incidence countries at a National Health Service (NHS) hospital trust in Northern England. In response, the trust screened current clinical employees from countries with a high TB prevalence for active and latent TB infection (LTBI).

Aims

To identify the number of HCWs, within the organization, who are at risk of TB infection.

Methods

Clinical employees from countries with a high TB prevalence (those described by the World Health Organization as having an incidence of >40 cases per 100000 populations) were reviewed. Employees were identified via human resource systems and occupational health records, from which nationality or country of birth was identified. A letter was sent to identified employees advising of the rationale for a reviewed screening process and inviting them to attend for an interferon-gamma release assay (IGRA) blood test.

Results

A total of 587 clinical staff were identified as fitting the criteria of clinical HCWs from high-incidence countries. Of 469 HCWs screened, 27% screened positive using IGRA. This represented 4% of the total clinical workforce for the organization.

Conclusions

A considerable proportion of the workforce at this NHS hospital trust had previously undiagnosed LTBI, carrying a risk of conversion to active disease. Further action, such as treatment of LTBI or increased workforce awareness of symptoms of active disease, could help to reduce the risk of transmission of TB to patients and the need for associated 'look-back' exercises.

Investigating Socioeconomic Position in Dental Caries and Traumatic Dental Injury among Children in Quebec

OBJECTIVES

Socioeconomic position (SEP) is inversely associated with most oral health outcomes, but the patterns of association may vary depending on the specific outcome. We estimated associations between SEP and two oral health outcomes, dental caries and traumatic dental injuries (TDI), in Quebec children.

METHODS

We used data from the baseline visit of the QUALITY (QUebec Adipose and Lifestyle Investigation in Youth) Cohort, an ongoing study in Montreal and Quebec, Canada. The analytical sample included 590 children aged 8-10 years. Data on parents' SEP (household income, education) and children's health behaviours and involvement in sports were obtained through questionnaires and interviews. Oral health outcomes (dental caries and TDI in permanent teeth) were assessed by clinical oral exam. Negative binomial regression was used to model dental caries (DMFS index) and number of teeth with TDI adjusting for selected covariates.

RESULTS

The mean (SD) DMFS and number of TDI were 0.61 (1.43) and 0.12 (0.43), respectively. Compared to the upper quartile of income, children in the lower quartile had a DMFS approximately 3 times higher (PRR=2.68, 95% CI: 1.43, 5.04). Adjusting for oral health and nutritional behaviours had no effect. Conversely, children in the highest income quartile had a 3 times higher number of teeth with TDI compared to the lowest quartile (PRR=3.14, 95% CI: 1.22, 8.08). Physical activity did not explain this relationship. Parents' education was not associated with dental caries or TDI.

CONCLUSION

SEP seems to play a different role in the cause of dental caries and TDI.

Psychological Services in Hospices in the UK and Republic of Ireland

OBJECTIVE

To evaluate the level of psychological services available to patients and staff in hospices.

DESIGN

Questionnaire analysis.

SETTING

Hospices in the UK and Republic of Ireland.

PARTICIPANTS

224 hospices.

MAIN OUTCOME MEASURES

The availability of professional psychological support for those with advanced disease.

RESULTS

Responses were received from 166 hospices (74%). Only 50 hospices (30%) have access to a psychiatrist, whilst 68 (41%) have access to a clinical psychologist and 92 (45%) have neither. Only 21 hospices (12%) have service level agreements with local mental health trusts. Counsellors, complementary therapists and spiritual advisors such as chaplains were more plentiful.

CONCLUSIONS

Delivery of the NICE guidelines, especially tier four, may be compromised by limited availability of specialist services. This has implications for the psychological assessment of applicants for voluntary euthanasia under an Assisted Dying Act.

Association between metabolic syndrome and gingival inflammation in obese children

BACKGROUND AND OBJECTIVE

Our previous work showed a positive association between metabolic syndrome (MetS) and gingival crevicular fluid (GCF) tumour necrosis factor-alpha (TNF-α) in a sample of obese and non-obese children. However, whether this association persists among obese children is unknown. We aim to investigate the extent to which MetS is associated with GCF TNF-α level among obese children.

METHODOLOGY

We performed a cross-sectional analysis using data from visit 1 of the QUebec Adipose and Lifestyle InvesTigation in Youth cohort. A total of 219 obese children aged 8-10 years, for whom data were available for both MetS and TNF-α, were included in our analysis. The independent variable, MetS, was defined according to the International Diabetes Federation recommendations. GCF samples were collected from the gingival sulcus using a paper strip, and the concentration of TNF-α was determined by enzyme-linked immunosorbent assay. Analyses included descriptive statistics and sex-specific linear regression analyses adjusting for potential confounders.

RESULTS

In this sample comprising only obese children, 24 (10.9%) had MetS. Among obese boys, those with MetS had 44.9% higher GCF TNF-α (95% confidence interval: 16.5%-73.3%) compared to those without MetS. No such association was detected in obese girls.

CONCLUSION

MetS was positively associated with GCF TNF-α concentration in obese boys. These results suggest that obese boys with MetS may have a worse gingival health profile compared to their obese counterpart without MetS.

A case series of anal melanoma including the results of treatment with imatinib in selected patients

AIM

Anal melanoma is a rare malignancy with a poor prognosis.

METHOD

All patients with a diagnosis of anal melanoma treated at a single institution between 2000 and 2012 were identified and their treatment and outcome were evaluated.

RESULTS

Sixteen patients had a median survival of 2.9 years. Fourteen had Stage I or II disease with a median survival of 4.0 years and progression-free survival of 1.5 years. When used for disease staging, whole body positron emission tomography/CT identified an additional three sites of metastasis in five patients compared with CT of the chest, abdomen and pelvis. Surgery involved wide local excision or abdominoperineal excision with respective local recurrence rates of 50% and 66%. Eleven patients underwent testing for c-Kit mutations, of whom five were positive. Four of these were treated with the tyrosine kinase inhibitor imatinib, and showed rapid response of metastases outside the central nervous system.

CONCLUSION

The outcome of this malignancy remains poor. PET is the modality of choice for disease staging. Testing tumours for c-Kit mutations may allow selected patients to participate in trials of tyrosine kinase inhibitors.

Pulmonary Hilar Stereotactic Body Radiation Therapy in the Rat

Stereotactic Body Radiation therapy (SBRT) is an emerging modality of treatment for early stage non-small cell lung carcinoma. Concerns have arisen related to increased toxicities for medial tumors. We have developed a model of high dose, hypofractionated radiotherapy to the pulmonary hilum using the Leksell Gamma-Knife™. Sprague-Dawley rats received hypofractionated SBRT to the unilateral lung hilum using a custom immobilization device on the Gamma Knife. Each animal was individually scanned, treatment planned, and treated with either two 4 mm or one 8 mm collimated shots at escalating doses of 20, 40, and 80 Gy to the 50% isodose volume, encompassing the right mainstem bronchus. All animals were carefully followed post-treatment and imaged by plain film and CT. In addition, histopathological analysis of all rats was performed at selected time points. Animals treated with 4 mm collimated shots demonstrated no appreciable changes on plain films or sequential, follow-up CT scans, or histopathologically. Animals irradiated with the 8 mm collimator were less active, gained weight at a reduced rate, and demonstrated histopathological changes in 7/34 animals six months post-irradiation. Cellular atypia and interstitial pneumonitis were found, three of the seven of the animals showed clear bronchial damage and two showed vascular damage. Significant volume and time effects were found. Utilizing a novel Gamma Knife based animal model to study SBRT toxicity, it was found that the bronchus will tolerate small volumes of very high dose radiotherapy. It was postulated that radiation of the surrounding support stroma and normal tissue are important in the etiology of bronchial or hilar damage.

Assessing Children's Time-Use in Relation to Physical Fitness and Risks of Obesity and Diabetes: Development of a New Physical Activity Self-Report Instrument

BACKGROUND

This study introduces a novel self-report instrument to measure children's time-use in physical and sedentary activities and examines the relationships between children's time-use and physical fitness and risks of obesity and diabetes.

METHODS

The new instrument utilizes a series of timelines, each representing an activity type. 188 children (53% girls) aged 10 to 14 year-old participated in the study. Their time-use data for two weekdays and one weekend day were collected. Anthropometrics and cardiovascular fitness were measured and children's BMI z-score and PACER z-score were computed. One-time blood draw for fasting glucose and insulin were used to calculate insulin resistance using homeostasis model assessment for insulin resistance (HOMAIR).

RESULTS

The reliability assessment of this instrument indicated a moderately reproducible procedure (ICC > 0.6) for six activity types. The validity correlation for motorized travel time was high (r = 0.226, P < 0.05) between self-report instrument and GPS tracks. PACER z-score was positively correlated with time-uses of play (r = 0.159, P < 0.05), and organized sports (r = 0.198, P < 0.05); and was highly inversely correlated with BMI z-score (r = -0.441, P < 0.0001) and HOMAIR (r = -0.472, P < 0.0001). Overall, only 14% of the children had physical activity for more than 60 minutes daily over three observation days.

CONCLUSIONS

This instrument is particularly useful in assessing children's activity patterns, especially for specific physical activities. The new instrument provides a reproducible measure of children's perception of their activities. Our results emphasize the temporal context which is critical to formulating effective interventions targeting physical activity increase in children. Further efforts are needed to understand the differences between activity time obtained by the new self-report instrument and GPS tracks.

An in vitro evaluation of gaseous microemboli handling by contemporary venous reservoirs and oxygenator systems using EDAC

Gaseous microemboli (GME) generated during cardiopulmonary bypass (CPB) can present a significant risk to patient outcomes, specifically if they are delivered to the cerebral vasculature. A number of GME sources have been identified, leading to improved clinical practice and equipment design to ameliorate the presence and intensity of GME during CPB. Recently, a number of new venous reservoir/oxygenator systems have entered the market, including the Sorin Inspire6 and Inspire8, the Terumo FX15 and FX25 and the Maquet Quadrox-i. The goal of the current study was to evaluate the GME-handling capacity of these contemporary venous reservoirs, oxygenators and complete systems, as well as our currently used Sorin Synthesis, using the EDAC system. The venous reservoir of the Quadrox-i was the most effective in removing all sizes of GME and total GME load, while the Synthesis was the least effective. The FX15 and FX25 were least effective removing small GME, while the FX15 and Quadrox-i were the least effective at removing medium GME. The Quadrox-i was least effective at removing large GME. In terms of complete venous reservoir/oxygenator systems, the Synthesis permitted the greatest amount of GME to pass, while the other systems appeared largely equivalent.

Active and passive smoking in relation to lung cancer incidence in the Women's Health Initiative Observational Study prospective cohort

BACKGROUND

Lung cancer is the leading cause of worldwide cancer deaths. While smoking is its leading risk factor, few prospective cohort studies have reported on the association of lung cancer with both active and passive smoking. This study aimed to determine the relationship between lung cancer incidence with both active and passive smoking (childhood, adult at home, and at work).

PATIENTS AND METHODS

The Women's Health Initiative Observational Study (WHI-OS) was a prospective cohort study conducted at 40 US centers that enrolled postmenopausal women from 1993 to 1999. Among 93 676 multiethnic participants aged 50-79, 76 304 women with complete smoking and covariate data comprised the analytic cohort. Lung cancer incidence was calculated by Cox proportional hazards models, stratified by smoking status.

RESULTS

Over 10.5 mean follow-up years, 901 lung cancer cases were identified. Compared with never smokers (NS), lung cancer incidence was much higher in current [hazard ratio (HR) 13.44, 95% confidence interval (CI) 10.80-16.75] and former smokers (FS; HR 4.20, 95% CI 3.48-5.08) in a dose-dependent manner. Current and FS had significantly increased risk for all lung cancer subtypes, particularly small-cell and squamous cell carcinoma. Among NS, any passive smoking exposure did not significantly increase lung cancer risk (HR 0.88, 95% CI 0.52-1.49). However, risk tended to be increased in NS with adult home passive smoking exposure ≥30 years, compared with NS with no adult home exposure (HR 1.61, 95% CI 1.00-2.58).

CONCLUSIONS

In this prospective cohort of postmenopausal women, active smoking significantly increased risk of all lung cancer subtypes; current smokers had significantly increased risk compared with FS. Among NS, prolonged passive adult home exposure tended to increase lung cancer risk. These data support continued need for smoking prevention and cessation interventions, passive smoking research, and further study of lung cancer risk factors in addition to smoking. CLINICALTRIALS.GOV: NCT00000611.

Insulin secretion and its association with physical activity, fitness and screen time in children

OBJECTIVES

To determine the independent associations of moderate to vigorous physical activity (MVPA), fitness, screen time, and adiposity with insulin secretion in children.

DESIGN AND METHODS

Caucasian youth (n = 423/630), 8-10 years old, with at least one obese biological parent, were studied (QUALITY cohort). Insulin secretion was measured using HOMA2-%B, area under the curve (AUC) of insulin to glucose over the first 30 minutes (AUC I/G(t30min)) of the OGTT and AUC I/G(t120min) over 2 hours. Fitness was measured by VO₂peak ; percent fat mass (PFM) by DXA; 7-day MVPA by accelerometry; self-reported screen time included television, video game, or computer use. Models were adjusted for age, sex, season, puberty, PFM, and insulin sensitivity [IS] (HOMA2-IS, Matsuda-ISI).

RESULTS

PFM was strongly associated with insulin secretion, even after adjustment for IS: for every 1% increase in PFM, insulin secretion increased from 0.3% to 0.8% across indices. MVPA was negatively associated with HOMA2-%B (P < 0.05), but not with OGTT-derived measures. Fitness was negatively associated with AUC I/G(t120min) (P < 0.05). Screen time showed a trend toward higher HOMA2-%B in girls (P = 0.060).

CONCLUSIONS

In children with an obese parent, lower insulin secretion is associated with lower adiposity, higher MVPA, better fitness, and possibly reduced screen time.

Prophylactic fibrinogen administration during complex congenital cardiac surgery leading to thrombosis of a patient's brachial artery and the cardiopulmonary bypass circuit: a case report

Cardiac surgery represents one of the largest consumers of blood products due to the level of blood loss in these patients. As such, there is considerable interest in hemostatic therapies for this patient population. A hemostatic agent that has recently garnered interest is fibrinogen. The conversion of fibrinogen to fibrin by activated thrombin results in clot formation, leading to hemostasis. Currently, a number of studies are underway to evaluate the efficacy of fibrinogen concentrate in cardiac surgery patients. While potentially beneficial in hemostasis for cardiac patients, the current case report provides evidence of the importance of timing in the administration of this product.