Vaccine Mandates and Cultural Safety

The issues and problems of mandatory vaccination policy and roll out in First Nations communities are unique and do not concern the safety and effectiveness of vaccines. These issues are also independent of more specific arguments of mandatory vaccination of healthcare workers as a condition of employment. As important as these issues are, they do not consider the complex politics of ongoing settler colonialism and First Nations community relations. In this paper, we also set aside the very real problems of disinformation, hesitancy, scientific and health illiteracy, and other concerns that drive vaccine hesitancy and refusal. These affect all communities, including First Nations communities. We, instead describe the dominant arguments in favour of mandatory vaccination and critique them in terms of the disputed legitimacy of Settler-Colonial decision-making as it impacts First Nations communities. We contend cultural responsiveness and safety-not state compulsion-must remain the first principles of any engagement-including vaccination-with First Nations Peoples, families, and communities.

Monitoring body composition change for intervention studies with advancing 3D optical imaging technology in comparison to dual-energy X-ray absorptiometry

BACKGROUND

Recent 3-dimensional optical (3DO) imaging advancements have provided more accessible, affordable, and self-operating opportunities for assessing body composition. 3DO is accurate and precise in clinical measures made by DXA. However, the sensitivity for monitoring body composition change over time with 3DO body shape imaging is unknown.

OBJECTIVES

This study aimed to evaluate the ability of 3DO in monitoring body composition changes across multiple intervention studies.

METHODS

A retrospective analysis was performed using intervention studies on healthy adults that were complimentary to the cross-sectional study, Shape Up! Adults. Each participant received a DXA (Hologic Discovery/A system) and 3DO (Fit3D ProScanner) scan at the baseline and follow-up. 3DO meshes were digitally registered and reposed using Meshcapade to standardize the vertices and pose. Using an established statistical shape model, each 3DO mesh was transformed into principal components, which were used to predict whole-body and regional body composition values using published equations. Body composition changes (follow-up minus the baseline) were compared with those of DXA using a linear regression analysis.

RESULTS

The analysis included 133 participants (45 females) in 6 studies. The mean (SD) length of follow-up was 13 (5) wk (range: 3-23 wk). Agreement between 3DO and DXA (R2) for changes in total FM, total FFM, and appendicular lean mass were 0.86, 0.73, and 0.70, with root mean squared errors (RMSEs) of 1.98 kg, 1.58 kg, and 0.37 kg, in females and 0.75, 0.75, and 0.52 with RMSEs of 2.31 kg, 1.77 kg, and 0.52 kg, in males, respectively. Further adjustment with demographic descriptors improved the 3DO change agreement to changes observed with DXA.

CONCLUSIONS

Compared with DXA, 3DO was highly sensitive in detecting body shape changes over time. The 3DO method was sensitive enough to detect even small changes in body composition during intervention studies. The safety and accessibility of 3DO allows users to self-monitor on a frequent basis throughout interventions. This trial was registered at clinicaltrials.gov as NCT03637855 (Shape Up! Adults; https://clinicaltrials.gov/ct2/show/NCT03637855); NCT03394664 (Macronutrients and Body Fat Accumulation: A Mechanistic Feeding Study; https://clinicaltrials.gov/ct2/show/NCT03394664); NCT03771417 (Resistance Exercise and Low-Intensity Physical Activity Breaks in Sedentary Time to Improve Muscle and Cardiometabolic Health; https://clinicaltrials.gov/ct2/show/NCT03771417); NCT03393195 (Time Restricted Eating on Weight Loss; https://clinicaltrials.gov/ct2/show/NCT03393195), and NCT04120363 (Trial of Testosterone Undecanoate for Optimizing Performance During Military Operations; https://clinicaltrials.gov/ct2/show/NCT04120363).

The Effect of Watermelon Juice Supplementation on Heart Rate Variability and Metabolic Response during an Oral Glucose Challenge: A Randomized, Double-Blind, Placebo-Controlled Crossover Trial

Heart rate variability (HRV) provides a simple method to evaluate autonomic function in health and disease. A reduction in HRV may indicate autonomic dysfunction and is strongly associated with aspects of cardiometabolic disease, including hyperglycemia. Reduced nitric oxide (NO) bioavailability is also implicated in the development of cardiometabolic disease and autonomic dysfunction. Watermelons are natural sources of L-arginine and L-citrulline, substrates used for NO synthesis. Watermelon consumption can improve NO bioavailability. We conducted a randomized, double-blind, placebo-controlled crossover trial to test the effects of 2 weeks of daily watermelon juice (WMJ) supplementation on HRV in response to an oral glucose challenge (OGC) in healthy young adults. We also performed indirect calorimetry to assess if our intervention altered the metabolic response to the OGC. WMJ supplementation preserved high-frequency power (HF) (treatment effect, p = 0.03) and the percentage of successive differences that differ by more than 50 ms (pNN50) (treatment effect, p = 0.009) when compared to the placebo treatment. There was no difference in resting energy expenditure or substate oxidation according to treatment. We report that WMJ supplementation attenuates OGC-induced reductions in HRV. Future work should emphasize the importance of NO bioavailability in autonomic dysfunction in cardiometabolic disease.

The impact of early versus late tocilizumab administration in patients with cytokine release syndrome secondary to immune effector cell therapy

INTRODUCTION

Cytokine release syndrome is a life-threatening hyper-inflammatory state induced by immune effector cell therapy. Anti-interleukin 6-(IL-6) therapy, such as tocilizumab, is the standard treatment for cytokine release syndrome since it reverses symptoms without compromising immune effector cell therapy efficacy. Glucocorticoids are reserved for refractory or severe cytokine release syndrome due to concern for attenuating antitumor activity. Optimizing the timing of tocilizumab could avoid glucocorticoid use and improve outcomes. This study assesses tocilizumab timing on patient outcomes and healthcare resource utilization.

METHODS

This is a retrospective single-institution analysis of 28 patients who received tocilizumab for cytokine release syndrome secondary to immune effector cell therapy. Patients were categorized into two groups: Early Tocilizumab (within 24 h) or Late Tocilizumab groups (more than 24 h) from fever onset. The composite primary endpoint was glucocorticoid use, intensive care unit admission, or inpatient mortality. Secondary outcomes include comparing the various presentations of cytokine release syndrome, need for vasopressors, length of stay, rates of neurotoxicity, and C-reactive protein and ferritin trends.

RESULTS

The Early Tocilizumab group presented with more rapid fever onset (35 vs.113 h, P = 0.017) and higher maximum cytokine release syndrome grade (Median, Grade 2 vs. Grade 1, P = 0.025). Additionally, the Early Tocilizumab group required more doses of tocilizumab (Median, 2 vs. 1, P = 0.037). Despite the difference in cytokine release syndrome presentation, the primary composite endpoint was not statistically different between groups.

CONCLUSION

Earlier onset of fever appears to be associated with more severe, progressive cytokine release syndrome requiring multiple doses of anti-interleukin-6 therapy. Prompt and aggressive tocilizumab treatment could be protective against the negative consequences of cytokine release syndrome.

Self-esteem as a catalyst for change in adolescent inpatients with anorexia nervosa: a pilot randomised controlled trial

PURPOSE

To determine the potential effectiveness of a six-session manualised self-esteem group using CBT approaches when given as an adjuvant to adolescent inpatients with Anorexia Nervosa (AN).

METHODS

Using a randomised controlled design, 50 girls aged 12-17 years with AN were assigned to either self-esteem group with treatment as usual (TAU) (n = 25) or TAU alone (n = 25). 50/78 (64%) consented to be randomised. Both groups completed self-report measures of self-esteem and eating disorder psychopathology at three time points to measure the potential effectiveness of the treatment. Qualitative feedback was collected to assess acceptability.

RESULTS

29 participants completed the study: 15 self-esteem group with TAU, 14 TAU alone. Self-esteem group participants had greater improvement in all outcomes than TAU participants at all time points, the difference in self-report self-esteem at T2 is 1.12 (95% CI - 1.44-3.69; effect size = 0.21). Similar small effect sizes were found for the eating disorder psychopathology measure following completion of the intervention but not at four-week follow-up. Favourable qualitative feedback was gained.

CONCLUSION

These findings demonstrate that the self-esteem group supplements an intensive treatment package which also addresses elements of low self-esteem. The self-esteem group was beneficial for addressing self-esteem and acted as a catalyst for change in eating disorder psychopathology. Positive qualitative feedback indicated the intervention was acceptable to users. Self-esteem group is a potential new adjuvant treatment for AN.

EMB RATING

Level 1.

Comorbid mental health issues in patients with pemphigus vulgaris and pemphigus foliaceus

The term 'pemphigus' refers to chronic autoimmune skin disorders that cause blistering erosions on the skin and oral mucosa. The two major clinical forms are pemphigus vulgaris and pemphigus foliaceus. Although rare, they confer a stark symptomatic burden upon patients that significantly impacts daily life. Comorbid mental health issues are not routinely screened for in patients with pemphigus, and current UK guidance provides no formal provision for the identification and treatment of psychological issues. This review is the first of its kind, to our knowledge, to systematically examine the available evidence on mental health issues in pemphigus. Published work suggests that the incidence of anxiety and depression is much higher in patients with pemphigus compared with both the general population and with patients having other chronic skin disorders. Disease severity appears to be closely linked to mental health, with worsening of pemphigus associated with deteriorations in psychological wellbeing. Corticosteroids, which are associated with depression in chronic use, are the current first-line therapy for pemphigus and have been identified as a potential confounder and independent risk factor for mental health comorbidity in pemphigus. Current evidence is unclear whether a bidirectional relationship exists between mental health and pemphigus severity, and more thorough research is required to develop understanding of this issue. In conclusion, we have identified a high incidence of mental health comorbidity in pemphigus, and recommend routine screening of patients with pemphigus for mental health issues and signposting toward mental health services as an initial measure to address this.

Overriding water table control on managed peatland greenhouse gas emissions

Global peatlands store more carbon than is naturally present in the atmosphere^1,2. However, many peatlands are under pressure from drainage-based agriculture, plantation development and fire, with the equivalent of around 3 per cent of all anthropogenic greenhouse gases emitted from drained peatland^3-5. Efforts to curb such emissions are intensifying through the conservation of undrained peatlands and re-wetting of drained systems⁶. Here we report eddy covariance data for carbon dioxide from 16 locations and static chamber measurements for methane from 41 locations in the UK and Ireland. We combine these with published data from sites across all major peatland biomes. We find that the mean annual effective water table depth (WTD_e; that is, the average depth of the aerated peat layer) overrides all other ecosystem- and management-related controls on greenhouse gas fluxes. We estimate that every 10 centimetres of reduction in WTD_e could reduce the net warming impact of CO₂ and CH₄ emissions (100-year global warming potentials) by the equivalent of at least 3 tonnes of CO₂ per hectare per year, until WTD_e is less than 30 centimetres. Raising water levels further would continue to have a net cooling effect until WTD_e is within 10 centimetres of the surface. Our results suggest that greenhouse gas emissions from peatlands drained for agriculture could be greatly reduced without necessarily halting their productive use. Halving WTD_e in all drained agricultural peatlands, for example, could reduce emissions by the equivalent of over 1 per cent of global anthropogenic emissions.

An evaluation of efficacy and acceptability of a novel manualised JuniorLEAP group programme for compulsive exercise, for children and adolescents with anorexia nervosa, within an inpatient setting

PURPOSE

Compulsive exercise is a symptom and a maintenance factor of eating disorders, which increases the risk of relapse. It has been considered a target for treatment, particularly for anorexia nervosa (AN). This audit aims to review the efficacy and acceptability of a new seven-week JuniorLEAP group therapy programme, for children and adolescents with anorexia nervosa. JuniorLEAP was adapted by the authors and based on the Loughborough Eating Disorder Activity Programme (LEAP) for adults.

METHODS

32 children and adolescents with anorexia nervosa were allocated to the group in an in-patient setting using entry criteria. All children and adolescents completed seven weekly sessions of the JuniorLEAP programme, as well as pre- and post-treatment questionnaires, including the Eating Disorder Examination Questionnaire (EDE-Q) and the Compulsive Exercise Test (CET). The children and adolescents were also asked to provide qualitative responses about the acceptability of the group. A paired t test was conducted to review the efficacy of the JuniorLEAP programme.

RESULTS

Significant changes in eating disorder psychopathology was observed, as measured by the EDE-Q, with total mean scores reducing from 3.53 to 2.77 (p = 0.001). Compulsive exercise attitudes were also observed to reduce, as measured by the CET, with total mean scores reducing from 15.39 to 10.90 (p ≤ 0.001). Furthermore, there was a significant reduction in all five subscales of the CET following completion of the group. Qualitative results also demonstrate the group to be acceptable to the patients.

CONCLUSION

This study finds that a new manualised JuniorLEAP group therapy, specifically adapted for adolescents and children with AN, when used as an adjuvant with other therapies in a residential setting, significantly reduces their compulsive exercise, as measured by CET. The patients reported that the treatment was acceptable. Further research testing the new treatment in a randomised controlled trial is now needed, particularly to disentangle the impact of other aspects of standard treatment in reducing compulsive exercise.

LEVEL OF EVIDENCE

II.

"A little (PPI) MAGIC can take you a long way" : involving children and young people in research from inception of a novel medical device to multi-centre clinical trial Roald Dahl, James and the Giant Peach (1961)

BACKGROUND

There is often a great urgency to be inclusive when conducting research and to focus efforts with groups and communities that can be referred to as marginalised. This is especially the case in research concerning medical devices aimed at children and young people (CYP). Although involvement methodology has developed over the last two decades, it can be challenging to involve and engage CYP with confidence and clarity of purpose.

MAIN BODY

Our aim was to provide a reflective narrative account of the involvement of CYP, over a period of 5 years, in a research project from conception of a new paediatric medical device through to practical application. We explored a model of patient and public involvement (PPI) through the Nottingham Young Persons Advisory Group (YPAG), part of the National Institute for Health Research (NIHR) GenerationR Alliance, in a NIHR funded research project. The YPAG designed and created a model of the human gut, co-designed the Transicap™ mini-capsules and their packaging, co-produced patient information sheets, came up with the idea to disseminate through a project website and co-wrote and created animation videos. The YPAG involvement continued through the writing and award of the follow-on research grant (MAGIC2). During this process the YPAG modified the clinical study protocol insisting that all participants in the control arm were given the imaging test results as well, save for a delayed reading compared to the intervention arm.

CONCLUSION

Involvement of the YPAG over the last 5 years, led to the development of a mutually beneficial partnership, enabling genuine knowledge exchange between researchers and CYP. This influenced the design, plans and actions of the MAGIC study and well into the subsequent MAGIC2 follow-on project. Moreover, these involvement models applied within a feasibility study setting, have enhanced the realism and pragmatism of the study, contributing to the project's overall success.

Working together to co-produce better health: The experience of the Collaboration for Leadership in Applied Health Research and Care for Northwest London

OBJECTIVES

To improve the provision of health care, academics can be asked to collaborate with clinicians, and clinicians with patients. Generating good evidence on health care practice depends on these collaborations working well. Yet such relationships are not the norm. We examine how social science research and health care improvement practice were linked through a programme designed to broker collaborations between clinicians, academics, and patients to improve health care - the UK National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Northwest London. We discuss the successes and challenges of the collaboration and make suggestions on how to develop synergistic relationships that facilitate co-production of social science knowledge and its translation into practice.

METHODS

A qualitative approach was used, including ethnographic elements and critical, reflexive dialogue between members of the two collaborating teams.

RESULTS

Key challenges and remedies were connected with the risks associated with new ways of working. These risks included differing ideas between collaborators about the purpose, value, and expectations of research, and institutional opposition. Dialogue between collaborators did not mean absence of tensions or clashes. Risk-taking was unpopular - institutions, funders, and partners did not always support it, despite simultaneously demanding 'innovation' in producing research that influenced practice.

CONCLUSIONS

Our path was made smoother because we had funding to support the creation of a 'potential space' to experiment with different ways of working. Other factors that can enhance collaboration include a shared commitment to dialogical practice, a recognition of the legitimacy of different partners' knowledge, a long timeframe to identify and resolve problems, the maintenance of an enabling environment for collaboration, a willingness to work iteratively and reflexively, and a shared end goal.

From physiotherapy to the army: negotiating previously developed professional identities in mature medical students

Professional identity formation, the process of transformation from lay person to doctor, is at the heart of medical education. Medical student cohorts can include students who enter medicine from a previous career, i.e. with developed professional identities and who are usually older and more mature. Students with previously developed professional identities may have specific challenges in negotiating their new 'doctor' identity. This study examined the development of professional identity in mature medical students who had a variety of previous careers prior to entering medical school. A narrative inquiry was undertaken using interviews of mature medical students with backgrounds that included physiotherapy, clinical physiology, public health and nutrition, and the armed forces. A narrative analysis was conducted combining both thematic and structural perspectives using linguistics and positioning theory as interpretive tools. Three main themes emerged that portray the development processes that arise in this cohort as they develop their medical professional identity: holding back aspects of the previous self; foregrounding aspects of the previous self; and developing new aspects towards forming a 'new' self. These themes and their implications are discussed in the context of current literature, highlighting some of the specific challenges that this cohort faces in developing their medical identity. We argue that dedicated faculty and student development be offered, exploring how professional identity formation in mature medical students can be facilitated and supported, so staff and students are better equipped to engage and shape mature students' professional identity in a meaningful way.

How helpful are Patient and Public Involvement strategic documents - Results of a framework analysis using 4Pi National Involvement Standards

BACKGROUND

Patient and Public Involvement (PPI) strategic documents are viewed as an essential feature of organisational commitment to openness and transparency. They provide a mechanism to communicate opportunities for wider community influence in healthcare. The absence of documentation can be negatively interpreted, for example during regulatory inspection, as a lack of intent by organisations to collaborate with a broad constituency. Published literature paints a confusing picture of rationale and evidence that could provide the foundation for strategic action. This makes it difficult for those responsible for turning goals into meaningful involvement. We investigated how content is presented and organised in strategic documents. This pragmatic study is intended to stimulate reflective practice, promote debate and generate further inquiry with a wide audience.

METHODS

We created and iterated a framework adapted from 4Pi National Involvement Standards to analyse organisational PPI strategic documents against five domains which are principles, purpose, presence, process and impact. Fifteen strategic documents were grouped into four categories (acute care providers; clinical commissioning groups; community healthcare providers; and other) and included for analysis. A matrix was produced. By reading the matrix vertically (down) and horizontally (across), comparisons can be made between 4Pi domains and across organisations.

RESULTS

There was no discernible pattern between domains or between organisations. There was variation in the level to which criteria were met. No single strategy fully met the criteria for all five domains of 4Pi National Involvement Standards. The criteria for purpose was fully met in eight strategic documents. Only two documents fully met impact criteria. Four organisations showed better completeness with fully or partially met criteria across five domains. A single organisation partially met the criteria for all domains. The remaining 10 were unable to meet the criteria in at least one domain.

CONCLUSION

Our findings align with published literature that suggests the underpinning rationale for PPI is confusing. A strategic aim is difficult to articulate. Context and complexity are at play making the sharing of generalisable knowledge elusive. We offer further critique about the value of these documents and consider: 'is there an alternative approach to construct PPI strategy to generate theory, capture learning and evaluate effectiveness at the same time?' We suggest testing the adoption of programme theory in PPI. The emergent nature and context sensitive features of programme theory enable curiosity, creativity and critical appraisal. It has the potential to release practitioners from the tokenistic cycle of monitoring and reporting and replace this with a richer understanding of 'what' works and 'how' tied to a 'why' - in order to achieve a shared aim that everyone can get behind.

The role of patients and carers in diffusing a health-care innovation: A case study of "My Medication Passport"

Background

Patients are increasingly recognized as playing important roles in improving health services. Little is known about the mechanisms by which patients develop and diffuse local innovations in a complex health‐care system.

Objective

To ascertain how diffusion of an innovation, My Medication Passport, occurred and roles played by patients in it.

Design

Case study: quantitative mapping of innovation's diffusion and analysis of the routes and occupations of those through whom the innovation spread; documentary analysis; reflective assessment of patient's roles.

Setting and participants

NHS Trusts, third sector organizations, patients and health‐care professionals.

Interventions studied

Co‐produced action to raise awareness and influence use of the innovation; order database which enabled ease of access to the innovation.

Main outcome measures

Geographical spread of innovation; occupations of individuals; types of organizations using the innovation.

Results

The innovation spread from initial development and use in Northwest London across the UK and beyond. Key roles played by patients were as follows: co‐producer; advocate; relationship builder; relationship broker; planner; presenter; awareness raiser; trainer; networker. Patients identified and introduced potential audiences and users to MMP, using social, organizational, sectoral, lay and professional networks to do so. They organized a range of awareness‐raising and communication activities, monitored feedback, evaluated the impact and responded to new interest.

Discussion and conclusions

The roles of patients in diffusing innovations are under‐recognized. Collaborative working between patients, carers and health‐care professionals in planning and progressing the use and supporting diffusion of the innovation was important. Principles described in this study are relevant to progressing other patient‐led ideas for innovative changes relating to health service development.

Toward Co-productive Learning? The Exchange Network as Experimental Space

Policy around patient and public involvement (PPI) in the production, design and delivery of health services, and research remains difficult to implement. Consequently, in the UK and elsewhere, recent years have seen a proliferation of toolkits, training, and guidelines for supporting good practice in PPI. However, such instruments rarely engage with the power asymmetries shaping the terrain of collaboration in research and healthcare provision. Toolkits and standards may tell us little about how different actors can be enabled to reflect on and negotiate such asymmetries, nor on how they may effectively challenge what count as legitimate forms of knowledge and expertise. To understand this, we need to turn our attention to the relational dynamic of collaboration itself. In this paper we present the development of the Exchange Network, an experimental learning space deliberately designed to foreground, and work on this relational dynamic in healthcare research and quality improvement. The Network brings together diverse actors (researchers, clinicians, patients, carers, and managers) for structured "events" which are not internal to particular research or improvement projects but subsist at a distance from these. Such events thus temporarily suspend the role allocation, structure, targets, and other pragmatic constraints of such projects. We discuss how Exchange Network participants make use of action learning techniques to reflect critically on such constraints; how they generate a "knowledge space" in which they can rehearse and test a capacity for dialogue: an encounter between potentially conflictual forms of knowledge. We suggest that Exchange Network events, by explicitly attending to the dynamics and tensions of collaboration, may enable participants to collectively challenge organizational norms and expectations and to seed capacities for learning, as well as generate new forms of mutuality and care.

Age and Ageing to introduce a new category of paper: healthcare improvement science

Age and Ageing is now inviting papers on healthcare improvement for older people. In this article we outline the nature and scope of healthcare improvement and reference improvement models and the tools and methods of improvement science. We emphasise the issues of sustainability, including scale and spread; evaluation - including associated ethical consideration and the involvement of patients and the public in healthcare improvement and associated research. Throughout we refer to resources the authors have found useful in their own work, and provide a bibliography of sources and web-links which will provide essential guidance and support for potential contributors to this new category of submission to Age and Ageing.

Reviewing progress in public involvement in NIHR research: developing and implementing a new vision for the future

OBJECTIVES

To review the progress of public involvement (PPI) in NIHR (National Institute for Health Research) research, identify barriers and enablers, reflect on the influence of PPI on the wider health research system in the UK and internationally and develop a vision for public involvement in research for 2025. The developing evidence base, growing institutional commitment and public involvement activity highlight its growth as a significant international social movement.

DESIGN

The 'Breaking Boundaries Review' was commissioned by the Department of Health. An expert advisory panel was convened. Data sources included: an online survey, international evidence sessions, workshop events, open submission of documents and supporting materials and existing systematic reviews. Thematic analysis identified key themes. NVivo was used for data management. The themes informed the report's vision, mission and recommendations, published as 'Going the Extra Mile-Improving the health and the wealth of the nation through public involvement in research'. The Review is now being implemented across the NIHR.

RESULTS

This paper reports the Review findings, the first of its type internationally. A range of barriers and enablers to progress were identified, including attitudes, resources, infrastructure, training and support and leadership. The importance of evidence to underpin practice and continuous improvement emerged. Co-production was identified as a concept central to strengthening public involvement in the future. The Vision and Mission are supported by four suggested measures of success, reach, refinement, relevance and relationships.

CONCLUSIONS

The NIHR is the first funder of its size and importance globally to review its approach to public involvement. While significant progress has been made, there is a need to consolidate progress and accelerate the spread of effective practice, drawing on evidence. The outcomes of the Review are being implemented across the NIHR. The findings and recommendations have transferability for other organisations, countries and individuals.

Selective progesterone receptor modulator (SPRM) ulipristal acetate (UPA) and its effects on the human endometrium

STUDY QUESTION

What is the impact of administration of the selective progesterone receptor modulator (SPRM), ulipristal acetate (UPA) on the endometrium of women with fibroids?

SUMMARY ANSWER

UPA administration altered expression of sex-steroid receptors and progesterone-regulated genes and was associated with low levels of glandular and stromal cell proliferation.

WHAT IS KNOWN ALREADY

Administration of all SPRM class members results in PAEC (progesterone receptor modulator associated endometrial changes). Data on the impact of the SPRM UPA administration on endometrial sex-steroid receptor expression, progesterone (P)-regulated genes and cell proliferation are currently lacking.

STUDY DESIGN SIZE, DURATION

Observational study with histological and molecular analyses to delineate impact of treatment with UPA on endometrium. Endometrial samples (n = 9) were collected at hysterectomy from women aged 39 to 49 with uterine fibroids treated with UPA (oral 5 mg daily) for 9-12 weeks. Control proliferative (n = 9) and secretory (n = 9) endometrium from women aged 38-52 with fibroids were derived from institutional tissue archives.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Study setting was a University Research Institute. Endometrial biopsies were collected with institutional ethical approval and written informed consent. Concentrations of mRNAs encoded by steroid receptors, P-regulated genes and factors in decidualised endometrium were quantified with qRT-PCR. Immunohistochemistry was employed for localization of progesterone (PR, PRB), androgen (AR), estrogen (ERα) receptors and expression of FOXO1, HAND2, HOXA10, PTEN homologue. Endometrial glandular and stromal cell proliferation was objectively quantified using Ki67.

MAIN RESULTS AND THE ROLE OF CHANCE

UPA induced morphological changes in endometrial tissue consistent with PAEC. A striking change in expression patterns of PR and AR was detected compared with either proliferative or secretory phase samples. There were significant changes in pattern of expression of mRNAs encoded by IGFBP-1, FOXO1, IL-15, HAND2, IHH and HOXA10 compared with secretory phase samples consistent with low agonist activity in endometrium. Expression of mRNA encoded by FOXM1, a transcription factor implicated in cell cycle progression, was low in UPA-treated samples. Cell proliferation (Ki67 positive nuclei) was lower in samples from women treated with UPA compared with those in the proliferative phase.

LARGE SCALE DATA

N/A.

LIMITATIONS REASONS FOR CAUTION

A small number of well-characterized patients were studied in-depth. The impacts on morphology, molecular and cellular changes with SPRM, UPA administration on symptom control remains to be determined.

WIDER IMPLICATIONS OF THE FINDINGS

P plays a pivotal role in endometrial function. P-action is mediated through interaction with the PR. These data provide support for onward development of the SPRM class of compounds as effective long-term medical therapy for heavy menstrual bleeding.

STUDY FUNDING/COMPETING INTEREST(S)

H.O.D.C. received has clinical research support for laboratory consumables and staff from Bayer Pharma Ag and provides consultancy advice (no personal remuneration) for Bayer Pharma Ag, PregLem SA, Gedeon Richter, Vifor Pharma UK Ltd, AbbVie Inc.; A.R.W.W. has received consultancy payments from Bayer, Gedeon Richter, Preglem SA, HRA Pharma; L.H.R.W., A.A.M., R.M., G.S. and P.T.K.S. have no conflicts of interest. Study funded in part from each of: Medical Research Council (G1002033; G1100356/1; MR/N022556/1); National Health Institute for Health Research (12/206/520) and TENOVUS Scotland.

Utility of 18F sodium fluoride PET/CT imaging in the evaluation of postoperative pain following surgical spine fusion

STUDY DESIGN

A retrospective case review of patients who underwent 18F sodium fluoride PET/CT imaging of the spine with postoperative pain following vertebral fusion.

OBJECTIVE

To determine the benefit of 18F sodium fluoride PET/CT imaging in the diagnosis of persistent pain in the postoperative spine. The diagnosis of pain generators in the postoperative spine has proven to be a diagnostic challenge. The conventional radiologic evaluation of persistent pain after spine surgery with the use of plain radiographs, MRI, and CT can often fall short of diagnosis in the complex patient. 18F sodium fluoride PET/CT imaging is an alternative tool to accurately identify a patient's source of pain in the difficult patient.

METHODS

This retrospective study looked at 25 adult patients who had undergone 18F sodium fluoride PET/CT imaging. All patients had persistent or recurrent back pain over the course of a 15-month period after having undergone spinal fusion surgery. All patients had inconclusive dedicated MRI. The clinical accuracy of PET/CT in identifying the pain generator and contribution to altering the decision making process was compared to the use of CT scan alone.

RESULTS

Of the 25 patients studied, 17 patients had increased uptake on the 18F sodium fluoride PET/CT fusion images. There was a high-level correlation of radiotracer uptake to the patients' pain generator. Overall 88% of the studies were considered beneficial with either PET/CT altering the clinical diagnosis and treatment plan of the patient or confirming unnecessary surgery.

CONCLUSION

18F sodium fluoride PET/CT proves to be a useful tool in the diagnosis of complex spine pathology of the postoperative patients. In varied cases, a high correlation of metabolic activity to the source of the patient's pain was observed.

Is any particular aspect of perceived quality associated with patients tending to promote a dental practice to their friends and colleagues?

AIMS

To investigate the relationship between perceived quality and patients' tendencies to recommend a practice to friends and colleagues.

METHODS

Data from 64 practices using the Denplan Excel Patient Survey (DEPS) were analysed. The Net Promoter Score (NPS max score 100), developed by Reichheld, is reported to each practice using DEPS. It is claimed that the NPS measures the likelihood that patients will recommend the practice to friends and colleagues. A Patient Perception Index (PPI max score 100) is also reported to practices. The PPI is calculated from the responses to the ten core questions of DEPS on perceived quality. The 64 practices were placed into three groups for data analysis according to their NPS result: group one practices receiving an NPS of less than 80, group two practices receiving an NPS of 80-89 and group three practices receiving an NPS of greater than 89. These groups represented practices scoring statistically significantly (to 90% confidence) below the mean NPS (group one), practices close to the mean NPS (group two) and practices statistically significantly (to 90% confidence) above the mean NPS.

RESULTS

Group one practices scored a mean PPI of 73, group two scored a mean PPI of 76 and group three a mean PPI of 80. These differences in values of PPI between the groups are statistically significant (to 90% confidence). Of the ten constituent issues which contribute to PPI, the greatest difference in scoring between group one and group three was found to be around perceived value for money.

CONCLUSION

The probability of patients recommending a dental practice seems to rise in direct proportion to favourable perceptions of quality. A perception of 'ideal' value for money is the most highly correlated aspect with a high NPS.

A Pilot Study Using a Newly Devised Manual in a Programme of Education and Support for Patients Waiting for Coronary Artery bypass Surgery

Background: Cardiac rehabilitation programmes are widely accepted as being of benefit to patients with cardiac disease. The time spent waiting for cardiac surgery can be extremely stressful but can be used to address risk factors and provide information to reduce anxiety and prepare the patient for surgery. Aims: To pilot the usefulness of a manual for pre-operative cardiac surgical patients, and assess the feasibility and usefulness to both nurses and patients of a monthly education and support programme for patients waiting for cardiac surgery. Methods: A pilot study of 42 patients followed up for 3 months. Research tools included patient questionnaires and telephone interviews, risk factor measurements and nurse focus groups. Results: Nurses and patients evaluated the manual and overall programme favourably, although the nurses found it was very labour intensive. Changes to risk factors made during the study were small but patients valued the opportunity to raise questions which fell into the categories of medical concerns, hospital procedure and risk factors. Conclusion: The manual is a useful tool for patients waiting for cardiac surgery. The programme is useful and feasible but could be targeted more specifically to patients with raised risk factors.

Continuing development of an oral health score for clinical audit

AIM

To compare the outcomes of a contemporary oral health status (OHS) scoring system with national oral health data from the 2009 Adult Dental Health Survey, and to explore the utility of the OHS in audit and service development.

METHODS

An OHS scoring system was developed as part of a previously reported comprehensive on-line patient assessment tool. The assessment tool also measured future disease risk and indicative capitation fee grading. The modified OHS score component was developed over 20 years of research and experience from the original Oral Health Index (Burke and Wilson 1995). The online tool was piloted by 25 volunteer dentists on 640 recall patients and qualitative and quantitative feedback provided. Anonymised data from the inputs and scores generated were collected centrally and analysed using descriptive statistics.

RESULTS

The modified OHS was reported to have good validity by the pilot group. Submitted data confirmed a mean age for the recall patients examined as 53 ± 15.8 years and an average oral health status score of 79.5 ± 10.8 where a score of 100 equates to perfect oral health. A breakdown of the scores into the eight principal components provided evidence of cross validation with the Adult Dental Health Survey (2009).

CONCLUSIONS

Scoring oral health status electronically offers valuable opportunities for clinical audit. The reported benchmark oral health score of 79.5 for recall patients can be updated as increased numbers of patients enter the centralised data recording system. Audit can be facilitated by this move from a paper-based system to an on-line tool with central data collection.

From tokenism to empowerment: progressing patient and public involvement in healthcare improvement

BACKGROUND

There have been repeated calls to better involve patients and the public and to place them at the centre of healthcare. Serious clinical and service failings in the UK and internationally increase the urgency and importance of addressing this problem. Despite this supportive policy context, progress to achieve greater involvement is patchy and slow and often concentrated at the lowest levels of involvement.

METHODS

A selective narrative literature search was guided by the authors' broad expertise, covering a range of disciplines across health and social care, policy and research. Published systematic literature reviews were used to identify relevant authors and publications. Google and hand searches of journal articles and reference lists and reports augmented identification of recent evidence.

RESULTS

Patients and the wider public can be involved at most stages of healthcare, and this can have a number of benefits. Uncertainty persists about why and how to do involvement well and evaluate its impact, how to involve and support a diversity of individuals, and in ways that allow them to work in partnership to genuinely influence decision-making. This exposes patient and public involvement (PPI) to criticisms of exclusivity and tokenism.

CONCLUSIONS

Current models of PPI are too narrow, and few organisations mention empowerment or address equality and diversity in their involvement strategies. These aspects of involvement should receive greater attention, as well as the adoption of models and frameworks that enable power and decision-making to be shared more equitably with patients and the public in designing, planning and co-producing healthcare.

Patient and public involvement: how much do we spend and what are the benefits?

BACKGROUND AND OBJECTIVES

Patient and public involvement (PPI) is seen as a way of helping to shape health policy and ensure a patient-focused health-care system. While evidence indicates that PPI can improve health-care decision making, it also consumes monetary and non-monetary resources. Given the financial climate, it is important to start thinking about the costs and benefits of PPI and how to evaluate it in economic terms.

DESIGN

We conducted a literature review to assess the potential benefits and costs of involvement and the challenges in carrying out an economic evaluation of PPI.

RESULTS

The benefits of PPI include effects on the design of new projects or services, on NHS governance, on research design and implementation and on citizenship and equity. Economic evaluation of PPI activities is limited. The lack of an appropriate analytical framework, data recording and understanding of the potential costs and benefits of PPI, especially from participants' perspectives, represent serious constraints on the full evaluation of PPI.

CONCLUSIONS

By recognizing the value of PPI, health-care providers and commissioners can embed it more effectively within their organizations. Better knowledge of costs may prompt organizations to effectively plan, execute, evaluate and target resources. This should increase the likelihood of more meaningful activity, avoid tokenism and enhance organizational efficiency and reputation.

Long-term validity and reliability of a patient survey instrument designed for general dental practice

AIM

To consider the extent to which the validity and reliability of the Denplan Excel Patient Survey (DEPS) has been confirmed during its development and by its use in general dental practice and to explore methods by which any survey instrument used in general dental practice might be validated and tested for reliability.

METHODS

DEPS seeks to measure perceived practice performance on those issues considered to be of greatest importance to patients. Content validity was developed by a literature review and tested in a pilot study. Criterion validity was tested by comparing patient retention in a payment plan for practices achieving the highest DEPS scores with those attaining the lowest scores over a two year period (surveys completed between 2010 and 2012). Reliability was assessed using the test/re-test method for 23 practices with approximately a three year time interval between tests. Internal consistency was tested by comparing Net Promoter Scores (NPS - which is measured in DEPS) attained by practices with their Patient Perception Index (PPI) as measured by the ten core questions in DEPS.

RESULTS

Practices in the pilot study strongly endorsed the content validity of DEPS. The 12 practices with the highest scores in the DEPS slightly increased their number of patients registered in Denplan payment plans during a two year period. The 12 lowest scoring practices saw 7% of their patients de-register during the same period. The 23 practices selected for the test/re-test study averaged more than 250 responses for both the test and re-test phases. The magnitude and pattern of their results were similar in both phases, while, on average, a modest improvement in results was observed. Internal consistency was confirmed as NPS results in DEPS closely mapped PPI results. The higher the measurement of perceived quality (PPI) the more likely patients were to recommend the practice (NPS).

CONCLUSION

Both through its development and use over the last four years The DEPS has demonstrated good validity and reliability. The authors conclude that this level of validity and reliability is adequate for the clinical/general care audit purpose of DEPS and that it is therefore likely to reliably inform practices where further development are indicated. It is important and quite straightforward to both validate and check the reliability of patient surveys used in general dental practice so that dental teams can be confident in the instrument they are using.

Clinical and demographic factors associated with fractures among older Americans

Medicare claims data were used to investigate associations between history of previous fractures, chronic conditions, and demographic characteristics and occurrence of fractures at six anatomic sites. The study confirmed previously established associations for hip and spine fractures and identified several new associations of interest for nonhip, nonspine fractures.

INTRODUCTION

This study investigates the associations of a history of fracture, comorbid chronic conditions, and demographic characteristics with incident fractures among Medicare beneficiaries. The majority of fracture incidence studies have focused on the hip and on white females. This study examines a greater variety of fracture sites and more population subgroups than prior studies.

METHODS

We used Medicare claims data to examine the incidence of fracture at six anatomic sites in a random 5% sample of Medicare beneficiaries during the time period 2000 through 2005.

RESULTS

For each type of incident fracture, women had a higher rate than men, and there was a positive association with age and an inverse association with income. Whites had a higher rate than nonwhites. Rates were lowest among African-Americans for all sites except ankle and tibia/fibula, which were lowest among Asian-Americans. Rates of hip and spine fracture were highest in the South, and fractures of other sites were highest in the Northeast. Fall-related conditions and depressive illnesses were associated with each type of incident fracture, conditions treated with glucocorticoids with hip and spine fractures and diabetes with ankle and humerus fractures. Histories of hip and spine fractures were associated positively with each site of incident fracture except ankle; histories of nonhip, nonspine fractures were associated with most types of incident fracture.

CONCLUSIONS

This study confirmed previously established associations for hip and spine fractures and identified several new associations of interest for nonhip, nonspine fractures.

Involving patients in service improvement

This article describes the experiences of two multidisciplinary teams that took part in a national initiative to improve care through the implementation of research evidence. Both teams worked with patients with chronic illnesses. The patients required regular admissions to hospital for treatment and care, and had reported difficulties when moving between different services.

Medical problems among dental patients at the school of dentistry, the university of the West Indies

This study ascertained demographic information and prevalence rates of medical problems among 571 new and consecutive dental patients attending the emergency clinic of the School of Dentistry, The University of the West Indies. Patients were interviewed by specially trained and calibrated dental students and interns. Various medical problems of patients were recorded in individual open-ended case sheets, maintaining their privacy and confidentiality. This information was then transcribed into a specially designed and pretested form. The data were entered into a Microsoft Excel spreadsheet and analyzed using the SPSS statistical package to obtain the prevalence rates of medical conditions, which were then cross-tabulated with gender, age, ethnicity, and other variables. Significance of differences, if any, was evaluated by chi-square test. In all, 303 medical conditions were encountered in 239 individuals, giving a prevalence rate of 42 percent. Hypertension (12.6 percent), diabetes (6.1 percent), asthma (5.8 percent), arthritis (4.7 percent), and various allergies (8.3 percent) constituted an important segment of the problems. Gender, ethnic, and age differences were also evident for some diseases. In this study-which was the first of this kind in the West Indies-vital information on medical problems among dental patients was obtained by interviews conducted by dental students and interns, forming an important part of their dental education.