Evaluating the efficacy and mechanisms of a ketogenic diet as adjunctive treatment for people with treatment-resistant depression: A protocol for a randomised controlled trial

BACKGROUND

One-third of people with depression do not respond to antidepressants, and, after two adequate courses of antidepressants, are classified as having treatment-resistant depression (TRD). Some case reports suggest that ketogenic diets (KDs) may improve some mental illnesses, and preclinical data indicate that KDs can influence brain reward signalling, anhedonia, cortisol, and gut microbiome which are associated with depression. To date, no trials have examined the clinical effect of a KD on TRD.

METHODS

This is a proof-of-concept randomised controlled trial to investigate the efficacy of a six-week programme of weekly dietitian counselling plus provision of KD meals, compared with an intervention involving similar dietetic contact time and promoting a healthy diet with increased vegetable consumption and reduction in saturated fat, plus food vouchers to purchase healthier items. At 12 weeks we will assess whether participants have continued to follow the assigned diet. The primary outcome is the difference between groups in the change in Patient Health Questionnaire-9 (PHQ-9) score from baseline to 6 weeks. PHQ-9 will be measured at weeks 2, 4, 6 and 12. The secondary outcomes are the differences between groups in the change in remission of depression, change in anxiety score, functioning ability, quality of life, cognitive performance, reward sensitivity, and anhedonia from baseline to 6 and 12 weeks. We will also assess whether changes in reward sensitivity, anhedonia, cortisol awakening response and gut microbiome may explain any changes in depression severity.

DISCUSSION

This study will test whether a ketogenic diet is an effective intervention to reduce the severity of depression, anxiety and improve quality of life and functioning ability for people with treatment-resistant depression.

The association between restricted activity and patient outcomes in older adults: systematic literature review and meta-analysis

BACKGROUND

Restricted activity is a potential early marker of declining health in older adults. Previous studies of this association with patient outcomes have been inconclusive. This review aimed to evaluate the extent to which restricted activity is associated with decline in health.

METHODS

A search was conducted for studies including people over 65 years old which investigated the association between measures of restricted activity and hospitalisation, cognitive decline, and mortality. Following data extraction by two reviewers, eligible studies were summarised using Inverse Variance Heterogeneity meta-analysis.

RESULTS

The search identified 8,434 unique publications, with 11 eligible studies. Three measures of restricted activity were identified: bed rest, restricted movement, and dependency for activities of daily living (ADL). Three studies looked at hospitalisations, with two finding a significant association with bed rest or restricted movement and one showing no evidence of an association. Restricted activity was associated with a significant increase in mortality across all three measures (bed rest odds ratio [OR] 6.34, 95%CI 2.51-16.02, I2 = 76%; restricted movement OR 5.38 95%CI 2.60-11.13, I2 = 69%; general ADL dependency OR 4.65 95%CI 2.25-9.26, I2 = 84%). The significant heterogeneity observed could not be explained by restricting the analysis by length of follow-up, or measure of restricted activity. No meta-analysis was conducted on the limited evidence for cognitive decline outcomes.

CONCLUSIONS

Limited studies have considered the prognostic value of restricted activity in terms of predicting future declining health. Current evidence suggests restricted activity is associated with hospitalisation and mortality, and therefore could identify a group for whom early intervention might be possible.

How has the COVID-19 pandemic affected the delivery of preventive healthcare? An interrupted time series analysis of adults in English primary care from 2018 to 2022

OBJECTIVE

Offering advice and support for smoking, obesity, excess alcohol, and physical inactivity is an evidence-based component of primary care. The objective was to quantify the impact of the pandemic on the rate of advice or referral for these four risk factors.

METHODS

A retrospective cohort study using primary care data from 1847 practices in England and 21,191,389 patients contributing to the Oxford Clinical Informatics Digital Hub. An interrupted time series analysis was undertaken with a single change point (March 2020). Monthly trends were modelled from 1st January 2018 - 30th June 2022 using segmented linear regression.

RESULTS

There was an initial step reduction in advice and referrals for smoking, obesity, excess alcohol, and physical inactivity in March 2020. By June 2022, advice on smoking (slope change -0.02 events per hundred patient years/month (EPH/month); 95% confidence interval (CI) -0.17, 0.21), obesity (0.06 EPH/month; 95% CI 0.01, 0.12), alcohol (0.02 EPH/month; 95% CI -0.01, 0.05) and physical inactivity (0.05 EPH/month; 95% CI 0.01, 0.09) had not returned to pre-pandemic levels. Similarly, smoking cessation referral remained lower (0.01 EPH/month; 95% CI -0.01, 0.09), excess alcohol referral returned to similar levels (0.0005 EPH/month; 95% CI 0.0002, 0.0008), while referral for obesity (0.14 EPH/month; 95% CI 0.10, 0.19) and physical inactivity (0.01 EPH/month; 95% CI 0.01, 0.02) increased relative to pre-pandemic rates.

CONCLUSION

Advice and support for smoking, and advice for weight, excess alcohol and physical inactivity have not returned to pre-pandemic levels. Clinicians and policy makers should prioritise preventive care in COVID-19 recovery plans.

The diagnostic Accuracy of Visual versus automated dipstick proteinuria testing in Pregnancy: A systematic review and Meta-Analysis

OBJECTIVE

To evaluate the diagnostic accuracy of point-of-care (POC) tests for detecting proteinuria in pregnant women.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE and EMBASE databases were searched from inception to 13 November 2020.

ELIGIBILITY CRITERIA AND DATA ANALYSIS

Included studies measured the sensitivity and specificity ofPOC proteinuria testing compared to laboratory reference standards (protein-creatinine ratio (PCR), 24-hour urine collection). Bivariate meta-analyses determined pooled sensitivity and specificity. Random-effects inverse-variance model determinedheterogeneity.

MAIN OUTCOME MEASURES

The primary outcome was overall sensitivity and specificity, stratified by method of POC testing and reference standard. Secondary outcomes were sensitivity and specificity within thesubgroupstest brand, reference standard, and hypertension status.

RESULTS

1078 studies were identified, 17 studies comprising 23 comparisons were included. The meta-analysis included 13 studies with 19 comparisons. Pooled sensitivity and specificity of visual dipsticks against PCR was 72 % (95 % CI: 56 % to 84 %) and 92 % (95 % CI: 76 % to 98 %), respectively. Pooled sensitivity and specificity of visual dipsticks against 24-hour collection was 69 % (55 % to 80 %) and 70 % (51 % to 84 %), respectively. Pooled sensitivity and specificity for automated readers against PCR was 73 % (53 % to 86 %) and 91 % (83 % to 95 %), respectively. Pooled sensitivity and specificity of automated readers against 24-hour collection was 65 % (42 % to 83 %) and 82 % (46 % to 96 %), respectively.

CONCLUSION

Visual dipsticks have comparable accuracy to automated readers, yet are notadequate as a rule-out test for proteinuria. Proteinuria POC testing maybe beneficial inantenatal care when repeatfollow-up tests are performed. PROSPERO Registration Number: CRD42021231914.

Comparison of clinic and home blood pressure readings in higher risk pregnancies - Secondary analysis of the BUMP 1 trial

OBJECTIVE

To compare clinic and home blood pressure readings in higher risk pregnancies in the antenatal period from 20 weeks gestation, and to evaluate differences between the two modalities.

STUDY DESIGN

A cohort study comprising a secondary analysis of a large randomised controlled trial (BUMP 1).

POPULATION

Normotensive women at higher risk of pregnancy hypertension randomised to self-monitoring of blood pressure.

MAIN OUTCOME MEASURES

The primary outcome was the overall mean difference between clinic and home readings for systolic blood pressure (sBP) and diastolic blood pressure (dBP). Blood pressure readings were averaged across each gestational week for each participant and compared within the same gestational week. Calculations of the overall differences were based on the average difference for each week for each participant.

RESULTS

The cohort comprised 925 participants. In total, 92 (10 %) developed a hypertensive disorder during the pregnancy. A significant difference in the overall mean sBP (clinic - home) of 1.1 mmHg (0.5-1.6 95 %CI) was noted, whereas no significant difference for the overall mean dBP was found (0.0 mmHg (-0.4-0.4 95 %CI)). No tendency of proportional bias was noted based on Bland-Altman plots. Increasing body mass index in general increased the difference (clinic - home) for both sBP and dBP in a multivariate analysis.

CONCLUSIONS

No clinically significant difference was found between clinic and home blood pressure readings in normotensive higher risk pregnancies from gestational week 20+0 until 40+0. Clinic and home blood pressure readings might be considered equal during pregnancy in women who are normotensive at baseline.

Association between the month of starting a weight management program and weight change in people at high risk of type 2 diabetes: A prospective cohort study

OBJECTIVE

Weight loss is one of the most common New Year's resolutions, but it is unclear whether attempting to lose weight in January is more successful than attempting it at other times of the year.

METHODS

In this prospective cohort study from the English National Health Service (NHS) Diabetes Prevention Program, adults with nondiabetic hyperglycemia were enrolled in a structured behavioral weight management program. Repeated measures models assessed the mean difference between baseline and follow-up weight adjusting for monthly variation in weight among those with ≥1 weight measurement.

RESULTS

Among 85,514 participants with a mean baseline BMI of 30.3 kg/m² (range: 13.4 to 84.2), mean weight change at the end of the program after an average 7.9 (SD: 4.5) sessions over 6.4 (SD: 5.6) months was -2.00 kg (95% CI: -2.02 to -1.97 kg) or -2.33% (95% CI: -2.35% to -2.32%). Compared with participants starting in January, participants starting in other months lost less weight, ranging between 0.28 kg (95% CI: 0.10 to 0.45 kg) less weight in those starting in March and 0.71 kg (95% CI: 0.55 to 0.87 kg) less weight in those starting in November. April and May were the only exceptions, in which the estimates followed the same direction but were not statistically significant. Higher session attendance mediated the effects, with participants starting in January attending, on average, 0.2 to 0.7 more sessions than those starting in other months.

CONCLUSIONS

People starting a weight management program in January lost 12% to 30% more weight than people starting it at other times of the year.

Crop domestication as a step towards reproductive isolation

Speciation, Darwin's mystery of mysteries, is a continuous process that results in genomic divergence accompanied by the gradual increment of reproductive barriers between lineages. Since the beginning of research on the genetics of speciation, several questions have emerged such as: What are the genetic bases of incompatibilities? How many loci are necessary to prevent hybridization and how are they distributed along genomes? Can speciation occur despite gene flow and how common is ecological speciation? Early stages of divergence are key to understand the ecology and genetics of speciation, and semi-isolated species where hybrids can still be produced are particularly relevant This article is protected by copyright. All rights reserved.

The association between antihypertensive treatment and serious adverse events by age and frailty: A cohort study

BACKGROUND

Antihypertensives are effective at reducing the risk of cardiovascular disease, but limited data exist quantifying their association with serious adverse events, particularly in older people with frailty. This study aimed to examine this association using nationally representative electronic health record data.

METHODS AND FINDINGS

This was a retrospective cohort study utilising linked data from 1,256 general practices across England held within the Clinical Practice Research Datalink between 1998 and 2018. Included patients were aged 40+ years, with a systolic blood pressure reading between 130 and 179 mm Hg, and not previously prescribed antihypertensive treatment. The main exposure was defined as a first prescription of antihypertensive treatment. The primary outcome was hospitalisation or death within 10 years from falls. Secondary outcomes were hypotension, syncope, fractures, acute kidney injury, electrolyte abnormalities, and primary care attendance with gout. The association between treatment and these serious adverse events was examined by Cox regression adjusted for propensity score. This propensity score was generated from a multivariable logistic regression model with patient characteristics, medical history and medication prescriptions as covariates, and new antihypertensive treatment as the outcome. Subgroup analyses were undertaken by age and frailty. Of 3,834,056 patients followed for a median of 7.1 years, 484,187 (12.6%) were prescribed new antihypertensive treatment in the 12 months before the index date (baseline). Antihypertensives were associated with an increased risk of hospitalisation or death from falls (adjusted hazard ratio [aHR] 1.23, 95% confidence interval (CI) 1.21 to 1.26), hypotension (aHR 1.32, 95% CI 1.29 to 1.35), syncope (aHR 1.20, 95% CI 1.17 to 1.22), acute kidney injury (aHR 1.44, 95% CI 1.41 to 1.47), electrolyte abnormalities (aHR 1.45, 95% CI 1.43 to 1.48), and primary care attendance with gout (aHR 1.35, 95% CI 1.32 to 1.37). The absolute risk of serious adverse events with treatment was very low, with 6 fall events per 10,000 patients treated per year. In older patients (80 to 89 years) and those with severe frailty, this absolute risk was increased, with 61 and 84 fall events per 10,000 patients treated per year (respectively). Findings were consistent in sensitivity analyses using different approaches to address confounding and taking into account the competing risk of death. A strength of this analysis is that it provides evidence regarding the association between antihypertensive treatment and serious adverse events, in a population of patients more representative than those enrolled in previous randomised controlled trials. Although treatment effect estimates fell within the 95% CIs of those from such trials, these analyses were observational in nature and so bias from unmeasured confounding cannot be ruled out.

CONCLUSIONS

Antihypertensive treatment was associated with serious adverse events. Overall, the absolute risk of this harm was low, with the exception of older patients and those with moderate to severe frailty, where the risks were similar to the likelihood of benefit from treatment. In these populations, physicians may want to consider alternative approaches to management of blood pressure and refrain from prescribing new treatment.

Cross-sectional diagnostic accuracy study of self-testing for proteinuria during hypertensive pregnancies: The UDIP study

OBJECTIVE

To determine the accuracy of self-testing for proteinuria during pregnancy.

DESIGN

Diagnostic accuracy study.

SETTING

Antenatal clinics, maternity assessment units and inpatient wards at three hospital sites.

POPULATION OR SAMPLE

345 pregnant women.

METHODS

Pregnant women self-tested in-clinic for urinary protein using visually read dipsticks with samples then sent for laboratory estimation of the spot protein-creatinine ratio (PCR) (primary reference test). Secondary index tests included testing by antenatal healthcare professionals and an automated colorimetric reader.

MAIN OUTCOME MEASURES

Sensitivity, specificity, negative predictive value, positive predictive value and likelihood ratios were calculated for self-testing (primary index test) along with healthcare professional and colorimetric testing compared to the primary reference test (PCR).

RESULTS

335/345 (97%) had sufficient data to be included in the analysis. Self-testing had a sensitivity of 0.71 (95% confidence interval [CI] 0.62-0.79) and a specificity of 0.89 (95% CI 0.84-0.92) compared to PCR. Sensitivity and specificity of testing by healthcare professionals and the colorimetric reader were similar: sensitivity 0.73 (95% CI 0.64-0.80) and 0.78 (95% CI 0.69-0.85), respectively; specificity 0.88 (95% CI 0.82-0.92) and 0.83 (95% CI 0.78-0.88), respectively.

CONCLUSION

Pregnant women can visually read a dipstick for urinary protein with similar accuracy to antenatal healthcare professionals. Automated colorimetric testing was not significantly different, in contrast to some previous studies. Self-testing has the potential to form part of a self-monitoring regime in pregnancy.

[An intracranial haemorrhage in a febrile newborn]

A 15 days old newborn was admitted to the emergency room for a recent fever onset. In newborns, the priority is to rule out any bacterial infection and initiate broad spectrum antibiotics. The hemorrhagic appearance of the cerebrospinal fluid after lumbar puncture can sometimes be the only sign to suspect, other than obvious infectious aetiology, an intracranial haemorrhage.

Development and external validation of a risk prediction model for falls in patients with an indication for antihypertensive treatment: retrospective cohort study

OBJECTIVE

To develop and externally validate the STRAtifying Treatments In the multi-morbid Frail elderlY (STRATIFY)-Falls clinical prediction model to identify the risk of hospital admission or death from a fall in patients with an indication for antihypertensive treatment.

DESIGN

Retrospective cohort study.

SETTING

Primary care data from electronic health records contained within the UK Clinical Practice Research Datalink (CPRD).

PARTICIPANTS

Patients aged 40 years or older with at least one blood pressure measurement between 130 mm Hg and 179 mm Hg.

MAIN OUTCOME MEASURE

First serious fall, defined as hospital admission or death with a primary diagnosis of a fall within 10 years of the index date (12 months after cohort entry). Model development was conducted using a Fine-Gray approach in data from CPRD GOLD, accounting for the competing risk of death from other causes, with subsequent recalibration at one, five, and 10 years using pseudo values. External validation was conducted using data from CPRD Aurum, with performance assessed through calibration curves and the observed to expected ratio, C statistic, and D statistic, pooled across general practices, and clinical utility using decision curve analysis at thresholds around 10%.

RESULTS

Analysis included 1 772 600 patients (experiencing 62 691 serious falls) from CPRD GOLD used in model development, and 3 805 366 (experiencing 206 956 serious falls) from CPRD Aurum in the external validation. The final model consisted of 24 predictors, including age, sex, ethnicity, alcohol consumption, living in an area of high social deprivation, a history of falls, multiple sclerosis, and prescriptions of antihypertensives, antidepressants, hypnotics, and anxiolytics. Upon external validation, the recalibrated model showed good discrimination, with pooled C statistics of 0.833 (95% confidence interval 0.831 to 0.835) and 0.843 (0.841 to 0.844) at five and 10 years, respectively. Original model calibration was poor on visual inspection and although this was improved with recalibration, under-prediction of risk remained (observed to expected ratio at 10 years 1.839, 95% confidence interval 1.811 to 1.865). Nevertheless, decision curve analysis suggests potential clinical utility, with net benefit larger than other strategies.

CONCLUSIONS

This prediction model uses commonly recorded clinical characteristics and distinguishes well between patients at high and low risk of falls in the next 1-10 years. Although miscalibration was evident on external validation, the model still had potential clinical utility around risk thresholds of 10% and so could be useful in routine clinical practice to help identify those at high risk of falls who might benefit from closer monitoring or early intervention to prevent future falls. Further studies are needed to explore the appropriate thresholds that maximise the model's clinical utility and cost effectiveness.

Effects of a group-based weight management programme on anxiety and depression: A randomised controlled trial (RCT)

OBJECTIVES

The aim was to investigate the impact of a group-based weight management programme on symptoms of depression and anxiety compared with self-help in a randomised controlled trial (RCT).

METHOD

People with overweight (Body Mass Index [BMI]≥28kg/m2) were randomly allocated self-help (n = 211) or a group-based weight management programme for 12 weeks (n = 528) or 52 weeks (n = 528) between 18/10/2012 and 10/02/2014. Symptoms were assessed using the Hospital Anxiety and Depression Scale, at baseline, 3, 12 and 24 months. Linear regression modelling examined changes in Hospital Anxiety and Depression Scale between trial arms.

RESULTS

At 3 months, there was a -0.6 point difference (95% confidence interval [CI], -1.1, -0.1) in depression score and -0.1 difference (95% CI, -0.7, 0.4) in anxiety score between group-based weight management programme and self-help. At subsequent time points there was no consistent evidence of a difference in depression or anxiety scores between trial arms. There was no evidence that depression or anxiety worsened at any time point.

CONCLUSIONS

There was no evidence of harm to depression or anxiety symptoms as a result of attending a group-based weight loss programme. There was a transient reduction in symptoms of depression, but not anxiety, compared to self-help. This effect equates to less than 1 point out of 21 on the Hospital Anxiety and Depression Scale and is not clinically significant.

An overview of orthodontic malpractice liability based on a survey and case assessment review

Background

The purpose of this survey study and case review was to identify 1) the common causes related to filing a malpractice claim against an orthodontist and, 2) the factors mitigating against a potential malpractice claim in the United States (U.S). The objectives of the case review were to examine the current state of orthodontic malpractice litigation from a cause and mitigating point of view.

Material and Methods

Data for this research was collected and reviewed using the following two methods: 1) A survey questionnaire on aspects of malpractice liability was electronically distributed to 2,241 active U.S. members of the American Association of Orthodontists (AAO). 2) Legal cases were reviewed on the online legal research database Lexis Advance Research, and 35 cases were analyzed.

Results

Survey questionnaire results and legal case review results are as follows: 1) 77 orthodontists completed the survey. 9.1% of the respondents reported a malpractice claim having been filed against them with periodontal issues accounting for most of the claims. Survey participants reported good doctor-patient communication as being the most relevant contributory factor and most relevant mitigating factor in malpractice claims. 2) Negligence is the main reason patients sue a doctor for clinically related litigation, and failure to obtain a proper informed consent from the patient is the main cause of action for non-clinically related litigation.

Conclusions

Most respondents reported doctor-patient communication, periodontal issues, and a lack of informed consent as the main triggering elements of a lawsuit, which is similar to other studies and case review analysis. Good doctor-patient rapport was ranked as being most helpful in mitigating a potential claim, which is also similar to other studies. Another aspect of the survey questionnaire that was evaluated was whether a non-orthodontist can provide expert testimony against an orthodontist, with most respondents reporting that this is not possible. It has been ruled, though, that a general dentist can be an expert witness and provide expert testimony against an orthodontist in a lawsuit depending on the circumstances. Negligence was the most common cause of clinically related orthodontic litigation, and a failure of the practitioner to obtain a proper informed consent from the patient was the most common cause of non-clinically related orthodontic litigation.

Key words:Orthodontist, malpractice, legal, lawsuit, liability, medicolegal.

Public Perceptions and Understanding of Risks Associated with Do-It-Yourself Orthodontics: A Survey Study

Background

The purpose of this study was to evaluate general public’s perception, knowledge and preferences on orthodontic treatment rendered by an orthodontist versus the “Do-It-Yourself” orthodontics (DIYO) concept without professional supervision. The secondary objective was to assess laypeople’s awareness on the risks and limitations of DIYO.

Material and Methods

A 24-question online survey questionnaire was administered to 526 laypeople who had no professional experience or background in dentistry and orthodontics. All data was collected over 3 days (July 20-23, 2020) by Qualtrics server and forwarded to the principal investigator. Statistical analysis was done with statistical software SPSS® version 26.

Results

The most important reason for laypeople to opt for DIYO is financial reason. People who have undergone orthodontic treatment know the difference between a general dentist and an orthodontist, whereas people who have not had orthodontic treatment are less likely to know the difference. Of the 285 people who did not receive orthodontic treatment before by a dental professional, 43 have considered DIYO. 122 of the 526 people considered DIYO, and 79 of the 122 had orthodontic treatment before. 26 of the 122 did not consider the clinical exam and diagnostic records important and would be comfortable without in-person supervision. 83 of the 122 would be comfortable not having in-person supervision, and still considered this treatment modality “Doctor-Directed”.

Conclusions

The main reason laypeople utilize DIYO is the low cost. Some DIYO users do not consider risks involved and a small percentage consider their own dentist to be responsible if any issues arise with DIYO. One third of survey respondents will consider DIYO in the future.

Key words:Do-It-Yourself (DIY), Direct-To-Consumer (DTC), Adult, Orthodontics, Dentistry, Surveys and Questionnaires.

Let's embed peer-support groups into the medical curriculum for all

Even before the COVID-19 pandemic, attending to the mental wellbeing of all doctors was high on the political agenda. The quality of patient care is also known to be related to doctors' wellbeing. Now, in the midst of a global pandemic, doctors are having to cope with ever more trauma and moral injury. Group-based peer support and regular reflective practice are interventions known to reduce clinician burnout and optimise wellbeing. Junior doctors are the most likely of all medical groups to be at a high risk of burnout. The NHS Staff and Learners' Mental Wellbeing Commission report advocates establishing explicit peer support mechanisms and the use of peer support as part of the first line of psychological first aid. Peer support is not addressed in the curriculum for the majority of medical specialties. We recommend that regular peer-support reflective groups are provided during protected time for all trainees.

Practice of lingual orthodontics and practitioners' opinion and experience with lingual braces in the United States

Background

A survey was done on practicing Orthodontists in the United States on their experience with lingual orthodontics. The objectives of this survey study were to assess 1) the satisfaction level with cases treated with lingual orthodontics, 2) factors that influence clinicians’ decision to utilize or not utilize lingual braces in their current practices, and 3) intention of using lingual braces in their future practices, if not used currently, in the U.S.

Material and Methods

A survey questionnaire was electronically distributed to 2,200 active U.S. members of the American Association of Orthodontists (AAO).

Results

85 orthodontists completed the survey. About 25% of respondents practiced lingual orthodontics. Direct mentorship was the most common approach used by orthodontists to learn lingual technique. The most used lingual system among the clinicians that use lingual braces was INBRACE® (34.6%). All respondents were either satisfied or very satisfied with their treatment outcome of cases treated with lingual braces. Improved esthetics and practice differentiation were perceived to be the biggest advantages of practicing lingual orthodontics. Biggest challenges with lingual orthodontics were found to be patient discomfort, cost, longer chair time and technical difficulties. Most common reason for not using lingual braces was technical difficulty, followed by availability of alternative appliances, lack of demand and patient discomfort. Approximately, 70% of those that did not use lingual orthodontics in their current practices responded that they were very likely to incorporate lingual orthodontics in their future practices.

Conclusions

Overall outcome satisfaction level with cases treated with lingual braces was high among the orthodontists that practiced lingual orthodontics. There seemed to be a strong interest in incorporating lingual orthodontics in future practices by clinicians that did not use lingual braces in their current practices. Some of the factors that influenced clinicians’ decision to practice lingual orthodontics were improved esthetics, practice differentiation and increased case acceptance. Technical difficulties, availability of alternative appliances, lack of demand and patient discomfort were some of the factors that were identified to have influenced practitioners’ decision to not offer lingual orthodontics in their current practices.

Key words:Orthodontic brackets, Lingual braces, Lingual orthodontics.

Long-term monitoring in primary care for chronic kidney disease and chronic heart failure: a multi-method research programme

Background

Long-term monitoring is important in chronic condition management. Despite considerable costs of monitoring, there is no or poor evidence on how, what and when to monitor. The aim of this study was to improve understanding, methods, evidence base and practice of clinical monitoring in primary care, focusing on two areas: chronic kidney disease and chronic heart failure.

Objectives

The research questions were as follows: does the choice of test affect better care while being affordable to the NHS? Can the number of tests used to manage individuals with early-stage kidney disease, and hence the costs, be reduced? Is it possible to monitor heart failure using a simple blood test? Can this be done using a rapid test in a general practitioner consultation? Would changes in the management of these conditions be acceptable to patients and carers?

Design

Various study designs were employed, including cohort, feasibility study, Clinical Practice Research Datalink analysis, seven systematic reviews, two qualitative studies, one cost-effectiveness analysis and one cost recommendation.

Setting

This study was set in UK primary care.

Data sources

Data were collected from study participants and sourced from UK general practice and hospital electronic health records, and worldwide literature.

Participants

The participants were NHS patients (Clinical Practice Research Datalink: 4.5 million patients), chronic kidney disease and chronic heart failure patients managed in primary care (including 750 participants in the cohort study) and primary care health professionals.

Interventions

The interventions were monitoring with blood and urine tests (for chronic kidney disease) and monitoring with blood tests and weight measurement (for chronic heart failure).

Main outcome measures

The main outcomes were the frequency, accuracy, utility, acceptability, costs and cost-effectiveness of monitoring.

Results

Chronic kidney disease: serum creatinine testing has increased steadily since 1997, with most results being normal (83% in 2013). Increases in tests of creatinine and proteinuria correspond to their introduction as indicators in the Quality and Outcomes Framework. The Chronic Kidney Disease Epidemiology Collaboration equation had 2.7% greater accuracy (95% confidence interval 1.6% to 3.8%) than the Modification of Diet in Renal Disease equation for estimating glomerular filtration rate. Estimated annual transition rates to the next chronic kidney disease stage are ≈ 2% for people with normal urine albumin, 3–5% for people with microalbuminuria (3–30 mg/mmol) and 3–12% for people with macroalbuminuria (> 30 mg/mmol). Variability in estimated glomerular filtration rate-creatinine leads to misclassification of chronic kidney disease stage in 12–15% of tests in primary care. Glycaemic-control and lipid-modifying drugs are associated with a 6% (95% confidence interval 2% to 10%) and 4% (95% confidence interval 0% to 8%) improvement in renal function, respectively. Neither estimated glomerular filtration rate-creatinine nor estimated glomerular filtration rate-Cystatin C have utility in predicting rate of kidney function change. Patients viewed phrases such as ‘kidney damage’ or ‘kidney failure’ as frightening, and the term ‘chronic’ was misinterpreted as serious. Diagnosis of asymptomatic conditions (chronic kidney disease) was difficult to understand, and primary care professionals often did not use ‘chronic kidney disease’ when managing patients at early stages. General practitioners relied on Clinical Commissioning Group or Quality and Outcomes Framework alerts rather than National Institute for Health and Care Excellence guidance for information. Cost-effectiveness modelling did not demonstrate a tangible benefit of monitoring kidney function to guide preventative treatments, except for individuals with an estimated glomerular filtration rate of 60–90 ml/minute/1.73 m2, aged < 70 years and without cardiovascular disease, where monitoring every 3–4 years to guide cardiovascular prevention may be cost-effective. Chronic heart failure: natriuretic peptide-guided treatment could reduce all-cause mortality by 13% and heart failure admission by 20%. Implementing natriuretic peptide-guided treatment is likely to require predefined protocols, stringent natriuretic peptide targets, relative targets and being located in a specialist heart failure setting. Remote monitoring can reduce all-cause mortality and heart failure hospitalisation, and could improve quality of life. Diagnostic accuracy of point-of-care N-terminal prohormone of B-type natriuretic peptide (sensitivity, 0.99; specificity, 0.60) was better than point-of-care B-type natriuretic peptide (sensitivity, 0.95; specificity, 0.57). Within-person variation estimates for B-type natriuretic peptide and weight were as follows: coefficient of variation, 46% and coefficient of variation, 1.2%, respectively. Point-of-care N-terminal prohormone of B-type natriuretic peptide within-person variability over 12 months was 881 pg/ml (95% confidence interval 380 to 1382 pg/ml), whereas between-person variability was 1972 pg/ml (95% confidence interval 1525 to 2791 pg/ml). For individuals, monitoring provided reassurance; future changes, such as increased testing, would be acceptable. Point-of-care testing in general practice surgeries was perceived positively, reducing waiting time and anxiety. Community heart failure nurses had greater knowledge of National Institute for Health and Care Excellence guidance than general practitioners and practice nurses. Health-care professionals believed that the cost of natriuretic peptide tests in routine monitoring would outweigh potential benefits. The review of cost-effectiveness studies suggests that natriuretic peptide-guided treatment is cost-effective in specialist settings, but with no evidence for its value in primary care settings.

Limitations

No randomised controlled trial evidence was generated. The pathways to the benefit of monitoring chronic kidney disease were unclear.

Conclusions

It is difficult to ascribe quantifiable benefits to monitoring chronic kidney disease, because monitoring is unlikely to change treatment, especially in chronic kidney disease stages G3 and G4. New approaches to monitoring chronic heart failure, such as point-of-care natriuretic peptide tests in general practice, show promise if high within-test variability can be overcome.

Future work

The following future work is recommended: improve general practitioner–patient communication of early-stage renal function decline, and identify strategies to reduce the variability of natriuretic peptide.

Study registration

This study is registered as PROSPERO CRD42015017501, CRD42019134922 and CRD42016046902.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 10. See the NIHR Journals Library website for further project information.

Estimating the effect of moving meat-free products to the meat aisle on sales of meat and meat-free products: A non-randomised controlled intervention study in a large UK supermarket chain

BACKGROUND

Reducing meat consumption could bring health and environmental benefits, but there is little research to date on effective interventions to achieve this. A non-randomised controlled intervention study was used to evaluate whether prominent positioning of meat-free products in the meat aisle was associated with a change in weekly mean sales of meat and meat-free products.

METHODS AND FINDINGS

Weekly sales data were obtained from 108 stores: 20 intervention stores that moved a selection of 26 meat-free products into a newly created meat-free bay within the meat aisle and 88 matched control stores. The primary outcome analysis used a hierarchical negative binomial model to compare changes in weekly sales (units) of meat products sold in intervention versus control stores during the main intervention period (Phase I: February 2019 to April 2019). Interrupted time series analysis was also used to evaluate the effects of the Phase I intervention. Moreover, 8 of the 20 stores enhanced the intervention from August 2019 onwards (Phase II intervention) by adding a second bay of meat-free products into the meat aisle, which was evaluated following the same analytical methods. During the Phase I intervention, sales of meat products (units/store/week) decreased in intervention (approximately -6%) and control stores (-5%) without significant differences (incidence rate ratio [IRR] 1.01 [95% CI 0.95-1.07]. Sales of meat-free products increased significantly more in the intervention (+31%) compared to the control stores (+6%; IRR 1.43 [95% CI 1.30-1.57]), mostly due to increased sales of meat-free burgers, mince, and sausages. Consistent results were observed in interrupted time series analyses where the effect of the Phase II intervention was significant in intervention versus control stores.

CONCLUSIONS

Prominent positioning of meat-free products into the meat aisle in a supermarket was not effective in reducing sales of meat products, but successfully increased sales of meat-free alternatives in the longer term. A preregistered protocol (https://osf.io/qmz3a/) was completed and fully available before data analysis.

Recommendations for accurate genotyping of SARS-CoV-2 using amplicon-based sequencing of clinical samples

OBJECTIVES

Genotyping of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been instrumental in monitoring viral evolution and transmission during the pandemic. The quality of the sequence data obtained from these genotyping efforts depends on several factors, including the quantity/integrity of the input material, the technology, and laboratory-specific implementation. The current lack of guidelines for SARS-CoV-2 genotyping leads to inclusion of error-containing genome sequences in genomic epidemiology studies. We aimed to establish clear and broadly applicable recommendations for reliable virus genotyping.

METHODS

We established and used a sequencing data analysis workflow that reliably identifies and removes technical artefacts; such artefacts can result in miscalls when using alternative pipelines to process clinical samples and synthetic viral genomes with an amplicon-based genotyping approach. We evaluated the impact of experimental factors, including viral load and sequencing depth, on correct sequence determination.

RESULTS

We found that at least 1000 viral genomes are necessary to confidently detect variants in the SARS-CoV-2 genome at frequencies of ≥10%. The broad applicability of our recommendations was validated in over 200 clinical samples from six independent laboratories. The genotypes we determined for clinical isolates with sufficient quality cluster by sampling location and period. Our analysis also supports the rise in frequencies of 20A.EU1 and 20A.EU2, two recently reported European strains whose dissemination was facilitated by travel during the summer of 2020.

CONCLUSIONS

We present much-needed recommendations for the reliable determination of SARS-CoV-2 genome sequences and demonstrate their broad applicability in a large cohort of clinical samples.

POS0106 BILAG-2004 LDA AND BST LDA ARE VALID TREAT TO TARGET IN SLE

Background:

Low disease activity state has been defined using SLEDAI and used as treatment target in SLE. However, there has not been any such definition using BILAG-2004 index (BILAG-2004).

Objectives:

This study was to determine if low disease activity state according to BILAG-2004 is valid for use as treatment target in SLE. We also assessed disease activity longitudinally using BILAG-2004 systems tally (BST). BST is an alternative way of representing BILAG-2004 scores that combines the flexibility and simplification of numerical scoring of BILAG-2004 with the clinical intuitiveness of BILAG-2004 structure.

Methods:

This was a prospective multi-centre longitudinal study in the UK of an inception cohort of SLE patients (recruited within 12 months of achieving 1997 ACR revised criteria for SLE). Data were collected on disease activity (BILAG-2004 and BILAG2004-Pregnancy Index during pregnancy), SLICC/ACR DI (SDI), cumulative drug exposure and death at every visit. This study ran from 1st January 2005 to 31st December 2017. Four low disease activity states (LDA) were defined using BILAG-2004: 1) BILAG-2004 LDA when all 9 systems had scores of C, D or E on assessment (no Grade A or B), 2) BST LDA when there was persistent score of C, D or E in all 9 systems between 2 consecutive visits (equivalent to 2 consecutive visits with BILAG-2004 LDA), 3) BILAG-2004 Remission when all 9 systems had scores of D or E on assessment and 4) Persistent Remission when there was persistent score of D or E in all 9 systems between 2 consecutive visits. Longitudinal analysis using Poisson regression with random effects model was used with development of new damage as the outcome of interest. Gender, cardiovascular risk factors, antiphospholipid syndrome status and most drugs (except hydroxychloroquine, glucocorticoids, mycophenolate and cyclophosphamide) were excluded from the model as they were not associated with development of damage in univariate analysis.

Results:

273 patients were recruited (91.2% female, 59.3% Caucasian, 17.2% African/Caribbean, 17.2% South Asian) with mean age at recruitment of 38.5 years (SD 14.8). 97.8% had no damage at recruitment (2.2% had SDI score of 1). Median follow-up was 73.4 months (range: 1.8, 153.8) with total follow-up of 1767 patient-years. There were 13 deaths and 114 new damage items occurred during follow-up. There were 6674 assessments with disease activity score: 319 assessments with Grade A activity in 95 patients (84.6% had only 1 system with grade A, range: 1 - 4) and 1704 assessments with Grade A or B activity in 239 patients (78.7% had only 1 system with Grade A or B, range: 1 - 5).

BILAG-2004 LDA was achieved in 74.5% of assessments (from 271 patients). BILAG-2004 Remission occurred in 28.2% of assessments (from 234 patients).

6401 observations with BST were available (1 observation derived from change in activity between 2 consecutive assessments) and 63.7% were in BST LDA. There was no observation with Persistent Remission between consecutive visits.

Table 1 summarises multivariate analysis which showed BILAG-2004 LDA to be inversely associated with damage. Similar results were obtained with BILAG-2004 Remission (RR 0.60 with 95% CI 0.38, 0.96) and BST LDA (RR 0.65 with 95% CI 0.43, 0.99). Cumulative drug exposure since recruitment for mycophenolate was protective against new damage (RR 0.99 with 95% CI 0.99, 0.99).

Table 1.VariableRelative Risk (95% CI) for New DamageEthnicityAfro-Caribbean1.22 (0.68, 2.18)South Asian1.81 (0.97, 3.38)Others2.22 (0.63, 7.85)Age at diagnosis1.06 (1.04, 1.08)Prior SDI score0.68 (0.43, 1.06)BILAG-2004 LDA0.60 (0.39, 0.94)Hydroxychloroquine since last visit (per g)0.99 (0.98, 0.99)Steroids since last visit (per 100mg)1.02 (1.01, 1.03)Cyclophosphamide since last visit (per g)1.67 (1.15, 2.41)

Conclusion:

BILAG-2004 LDA and BST LDA are valid treatment targets in SLE. BILAG-2004 Remission and Persistent Remission are uncommon, which make them unrealistic as a treatment target.

References:

[1]Yee C. S., et al. The BILAG-2004 systems tally – a novel way of representing the BILAG-2004 index scores longitudinally. Rheumatology (Oxford) 2012; 51[11]: 2099-2105.

Acknowledgements :

Versus Arthritis, Vifor Pharma

Disclosure of Interests:

Chee-Seng Yee Consultant of: Bristol Myers Squibb, ImmuPharma, Grant/research support from: Vifor Pharma, Caroline Gordon Speakers bureau: UCB, Consultant of: Center for Disease Control, Astra-Zeneca, MGP, Sanofi and UCB, Mohammed Akil: None declared, Peter Lanyon: None declared, Christopher John Edwards Consultant of: Glaxo Smith Kline, Roche, Grant/research support from: Glaxo Smith Kline, Roche, David Isenberg: None declared, Anisur Rahman: None declared, Lee-Suan Teh: None declared, Sofia Tosounidou: None declared, Robert Stevens: None declared, Ahtiveer Prabu: None declared, Bridget Griffiths: None declared, Neil McHugh: None declared, Ian N. Bruce: None declared, Yasmeen Ahmad: None declared, Munther Khamashta: None declared, Vernon Farewell: None declared

Calibration of an in-situ fluorescence-based sensor platform for reliable BOD5 measurement in wastewater

Reliance on biochemical oxygen demand (BOD₅) as an indicator of wastewater quality has hindered the development of efficient process control due to the associated uncertainty and lag-times. Surrogate measurements have been proposed, with fluorescence spectroscopy a promising technique. Yet, assessment of in-situ fluorescence sensors across multiple wastewater treatment plants (WwTPs), and at different treatment stages, is limited. In this study a multi-parameter sonde (two fluorescence peaks, turbidity, temperature and electrical conductivity) was used to provide a BOD₅ surrogate measurement. The sonde was deployed at three WwTPs, on post primary settlement tanks (PST) and final effluent (FE). Triplicate laboratory measurements of BOD₅, from independent laboratories were used to calibrate the sensor, with high variability apparent for FE samples. Site and process specific sensor calibrations yielded the best results (R²_cv = 0.76-0.86; 10-fold cross-validation) and mean BOD₅ of the three laboratory measurements improved FE calibration. When combining PST sites a reasonable calibration was still achieved (R²_cv = 0.67) suggesting transfer of sensors between WwTPs may be possible. This study highlights the potential to use online optical sensors as robust BOD₅ surrogates in WwTPs. However, careful calibration (i.e. replicated BOD₅ measurements) is required for FE as laboratory measurements can be associated with high uncertainty.

POS0111 DEVELOPMENT OF DAMAGE AND MORTALITY IN AN INCEPTION COHORT OF SLE PATIENTS

Background:

There had been very limited data on the development of damage and mortality in an inception cohort of SLE patients who were recruited very soon after diagnosis.

Objectives:

This study aimed to analyse the development of damage and death in an inception cohort of SLE patients recruited within 1 year of diagnosis with up to 13 years of follow-up.

Methods:

This was a prospective multi-centre longitudinal study in the UK of SLE patients recruited within 12 months of achieving 1997 ACR revised criteria for SLE. Data were collected on BILAG-2004, BILAG2004-Pregnancy Index (during pregnancy), SLICC/ACR DI (SDI), cumulative drug exposure and death at every visit. Information on cardiovascular risk factors and antiphospholipid syndrome status were also collected. This study ran from 1st January 2005 to 31st December 2017. Mortality and development of damage were analysed.

Results:

There were 273 patients recruited (91.2% female, 59.3% Caucasian, 17.2% African/Caribbean, 17.2% South Asian) with mean age at recruitment of 38.5 years (SD 14.8). 97.8% had no damage at recruitment (2.2% had SDI score of 1). Median follow-up was 73.4 months (range: 1.8, 153.8) with total follow-up of 1767 patient-years.

There were 13 deaths (4.8%): 76.9% female, 84.6% Caucasian, 15.4% South Asian, mean age 62.6 years (± SD 15.8) and mean disease duration 3 years (± SD 1.8). Causes of death were cancer in 5 (38.5%), infection in 3 (23.1%), ischaemic heart disease in 1 (7.7%) and unknown in 4 (30.8%).

114 new damage items in 83 patients occurred during follow-up. The distribution of damage was musculoskeletal (21, 18.4%), ophthalmic (18, 15.8%), neuropsychiatric (18, 15.8%), renal (14, 12.3%), malignancy (12, 10.5%), cutaneous (7, 6.1%), GIT (7, 6.1%), cardiac (6, 5.3%), pulmonary (4, 3.5%), diabetes mellitus (4, 3.5%) and vascular (3, 2.6%). The rate of development of damage appears to be higher in the first 3 years which subsequently stabilised (Table 1).

Table 1.

Incidence rate of development of damage over period of follow-up at 3 yearly intervals

Period of follow-up (year)Person-years at riskNumber of new items of damageIncidence rate, per 1000 person-years (95% CI)0 – 3753.46079.6 (61.8, 102.6)3 – 6534.03158.1 (40.8, 82.6)6 – 9321.21237.4 (21.2, 35.8)9 – 12152.5532.8 (13.6, 78.7)> 125.90-

Conclusion:

Mortality is uncommon during the first 12 years of follow-up for newly diagnosed SLE patients. However, development of damage appears to be higher in the first 3 years before stabilizing to a lower rate subsequently.

Acknowledgements:

Versus Arthritis, VIfor Pharma

Disclosure of Interests:

Chee-Seng Yee Consultant of: Bristol Myer Squibb, ImmuPharma, Grant/research support from: Vifor Pharma, Vernon Farewell: None declared, Mohammed Akil: None declared, Peter Lanyon: None declared, Christopher John Edwards Consultant of: Glaxo Smith Kline, Roche, Grant/research support from: Glaxo Smith Kline, Roche, David Isenberg: None declared, Anisur Rahman: None declared, Lee-Suan Teh: None declared, Sofia Tosounidou: None declared, Robert Stevens: None declared, Ahtiveer Prabu: None declared, Bridget Griffiths: None declared, Neil McHugh: None declared, Ian N. Bruce: None declared, Yasmeen Ahmad: None declared, Munther Khamashta: None declared, Caroline Gordon Speakers bureau: UCB, Consultant of: Center for Disease Control, Astra-Zeneca, MGP, Sanofi and UCB

POS0705 BILAG-2004 INDEX ACTIVE DISEASE PREDICTS DEVELOPMENT OF DAMAGE

Background:

BILAG-2004 Index (BILAG-2004) has undergone construct and criterion validity and is used to assess disease activity in SLE. However, its predictive validity has yet to be established.

Objectives:

This study was to determine if disease activity according to BILAG-2004 was predictive of development of damage in an inception cohort.

Methods:

This was a prospective multi-centre longitudinal study in the UK of an inception cohort of SLE patients (recruited within 12 months of achieving 1997 ACR revised criteria for SLE). Data were collected on disease activity (BILAG-2004 and BILAG2004-Pregnancy Index during pregnancy), SLICC/ACR DI (SDI), cumulative drug exposure and death at every visit. Information on cardiovascular risk factors (hypertension, diabetes mellitus, hypercholesterolaemia and smoking status) and antiphospholipid syndrome status were also collected. This study ran from 1st January 2005 to 31st December 2017. Longitudinal analysis using Poisson regression with random effects model was used to determine predictors of development of new damage. Death was not included in the analysis due to small numbers.

Results:

273 patients were recruited (91.2% female, 59.3% Caucasian, 17.2% African/Caribbean, 17.2% South Asian) with mean age at recruitment of 38.5 years (SD 14.8). 97.8% had no damage at recruitment (2.2% had SDI score of 1). Median follow-up was 73.4 months (range: 1.8, 153.8) with total follow-up of 1767 patient-years. Prevalence of risk factors during follow-up were: hypertension 23.1%, hypercholesterolaemia 35.5%, diabetes mellitus 5.5%, smoker or ex-smoker 44% and antiphospholipid syndrome 7%. There were 13 deaths and 114 new damage items occurred during follow-up.

There were 6674 assessments with disease activity score: 293 assessments with Grade A activity in 95 patients (92.4% had only 1 system with grade A, range: 1 - 4) and 1704 assessments with Grade A or B activity in 239 patients (78.7% had only 1 system with Grade A or B, range: 1 - 5).

Univariate analysis showed that gender, cardiovascular risk factors, antiphospholipid syndrome and most drug exposure (except hydroxychloroquine, glucocorticoids, mycophenolate and cyclophosphamide) were not associated with new damage (they were not included in the multivariate analysis).

Table 1 summarises multivariate analysis. Similar results were obtained when the disease activity variable was changed to Number of Systems with Grade A per assessment (RR 2.04 with 95% CI: 1.05, 3.94). Analysis using BILAG-2004 systems tally showed that persistent minimal disease was protective of development of damage (RR 0.74 with 95% CI: 0.57, 0.95). Cumulative drug exposure since recruitment for mycophenolate was protective against new damage (RR 0.99 with 95% CI 0.99, 0.99) but not cumulative drug exposure since last visit.

VariableRisk Ratio (95% CI) for New DamageEthnicity Afro-Caribbean1.21 (0.68, 2.17) South Asian1.81 (0.97, 3.36) Others2.37 (0.68, 8.20)Age at diagnosis1.06 (1.04, 1.08)Prior SDI score0.69 (0.44, 1.08)Constitutional A or Bunreliable estimate due to low numbersMucocutaneous A or B1.80 (1.04, 3.14)Neuropsychiatric A or B4.68 (1.68, 13.05)Musculoskeletal A or B0.76 (0.33, 1.73)Cardiorespiratory A or B0.35 (0.05, 2.59)GIT A or Bunreliable estimate due to low numbersOphthalmic A or Bunreliable estimate due to low numbersRenal A or B2.08 (0.99, 4.40)Haematological A or B4.37 (1.15, 16.65)Hydroxychloroquine since last visit (per g)0.99 (0.98, 0.99)Prednisolone since last visit (per 100mg)1.01 (1.00, 1.02)Cyclophosphamide since last visit (per g)1.42 (0.94, 2.14)

Conclusion:

Active disease (Grade A or B) according to BILAG-2004 index is predictive of development of new damage in SLE patients.

References:

[1]Yee C. S., et al. The BILAG-2004 systems tally – a novel way of representing the BILAG-2004 index scores longitudinally. Rheumatology (Oxford) 2012; 51[11]: 2099-2105.

Acknowledgements:

Versus Arthritis and Vifor Pharma

Disclosure of Interests:

Chee-Seng Yee Consultant of: Bristol Myers Squibb, ImmuPharma, Grant/research support from: Vifor Pharma, Vernon Farewell: None declared, Mohammed Akil: None declared, Peter Lanyon: None declared, Christopher John Edwards Consultant of: Glaxo Smith Kline, Roche, Grant/research support from: Glaxo Smith Kline, Roche, David Isenberg: None declared, Anisur Rahman: None declared, Lee-Suan Teh: None declared, Sofia Tosounidou: None declared, Robert Stevens: None declared, Ahtiveer Prabu: None declared, Bridget Griffiths: None declared, Neil McHugh: None declared, Ian N. Bruce: None declared, Yasmeen Ahmad: None declared, Munther Khamashta: None declared, Caroline Gordon Speakers bureau: UCB, Consultant of: Center for Disease Control, Astra-Zeneca, MGP, Sanofi and UCB

Differential diagnosis of acute traumatic hip pain in the elderly

Elderly patients who present with an inability to weight bear following a fall, with normal radiographs, should be appropriately investigated to rule out an occult hip fracture (OHF). We aim to identify both the range and incidence of the differential diagnosis of acute traumatic hip pain in a large series of patients investigated for OHF. A retrospective analysis of consecutive patients investigated for an OHF with magnetic resonance imaging (MRI) was performed. Dedicated musculo- skeletal radiologists reported the MRI scans. All diagnoses including hip fractures, other fractures and soft tissue injuries were recorded. Case notes were reviewed for all patients to identify subsequent complications, management and outcomes. A total of 157 patients fulfilled the inclusion criteria. 52 (33%) patients had a fracture of the proximal femur. The majority of patients with proximal femoral fractures required surgical intervention. 9 patients who had fractures of the greater trochanter of the femur without fracture extension across the femoral neck were managed non-operatively. 40 (25%) patients had fractures of the pelvis, with a combined pubic rami and sacral fracture occurring frequently. The most common diagnosis was a soft tissue injury alone that was seen in 60 (38%) patients imaged. Injuries to the gluteal muscle group, iliopsaos complex and trochanteric bursa were most prevalent. All patients with soft tissue injuries or fractures of the pelvis were successfully managed non-operatively. This study highlights a wide range of differential diagnoses in elderly patients presenting with acute traumatic hip pain. The proximal femur was frac- tured in 33% of patients imaged for OHFs in our series. The most common diagnosis was a soft tissue injury around the hip and pelvis ; these injuries can be successfully managed without surgery.

Differential diagnosis of acute traumatic hip pain in the elderly

Elderly patients who present with an inability to weight bear following a fall, with normal radiographs, should be appropriately investigated to rule out an occult hip fracture (OHF). We aim to identify both the range and incidence of the differential diagnosis of acute traumatic hip pain in a large series of patients investigated for OHF. A retrospective analysis of consecutive patients investigated for an OHF with magnetic resonance imaging (MRI) was performed. Dedicated musculo- skeletal radiologists reported the MRI scans. All diagnoses including hip fractures, other fractures and soft tissue injuries were recorded. Case notes were reviewed for all patients to identify subsequent complications, management and outcomes. A total of 157 patients fulfilled the inclusion criteria. 52 (33%) patients had a fracture of the proximal femur. The majority of patients with proximal femoral fractures required surgical intervention. 9 patients who had fractures of the greater trochanter of the femur without fracture extension across the femoral neck were managed non-operatively. 40 (25%) patients had fractures of the pelvis, with a combined pubic rami and sacral fracture occurring frequently. The most common diagnosis was a soft tissue injury alone that was seen in 60 (38%) patients imaged. Injuries to the gluteal muscle group, iliopsaos complex and trochanteric bursa were most prevalent. All patients with soft tissue injuries or fractures of the pelvis were successfully managed non-operatively. This study highlights a wide range of differential diagnoses in elderly patients presenting with acute traumatic hip pain. The proximal femur was fractured in 33% of patients imaged for OHFs in our series. The most common diagnosis was a soft tissue injury around the hip and pelvis ; these injuries can be successfully managed without surgery.

Is current body temperature measurement practice fit-for-purpose?

There has been a marked rise in the number of avoidable deaths in health services around the world. At the same time there has been a growing increase in antibiotic resistant so-called "superbugs." We examine here the potential role of body temperature measurement in these adverse trends. Electronic based thermometers have replaced traditional mercury (and other liquid-in-glass type) thermometers for reasons of safety rather than superiority. Electronic thermometers are in general less robust from a measurement perspective than their predecessors. We illustrate the implications of unreliable temperature measurement on the diagnosis and management of disease, including COVID-19, through statistical calculations. Since a return to mercury thermometers is both undesirable and impractical, we call for better governance in the current practice of clinical thermometry to ensure the traceability and long-term accuracy of electronic thermometers and discuss how this could be achieved.

Association between antihypertensive treatment and adverse events: systematic review and meta-analysis

OBJECTIVE

To examine the association between antihypertensive treatment and specific adverse events.

DESIGN

Systematic review and meta-analysis.

ELIGIBILITY CRITERIA

Randomised controlled trials of adults receiving antihypertensives compared with placebo or no treatment, more antihypertensive drugs compared with fewer antihypertensive drugs, or higher blood pressure targets compared with lower targets. To avoid small early phase trials, studies were required to have at least 650 patient years of follow-up.

INFORMATION SOURCES

Searches were conducted in Embase, Medline, CENTRAL, and the Science Citation Index databases from inception until 14 April 2020.

MAIN OUTCOME MEASURES

The primary outcome was falls during trial follow-up. Secondary outcomes were acute kidney injury, fractures, gout, hyperkalaemia, hypokalaemia, hypotension, and syncope. Additional outcomes related to death and major cardiovascular events were extracted. Risk of bias was assessed using the Cochrane risk of bias tool, and random effects meta-analysis was used to pool rate ratios, odds ratios, and hazard ratios across studies, allowing for between study heterogeneity (τ2).

RESULTS

Of 15 023 articles screened for inclusion, 58 randomised controlled trials were identified, including 280 638 participants followed up for a median of 3 (interquartile range 2-4) years. Most of the trials (n=40, 69%) had a low risk of bias. Among seven trials reporting data for falls, no evidence was found of an association with antihypertensive treatment (summary risk ratio 1.05, 95% confidence interval 0.89 to 1.24, τ2=0.009). Antihypertensives were associated with an increased risk of acute kidney injury (1.18, 95% confidence interval 1.01 to 1.39, τ2=0.037, n=15), hyperkalaemia (1.89, 1.56 to 2.30, τ2=0.122, n=26), hypotension (1.97, 1.67 to 2.32, τ2=0.132, n=35), and syncope (1.28, 1.03 to 1.59, τ2=0.050, n=16). The heterogeneity between studies assessing acute kidney injury and hyperkalaemia events was reduced when focusing on drugs that affect the renin angiotensin-aldosterone system. Results were robust to sensitivity analyses focusing on adverse events leading to withdrawal from each trial. Antihypertensive treatment was associated with a reduced risk of all cause mortality, cardiovascular death, and stroke, but not of myocardial infarction.

CONCLUSIONS

This meta-analysis found no evidence to suggest that antihypertensive treatment is associated with falls but found evidence of an association with mild (hyperkalaemia, hypotension) and severe adverse events (acute kidney injury, syncope). These data could be used to inform shared decision making between doctors and patients about initiation and continuation of antihypertensive treatment, especially in patients at high risk of harm because of previous adverse events or poor renal function.

REGISTRATION

PROSPERO CRD42018116860.

Deep medical image analysis with representation learning and neuromorphic computing

Deep learning is increasingly used in medical imaging, improving many steps of the processing chain, from acquisition to segmentation and anomaly detection to outcome prediction. Yet significant challenges remain: (i) image-based diagnosis depends on the spatial relationships between local patterns, something convolution and pooling often do not capture adequately; (ii) data augmentation, the de facto method for learning three-dimensional pose invariance, requires exponentially many points to achieve robust improvement; (iii) labelled medical images are much less abundant than unlabelled ones, especially for heterogeneous pathological cases; and (iv) scanning technologies such as magnetic resonance imaging can be slow and costly, generally without online learning abilities to focus on regions of clinical interest. To address these challenges, novel algorithmic and hardware approaches are needed for deep learning to reach its full potential in medical imaging.

Design, methods, and reporting of impact studies of cardiovascular clinical prediction rules are suboptimal: a systematic review

OBJECTIVES

To evaluate design, methods, and reporting of impact studies of cardiovascular clinical prediction rules (CPRs).

STUDY DESIGN AND SETTING

We conducted a systematic review. Impact studies of cardiovascular CPRs were identified by forward citation and electronic database searches. We categorized the design of impact studies as appropriate for randomized and nonrandomized experiments, excluding uncontrolled before-after study. For impact studies with appropriate study design, we assessed the quality of methods and reporting. We compared the quality of methods and reporting between impact and matched control studies.

RESULTS

We found 110 impact studies of cardiovascular CPRs. Of these, 65 (59.1%) used inappropriate designs. Of 45 impact studies with appropriate design, 31 (68.9%) had substantial risk of bias. Mean number of reporting domains that impact studies with appropriate study design adhered to was 10.2 of 21 domains (95% confidence interval, 9.3 and 11.1). The quality of methods and reporting was not clearly different between impact and matched control studies.

CONCLUSION

We found most impact studies either used inappropriate study design, had substantial risk of bias, or poorly complied with reporting guidelines. This appears to be a common feature of complex interventions. Users of CPRs should critically evaluate evidence showing the effectiveness of CPRs.

GPs' familiarity with and use of cardiovascular clinical prediction rules: a UK survey study

BACKGROUND

Clinical prediction rules (CPRs) can help general practitioners (GPs) address challenges in cardiovascular disease. A survey published in 2014 evaluated GPs' awareness and use of CPRs in the UK. However, many new CPRs have been published since and it is unknown which cardiovascular CPRs are currently recognised and used.

AIM

To identify cardiovascular CPRs recognised and used by GPs, and to assess how GPs' familiarity and use have changed over time.

DESIGN & SETTING

An online survey of GPs in the UK was undertaken.

METHOD

Using comparable methods to the 2014 survey, GPs were recruited from a network of doctors in the UK. They were asked how familiar they were with cardiovascular CPRs, how frequently they used them, and why they used them. The results were compared with the 2014 survey.

RESULTS

Most of 401 GPs were familiar with QRISK scores, ABCD scores, CHADS scores, HAS-BLED score, Wells scores for deep vein thrombosis, and Wells scores for pulmonary embolism. The proportions of GPs using these CPRs were 96.3%, 65.1%, 97.3%, 93.0%, 92.5%, and 82.0%, respectively. GPs' use increased by 31.2% for QRISK scores, by 13.5% for ABCD scores, by 54.6% for CHADS scores, by 33.2% for Wells scores for deep vein thrombosis, and by 43.6% for Wells scores for pulmonary embolism; and decreased by 45.9% for the Joint British Societies (JBS) risk calculator, by 38.7% for Framingham risk scores, and by 8.7% for New Zealand tables. GPs most commonly used cardiovascular CPRs to guide therapy and referral.

CONCLUSION

The study found GPs' familiarity and use of cardiovascular CPRs changed substantially. Integrating CPRs into guidelines and practice software might increase familiarity and use.

Orthodontists' preference on type of rigid fixed functional appliance for skeletal Class II correction: A survey study

Background

Rigid fixed functional appliances are most commonly used to correct skeletal Class II malocclusions. The objective of this study was to assess orthodontists' preference of different rigid fixed functional appliances used in the U.S.A for correction of skeletal Class II malocclusions.

Material and Methods

A survey on use and preference of rigid fixed functional appliances for skeletal Class II correction was emailed to 2,227 members of the American Association of Orthodontists (AAO) in the U.S.A. Frequency distribution of different responses and their association with demographic factors was assessed.

Results

Out of 140 orthodontists completing the survey, 110 responded as using rigid fixed functional appliances. Eight incomplete responses were eliminated from data analysis. 51.5% (68/132) orthodontists used rigid fixed functional appliances. The most preferred rigid fixed functional appliance was the Herbst appliance with 72% response followed by Mandibular Anterior Repositioning Appliance (24%) and AdvanSync (4%). There was no statistically significant difference in use of rigid fixed functional appliances between different age groups (p=0.284). However, the 40-54 age group used the most rigid fixed functional appliances in practice, followed by the 25-39 year age group and the 55-69 age group using these appliances the least. There was statistical significance between the type of practice setting one works in and the use of rigid fixed functional appliances in practice (p=0.022).

Conclusions

About 52% of orthodontists use rigid fixed functional appliances to correct skeletal Class II malocclusions. The Herbst appliance is the most commonly used and most preferred amongst all rigid fixed functional appliances with a 72% preferred rate. Key words:Orthodontic, Rigid fixed functional appliance, Skeletal Class II, Class II Malocclusion, Mandibular retrognathism, Herbst, Mandibular Anterior Repositioning Appliance (MARA), AdvanSync, Molar to molar, M2M.

Survey on awareness and preference of ceramic bracket debonding techniques among orthodontists

Background

The objectives of this study was to evaluate the awareness of different ceramic bracket debonding techniques among orthodontists in the USA and the most commonly used debonding technique for ceramic bracket removal.

Material and Methods

A survey on preference for debonding and awareness of debonding techniques was emailed to 2,227 members of the American Association of Orthodontists (AAO).

Results

119 orthodontists completed the survey. 111 responses were included in the study analysis of ceramic bracket users. The most common technique used was mechanical debonding. 86.5% used a specially designed bracket removing plier from the manufacturer. Overall, there were 59.5% of surveyed orthodontists who were aware of electrothermal debonding, 73% were unaware of ultrasonic debonding and 83.8% were unaware of laser debonding. There were more orthodontists with an affiliation with an academic institution aware of electrothermal debonding (p=0.002). There also was a trend of orthodontists having no affiliation with an institution who were unaware of laser debonding (p=0.015).

Conclusions

This survey showed that the majority of orthodontists who responded to the questionnaire were unaware of alternative debonding techniques of ceramic brackets. All orthodontists who use ceramic brackets utilized mechanical debonding technique.

Key words:Orthodontic ceramic brackets, mechanical, electrothermal, ultrasonic, laser debonding.

The effects of a UK lockdown on orthopaedic trauma admissions and surgical cases: A multicentre comparative study

Aims

The current global pandemic due to COVID-19 is generating significant burden on the health service in the UK. On 23 March 2020, the UK government issued requirements for a national lockdown. The aim of this multicentre study is to gain a greater understanding of the impact lockdown has had on the rates, mechanisms and types of injuries together with their management across a regional trauma service.

Methods

Data was collected from an adult major trauma centre, paediatric major trauma centre, district general hospital, and a regional hand trauma unit. Data collection included patient demographics, injury mechanism, injury type and treatment required. Time periods studied corresponded with the two weeks leading up to lockdown in the UK, two weeks during lockdown, and the same two-week period in 2019.

Results

There was a 55.7% (12,935 vs 5,733) reduction in total accident and emergency (A&E) attendances with a 53.7% (354 vs 164) reduction in trauma admissions during lockdown compared to 2019. The number of patients with fragility fractures requiring admission remained constant (32 patients in 2019 vs 31 patients during lockdown; p > 0.05). Road traffic collisions (57.1%, n = 8) were the commonest cause of major trauma admissions during lockdown. There was a significant increase in DIY related-hand injuries (26% (n = 13)) lockdown vs 8% (n = 11 in 2019, p = 0.006) during lockdown, which resulted in an increase in nerve injuries (12% (n = 6 in lockdown) vs 2.5% (n = 3 in 2019, p = 0.015) and hand infections (24% (n = 12) in lockdown vs 6.2% (n = 8) in 2019, p = 0.002).

Conclusion

The national lockdown has dramatically reduced orthopaedic trauma admissions. The incidence of fragility fractures requiring surgery has not changed. Appropriate provision in theatres should remain in place to ensure these patients can be managed as a surgical priority. DIY-related hand injuries have increased which has led to an increased in nerve injuries requiring intervention.

OP0187 DETERMINING OPTIMAL COOLING AND ADMINISTRATION METHODS FOR CNTX-4975 INTRA-ARTICULAR INJECTION IN SUBJECTS WITH MODERATE TO SEVERE OSTEOARTHRITIS KNEE PAIN

Background:

CNTX-4975 is a highly purified, synthetic capsaicin being developed to provide long-term analgesia after a single intra-articular (IA) injection for patients with moderate to severe osteoarthritis (OA) knee pain. CNTX-4975 IA administration is associated with short-term post-procedural pain that can be attenuated with preemptive joint cooling.

Objectives:

To evaluate cooling and administration procedures for CNTX-4975 IA injection, with goals of balancing patient comfort and ease of use and assessing clinical response 8 weeks after injection.

Methods:

This phase 3, open-label, 8-week study (NCT03661996) enrolled subjects aged 40–95 y with Kellgren-Lawrence grade 1–4, BMI ≤45 kg/m2, and stable, moderate to severe OA knee pain and who failed ≥2 therapies. Subjects were assigned to unilateral/bilateral CNTX-4975 1 mg IA injections as determined by OA pain/joint replacement status, then randomized by study site to 1 of 5 treatment regimens (Figure). The primary outcome measure assessed Breg cooling control vs other cooling regimens on day 1 using a combined sum of 1) pain (0, none; 4, severe) 30 minutes after CNTX-4975 injection; 2) subject satisfaction (SS) with cooling/injection procedures; and 3) investigator satisfaction (IS) with procedures. SS and IS were measured on a 1–7 scale (1, completely dissatisfied; 7, completely satisfied); pain was reverse scored and normalized (1, severe; 7, none) for equal weighting. Geometric mean ratios (GMR) with 95% CIs were constructed for each regimen vs Breg control (ANCOVA); lower 95% CI >0.7 was considered clinically acceptable. Secondary endpoints included percentage of subjects by subject type meeting criteria for Outcome Measures in Rheumatology-Osteoarthritis Research Society International (OMERACT-OARSI) responders 8 weeks after injection. Safety assessments included TEAEs.

Results:

The intent-to-treat population included 848 subjects. The primary combined outcome showed that all cooling and administration regimens were clinically acceptable, with the evaluated cold gel wraps being at least as effective as the Breg circulating ice-water wrap (Table). For subjects with unilateral OA, OMERACT-OARSI response rates were 67% in those with no/mild nonindex knee pain and 81% in those with nonindex knee single joint replacement. For subjects with bilateral knee OA receiving bilateral injections, response rates for index and nonindex knees were 73% and 79%. TEAEs were reported in 22% of subjects; <1% were serious. TEAEs occurring in >2% of subjects were procedural pain (2.9%), arthralgia (2.2%), and nausea (2.1%), with no meaningful differences across groups.

Conclusion:

All cooling regimens for CNTX-4975 IA administration were clinically acceptable and well tolerated, offering feasible options for use in routine practice. Importantly, high levels of clinical response were observed 8 weeks after unilateral or bilateral knee injections for moderate to severe OA knee pain.

Primary Combined Endpoint Outcome in the Index Knee, Normalized Scale, by Cooling and Administration Procedure (ANCOVA Model)

Breg Cooling ControlN=162Gel Pack CoolingN=179Shortened Gel Pack CoolingN=175Single Needle Injection,Gel Pack Cooling,2% LidocaineN=160Single Needle Injection,Gel Pack Cooling,1% LidocaineN=172Mean (SD)17.23 (2.660)18.23 (2.023)16.81 (2.891)17.57 (3.049)16.43 (3.138)Geometric LS Mean (SE)17.18 (1.016)18.26 (1.015)16.48 (1.016)17.40 (1.016)16.00 (1.015)95% CI16.66, 17.7217.74, 18.8015.99, 16.9916.87, 17.9515.53, 16.49Comparison vs Breg CoolingGMR (SE)1.06 (1.022)0.96 (1.022)1.01 (1.022)0.93 (1.022)95% CI1.02, 1.110.92, 1.000.97, 1.060.89, 0.97Clinically Acceptable?YesYesYesYes

LS, least squares; SD, standard deviation; SE, standard error.

GMR lower 95% CI >0.7 considered clinically equivalent.

Disclosure of Interests:

Randall Stevens Shareholder of: Centrexion Therapeutics Corp, Employee of: Centrexion Therapeutics Corp, Peter Hanson Shareholder of: Centrexion Therapeutics Corp, Employee of: Centrexion Therapeutics Corp, Paul Tiseo Employee of: Centrexion Therapeutics Corp, Kimberly Guedes Shareholder of: Centrexion Therapeutics Corp, Employee of: Centrexion Therapeutics Corp, James Campbell Shareholder of: Centrexion Therapeutics Corp, Employee of: Centrexion Therapeutics Corp, James Connolly Employee of: Centrexion Therapeutics Corp, Stephanie Ruggiero Employee of: Centrexion Therapeutics Corp, Meg Corliss Employee of: Centrexion Therapeutics Corp, Valerie Smith Consultant of: Centrexion Therapeutics Corp, Philip G Conaghan Consultant of: AbbVie, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, GSK, Novartis, Pfizer, Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer

Community-based active case-finding to reach the most vulnerable: tuberculosis in tribal areas of India

<sec> <title>BACKGROUND</title> India has the world's largest indigenous/tribal population. Many areas with large tribal populations suffer from weak infrastructure and services. Surveys have shown a high prevalence of TB among Saharia communities, who rarely access public services. We evaluated a community-based active TB case-finding intervention. </sec> <sec> <title>METHODS</title> Community health workers screened people for TB symptoms in Saharia communities, made referrals, collected sputum for transport to laboratories, and initiated and supported anti-tuberculosis treatment. Microscopy testing was performed at government laboratories. The intervention tracked the people screened, referrals, the people tested, laboratory results, treatment initiation and outcomes. </sec> <sec> <title>RESULTS</title> Community health workers verbally screened 65 230 people, 8723 (13%) of whom had symptoms. Of these, 5600 were tested, 964 (17%) of whom were smear-positive. During the intervention, we observed a +52% increase in people tested at laboratories and an +84% increase in TB case notifications. Pre-treatment loss to follow-up decreased and treatment success increased slightly. </sec> <sec> <title>CONCLUSIONS</title> In India, particularly among tribal populations, many people with TB are missed by current approaches due to poor access. Community-based active case-finding can help identify more people with TB in tribal and remote rural areas by addressing barriers to health seeking as well as help reach ambitious country and global notification targets. </sec>.

Self-monitoring of Blood Pressure in Patients With Hypertension-Related Multi-morbidity: Systematic Review and Individual Patient Data Meta-analysis

BACKGROUND

Studies have shown that self-monitoring of blood pressure (BP) is effective when combined with co-interventions, but its efficacy varies in the presence of some co-morbidities. This study examined whether self-monitoring can reduce clinic BP in patients with hypertension-related co-morbidity.

METHODS

A systematic review was conducted of articles published in Medline, Embase, and the Cochrane Library up to January 2018. Randomized controlled trials of self-monitoring of BP were selected and individual patient data (IPD) were requested. Contributing studies were prospectively categorized by whether they examined a low/high-intensity co-intervention. Change in BP and likelihood of uncontrolled BP at 12 months were examined according to number and type of hypertension-related co-morbidity in a one-stage IPD meta-analysis.

RESULTS

A total of 22 trials were eligible, 16 of which were able to provide IPD for the primary outcome, including 6,522 (89%) participants with follow-up data. Self-monitoring was associated with reduced clinic systolic BP compared to usual care at 12-month follow-up, regardless of the number of hypertension-related co-morbidities (−3.12 mm Hg, [95% confidence intervals −4.78, −1.46 mm Hg]; P value for interaction with number of morbidities = 0.260). Intense interventions were more effective than low-intensity interventions in patients with obesity (P < 0.001 for all outcomes), and possibly stroke (P < 0.004 for BP control outcome only), but this effect was not observed in patients with coronary heart disease, diabetes, or chronic kidney disease.

CONCLUSIONS

Self-monitoring lowers BP regardless of the number of hypertension-related co-morbidities, but may only be effective in conditions such obesity or stroke when combined with high-intensity co-interventions.

Determination of Lead in Wine by Graphite Furnace Atomic Absorption Spectrophotometry: Interlaboratory Study

An interlaboratory study of a graphite furnace atomic absorption spectrophotometry (GFAAS) method for the determination of lead in wine was conducted. Seventeen laboratories from France, United States, and the United Kingdom, using a variety of GFAAS instruments, took part in the study. The method incorporated a novel matrix-matching procedure to minimize matrix effects between standards and samples. Six wine test materials were prepared and sent to participants as 12 blind duplicate or split level samples. There was good agreement between results obtained from participants and target values (24–279 μg/L) obtained with an inductively coupled plasma-mass spectrometry method. The precision of the GFAAS method was well within the range predicted by the Horwitz equation for the 6 test materials analyzed. Repeatability standard deviations ranged from 3 to 17%. Reproducibility standard deviations were in the range of 10 to 30%. The method is recommended for use for official purposes.

Comparison of Complication and Reoperation Rates for Minimally Invasive Versus Open Cheilectomy of the First Metatarsophalangeal Joint

BACKGROUND

Dorsal cheilectomy of the first metatarsophalangeal joint is an accepted treatment to alleviate dorsal impingement, pain, and reduced dorsiflexion in hallux rigidus. Traditionally performed via an open incision, this procedure has more recently been performed using minimally invasive techniques despite limited supportive published evidence.

METHODS

From December 2012 through December 2017, a retrospective analysis of all cheilectomies performed in our institution was done. The surgical technique was recorded along with any subsequent procedures performed for either persistent or recurrent pain, and complications were also noted. A comparison between open and minimally invasive outcomes was performed. In total, 171 cheilectomies were performed during this period. There were 38 open and 133 minimally invasive procedures.

RESULTS

At a mean 3-year follow-up, the reoperation rates of the 2 groups were different with only 1 (2.6%) of the open group requiring a fusion, while 17 (12.8%) of the minimally invasive surgical (MIS) group required further surgery (relative risk, 4.86; P = .059). In the open group, there was 1 (2.6%) complication, compared with 15 (11.3%) in the minimally invasive group (relative risk, 4.29; P = .076).

CONCLUSION

While patients may opt for MIS cheilectomy with a proposed faster recovery time and better cosmesis, they should be counseled about the risks and benefits of both methods, and that the technique of MIS cheilectomy utilized in this study appears to have an increased relative risk of requiring a further procedure.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Identification and characterization of an IgG sequence variant with an 11 kDa heavy chain C-terminal extension using a combination of mass spectrometry and high-throughput sequencing analysis

Protein primary structure is a potential critical quality attribute for biotherapeutics. Identifying and characterizing any sequence variants present is essential for product development. A sequence variant ~11 kDa larger than the expected IgG mass was observed by size-exclusion chromatography and two-dimensional liquid chromatography coupled with online mass spectrometry. Further characterization indicated that the 11 kDa was added to the heavy chain (HC) Fc domain. Despite the relatively large mass addition, only one unknown peptide was detected by peptide mapping. To decipher the sequence, the transcriptome of the manufacturing cell line was characterized by Illumina RNA-seq. Transcriptome reconstruction detected an aberrant fusion transcript, where the light chain (LC) constant domain sequence was fused to the 3ʹ end of the HC transcript. Translation of this fusion transcript generated an extended peptide sequence at the HC C-terminus corresponding to the observed 11 kDa mass addition. Nanopore-based genome sequencing showed multiple copies of the plasmid had integrated in tandem with one copy missing the 5ʹ end of the plasmid, deleting the LC variable domain. The fusion transcript was due to read-through of the HC terminator sequence into the adjacent partial LC gene and an unexpected splicing event between a cryptic splice-donor site at the 3ʹ end of the HC and the splice acceptor site at the 5ʹ end of the LC constant domain. Our study demonstrates that combining protein physicochemical characterization with genomic and transcriptomic analysis of the manufacturing cell line greatly improves the identification of sequence variants and understanding of the underlying molecular mechanisms.

Trends in kidney function testing in UK primary care since the introduction of the quality and outcomes framework: a retrospective cohort study using CPRD

OBJECTIVES

To characterise serum creatinine and urinary protein testing in UK general practices from 2005 to 2013 and to examine how the frequency of testing varies across demographic factors, with the presence of chronic conditions and with the prescribing of drugs for which kidney function monitoring is recommended.

DESIGN

Retrospective open cohort study.

SETTING

Routinely collected data from 630 UK general practices contributing to the Clinical Practice Research Datalink.

PARTICIPANTS

4 573 275 patients aged over 18 years registered at up-to-standard practices between 1 April 2005 and 31 March 2013. At study entry, no patients were kidney transplant donors or recipients, pregnant or on dialysis.

PRIMARY OUTCOME MEASURES

The rate of serum creatinine and urinary protein testing per year and the percentage of patients with isolated and repeated testing per year.

RESULTS

The rate of serum creatinine testing increased linearly across all age groups. The rate of proteinuria testing increased sharply in the 2009-2010 financial year but only for patients aged 60 years or over. For patients with established chronic kidney disease (CKD), creatinine testing increased rapidly in 2006-2007 and 2007-2008, and proteinuria testing in 2009-2010, reflecting the introduction of Quality and Outcomes Framework indicators. In adjusted analyses, CKD Read codes were associated with up to a twofold increase in the rate of serum creatinine testing, while other chronic conditions and potentially nephrotoxic drugs were associated with up to a sixfold increase. Regional variation in serum creatinine testing reflected country boundaries.

CONCLUSIONS

Over a nine-year period, there have been increases in the numbers of patients having kidney function tests annually and in the frequency of testing. Changes in the recommended management of CKD in primary care were the primary determinant, and increases persist even after controlling for demographic and patient-level factors. Future studies should address whether increased testing has led to better outcomes.

Schedules for Self-monitoring Blood Pressure: A Systematic Review

BACKGROUND

Self-monitoring of blood pressure better predicts prognosis than clinic measurement, is popular with patients, and endorsed in hypertension guidelines. However, there is uncertainty over the optimal self-monitoring schedule. We therefore aimed to determine the optimum schedule to predict future cardiovascular events and determine “true” underlying blood pressure.

METHODS

Six electronic databases were searched from November 2009 (updating a National Institute for Health and Care Excellence [NICE] systematic review) to April 2017. Studies that compared aspects of self-monitoring schedules to either prognosis or reliability/reproducibility in hypertensive adults were included. Data on study and population characteristics, self-monitoring regime, and outcomes were extracted by 2 reviewers independently.

RESULTS

From 5,164 unique articles identified, 25 met the inclusion criteria. Twelve studies were included from the original NICE review, making a total of 37 studies. Increasing the number of days of measurement improved prognostic power: 72%–91% of the theoretical maximum predictive value (asymptotic maximum hazard ratio) was reached by 3 days and 86%–96% by 7 days. Increasing beyond 3 days of measurement did not result in better correlation with ambulatory monitoring. There was no convincing evidence that the timing or number of readings per day had an effect, or that ignoring the first day’s measurement was necessary.

CONCLUSIONS

Home blood pressure should be measured for 3 days, increased to 7 only when mean blood pressure is close to a diagnostic or treatment threshold. Other aspects of a monitoring schedule can be flexible to facilitate patient uptake of and adherence with self-monitoring.

Benefits and Harms of Antihypertensive Treatment in Low-Risk Patients With Mild Hypertension

Importance

Evidence to support initiation of pharmacologic treatment in low-risk patients with mild hypertension is inconclusive, with previous trials underpowered to demonstrate benefit. Clinical guidelines across the world are contradictory.

Objective

To examine whether antihypertensive treatment is associated with a low risk of mortality and cardiovascular disease (CVD) in low-risk patients with mild hypertension.

Design, Setting, and Participants

In this longitudinal cohort study, data were extracted from the Clinical Practice Research Datalink, from January 1, 1998, through September 30, 2015, for patients aged 18 to 74 years who had mild hypertension (untreated blood pressure of 140/90-159/99 mm Hg) and no previous treatment. Anyone with a history of CVD or CVD risk factors was excluded. Patients exited the cohort if follow-up records became unavailable or they experienced an outcome of interest.

Exposures

Prescription of antihypertensive medication. Propensity scores for likelihood of treatment were constructed using a logistic regression model. Individuals treated within 12 months of diagnosis were matched to untreated patients by propensity score using the nearest-neighbor method.

Main Outcomes and Measures

The rates of mortality, CVD, and adverse events among patients prescribed antihypertensive treatment at baseline, compared with those who were not prescribed such treatment, using Cox proportional hazards regression.

Results

A total of 19 143 treated patients (mean [SD] age, 54.7 [11.8] years; 10 705 [55.9%] women; 10 629 [55.5%] white) were matched to 19 143 similar untreated patients (mean [SD] age, 54.9 [12.2] years; 10 631 [55.5%] female; 10 654 [55.7%] white). During a median follow-up period of 5.8 years (interquartile range, 2.6-9.0 years), no evidence of an association was found between antihypertensive treatment and mortality (hazard ratio [HR], 1.02; 95% CI, 0.88-1.17) or between antihypertensive treatment and CVD (HR, 1.09; 95% CI, 0.95-1.25). Treatment was associated with an increased risk of adverse events, including hypotension (HR, 1.69; 95% CI, 1.30-2.20; number needed to harm at 10 years [NNH10], 41), syncope (HR, 1.28; 95% CI, 1.10-1.50; NNH10, 35), electrolyte abnormalities (HR, 1.72; 95% CI, 1.12-2.65; NNH10, 111), and acute kidney injury (HR, 1.37; 95% CI, 1.00-1.88; NNH10, 91).

Conclusions and Relevance

This prespecified analysis found no evidence to support guideline recommendations that encourage initiation of treatment in patients with low-risk mild hypertension. There was evidence of an increased risk of adverse events, which suggests that physicians should exercise caution when following guidelines that generalize findings from trials conducted in high-risk individuals to those at lower risk.

Human Alzheimer's disease gene expression signatures and immune profile in APP mouse models: a discrete transcriptomic view of Aβ plaque pathology

Background

Alzheimer’s disease (AD) is a chronic neurodegenerative disease with pathological hallmarks including the formation of extracellular aggregates of amyloid-beta (Aβ) known as plaques and intracellular tau tangles. Coincident with the formation of Aβ plaques is recruitment and activation of glial cells to the plaque forming a plaque niche. In addition to histological data showing the formation of the niche, AD genetic studies have added to the growing appreciation of how dysfunctional glia pathways drive neuropathology, with emphasis on microglia pathways. Genomic approaches enable comparisons of human disease profiles between different mouse models informing on their utility to evaluate secondary changes to triggers such as Aβ deposition.

Methods

In this study, we utilized two animal models of AD to examine and characterize the AD-associated pathology: the Tg2576 Swedish APP (KM670/671NL) and TgCRND8 Swedish plus Indiana APP (KM670/671NL + V717F) lines. We used laser capture microscopy (LCM) to isolate samples surrounding Thio-S positive plaques from distal non-plaque tissue. These samples were then analyzed using RNA sequencing.

Results

We determined age-associated transcriptomic differences between two similar yet distinct APP transgenic mouse models, known to differ in proportional amyloidogenic species and plaque deposition rates. In Tg2576, human AD gene signatures were not observed despite profiling mice out to 15 months of age. TgCRND8 mice however showed progressive and robust induction of lysomal, neuroimmune, and ITIM/ITAM-associated gene signatures overlapping with prior human AD brain transcriptomic studies. Notably, RNAseq analyses highlighted the vast majority of transcriptional changes observed in aging TgCRND8 cortical brain homogenates were in fact specifically enriched within the plaque niche samples. Data uncovered plaque-associated enrichment of microglia-related genes such as ITIM/ITAM-associated genes and pathway markers of phagocytosis.

Conclusion

This work may help guide improved translational value of APP mouse models of AD, particularly for strategies aimed at targeting neuroimmune and neurodegenerative pathways, by demonstrating that TgCRND8 more closely recapitulates specific human AD-associated transcriptional responses.

Electronic supplementary material

The online version of this article (10.1186/s12974-018-1265-7) contains supplementary material, which is available to authorized users.