The impact of the Covid-19 pandemic on postnatal anxiety and posttraumatic stress: Analysis of two population-based national maternity surveys in England

BACKGROUND

Few studies have evaluated postnatal anxiety and posttraumatic stress (PTS) before and during the Covid-19 pandemic using comparable data across time. We used data from two national maternity surveys in England to explore the impact of the pandemic on prevalence and risk factors for postnatal anxiety and PTS.

METHODS

Analysis was conducted using population-based surveys carried out in 2018 (n = 4509) and 2020 (n = 4611). Weighted prevalence estimates for postnatal anxiety and PTS were compared across surveys. Adjusted risk ratios (aRR) were estimated for the association between risk factors and postnatal anxiety and PTS.

FINDINGS

Prevalence of postnatal anxiety increased from 13.7 % in 2018 to 15.1 % in 2020 (+1.4 %(95%CI:-0.4-3.1)). Prevalence of postnatal PTS increased from 9.7 % in 2018 to 11.5 % in 2020 (+1.8 %(95%CI:0.3-3.4)), due to an increase in PTS related to birth trauma from 2.5 % to 4.3 % (+1.8 %(95%CI:0.9-2.6); there was no increase in PTS related to non-birth trauma. Younger age (aRR = 1.31-1.51), being born in the UK (aRR = 1.29-1.59), long-term physical or mental health problem(s) (aRR = 1.27-1.94), and antenatal anxiety (aRR = 1.97-2.22) were associated with increased risk of postnatal anxiety and PTS before and during the pandemic, whereas higher satisfaction with birth (aRR = 0.92-0.94) and social support (aRR = 0.81-0.82) were associated with decreased risk.

INTERPRETATION

Prevalence of postnatal PTS was significantly higher during the pandemic, compared to before the pandemic, due to an increase in PTS related to birth trauma. Prevalence of postnatal anxiety was not significantly higher during the pandemic. Risk factors for postnatal anxiety and PTS were similar before and during the pandemic.

The Nitrous Oxide Project: assessment of advocacy and national directives to deliver mitigation of anaesthetic nitrous oxide

The environmental emissions attributed to anaesthetic nitrous oxide across the NHS are comparable to the carbon dioxide released by 135,000 flights from Frankfurt to New York. Much of these emissions are attributable to cumbersome and inadequately managed piped systems, resulting in excessive loss and waste. Since 2020, multiple hospital sites have been engaging with the Nitrous Oxide Project, a quality improvement method supporting a 'lean systems' approach to the provision of nitrous oxide. This review considers the frameworks supporting medical gas management in UK healthcare systems, and the impact of professional advocacy and medical gas stewardship to drive anaesthetic nitrous oxide mitigation in the NHS. Nitrous oxide mitigation efforts by grassroots and professional advocacy networks are enhanced through national centralised emission monitoring, distribution of data, technical information and provision of quality analysis. Given the climate harms of nitrous oxide, concerted efforts should be made to rationalise its use, and resources should be committed to supporting this at local, regional and national levels.

Polygamous Interest in a Mononormative Nation: The Roles of Sex and Sociosexuality in Polygamous Interest in a Heterosexual Sample from the UK

Polygamy is a form of "one-sided" consensually non-monogamous relationship where one person has multiple committed partners, each of whom is only involved with that one person. It was likely a reoccurring feature of ancestral mating that posed adaptive problems for our ancestors. Yet polygamy, and multi-partnering more generally, is understudied in Western cultures, raising questions about the existence of polygamous interest and whether this is calibrated adaptively to personal conditions. In two studies, we examined polygamous interest in two heterosexual online samples from the UK. In Study 1 (N = 393), modest interest was found for polygamous relationships overall. Men were six times more open to polygyny than women, but there was little sex difference in openness to polyandry. Further analysis revealed that all forms of multi-partnering were undesirable relative to singlehood and monogamy; however, consensual multi-partner relationships were less undesirable than non-consensual ones. Sex differences were largest for polygyny and arrangements where men had agreed access to a casual partner alongside a committed one, yet these were two of the most acceptable forms of multi-partnering when men and women's responses were combined. Sociosexuality positively predicted interest in most forms of multi-partnering. Study 2 (N = 735) focused on polygyny and added status-linked traits as predictors. The results of Study 1 were broadly replicated, though the status-linked traits did not predict polygynous interest specifically. Instead, sociosexuality and male intrasexual competitiveness uniquely predicted general interest in multi-partner relationships. Overall, interest in polygamy appears to emerge despite social discouragement and sex differences in interest track the relative costs and benefits associated with it. However, there is no strong evidence that polygamous interest is uniquely calibrated to personal conditions when compared to other forms of multi-partnering.

Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy.

METHODS

For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU.

FINDINGS

For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier.

INTERPRETATION

Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes.

FUNDING

British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

Stroke-heart syndrome: sex-specific incidence, risk factors, and major adverse cardiovascular events in 486,515 patients with incident ischaemic stroke

Background

Newly diagnosed cardiovascular complications post-stroke, termed stroke-heart syndrome, are common and associate with worsened prognosis.

Purpose

To investigate the sex-specific incidence and 5-year major adverse cardiovascular events following stroke-heart syndrome, stratified by pre-existing risk factors (sex, age, obesity, hypertension, type 2 diabetes mellitus, and high LDL cholesterol).

Methods

A retrospective cohort study was conducted using anonymised electronic medical records from 56 participating healthcare organizations. Patients with incident ischaemic stroke aged ≥18 years with 5-years of follow-up were included. Patients diagnosed with new-onset cardiovascular complications (heart failure, severe ventricular arrhythmia, atrial fibrillation, ischaemic heart disease, takotsubo syndrome) within 4-weeks of incident ischaemic stroke (exposure) were 1:1 propensity score-matched (age, sex, ethnicity, comorbidities, cardiovascular care) with ischaemic stroke patients without newly diagnosed cardiovascular complications (control). Cox proportional hazards regression models produced hazard ratios (HR) with 95% confidence intervals (CIs) and Kaplan-Meier curves for 5-year risk of all-cause mortality, recurrent stroke, and acute myocardial infarction (AMI).

Results

Of 486,515 patients with ischaemic stroke, 18% (n=87,786) presented with stroke-heart syndrome (47% (n=41,088) female and 52% (n=45,891) male). Following propensity score matching, composite stroke-heart syndrome associated with significantly higher risk of 5-year mortality (HR 1.66 (95% CI 1.62,1.70), P<0.01), recurrent stroke (1.26 (1.24,1.28), P<0.01), and AMI (2.58 (2.50,2.67), P<0.01). These outcomes were similar for both males and females (Figure 1). The risk of mortality, recurrent stroke and AMI following stroke-heart syndrome was relatively higher for patients aged <75 compared to those >75. The risk of all adverse outcomes were relatively higher for females aged <75 compared to males aged <75. Pre-existing obesity associated with a lower risk of mortality for females and males, but a higher risk of recurrent stroke for females. Pre-existing hypertension associated with a lower risk of all outcomes, except recurrent stroke in males. Pre-existing diabetes associated with higher risks for mortality and AMI for both females and males. High LDL cholesterol associated with lower risk of mortality but a higher risk of recurrent stroke and AMI in males and females (Figure 1).

Conclusions

In this cohort study of patients with incident ischaemic stroke, stroke-heart syndrome occurred in 18% of patients. The overall incidence and subsequent 5-year major adverse cardiovascular events following stroke-heart syndrome were similar for females and males, but with important sex-specific differences when stratified by pre-existing risk factors, including age, obesity, and hypertension.

Funding Acknowledgement

Type of funding sources: None.

Rock glaciers represent hidden water stores in the Himalaya

In the high mountains of Asia, ongoing glacier retreat threatens human and ecological systems through reduced water availability. Rock glaciers are climatically more resistant than glaciers and contain valuable water volume equivalents (WVEQ). Across High Mountain Asia (HMA) the WVEQ of rock glaciers is poorly quantified, and thus their hydrological significance versus glaciers is unknown. Here we present the first systematic assessment of Himalayan rock glaciers, totalling ~25,000 landforms with an areal coverage of ~3747 km². We calculate the WVEQ of Himalayan rock glaciers to be 51.80 ± 10.36 km³. Their comparative importance versus glaciers (rock glacier: glacier WVEQ ratio) is 1:25, which means that they constitute hydrologically valuable long-term water stores. In the context of climate-driven glacier recession, their relative hydrological value will likely increase. These cryospheric stores should be included in future scenario modelling to understand their role in sustainable water management for HMA.

Improved Constraints on Primordial Gravitational Waves using Planck, WMAP, and BICEP/Keck Observations through the 2018 Observing Season

We present results from an analysis of all data taken by the BICEP2, Keck Array, and BICEP3 CMB polarization experiments up to and including the 2018 observing season. We add additional Keck Array observations at 220 GHz and BICEP3 observations at 95 GHz to the previous 95/150/220  GHz dataset. The Q/U maps now reach depths of 2.8, 2.8, and 8.8  μK_{CMB} arcmin at 95, 150, and 220 GHz, respectively, over an effective area of ≈600 square degrees at 95 GHz and ≈400 square degrees at 150 and 220 GHz. The 220 GHz maps now achieve a signal-to-noise ratio on polarized dust emission exceeding that of Planck at 353 GHz. We take auto- and cross-spectra between these maps and publicly available WMAP and Planck maps at frequencies from 23 to 353 GHz and evaluate the joint likelihood of the spectra versus a multicomponent model of lensed ΛCDM+r+dust+synchrotron+noise. The foreground model has seven parameters, and no longer requires a prior on the frequency spectral index of the dust emission taken from measurements on other regions of the sky. This model is an adequate description of the data at the current noise levels. The likelihood analysis yields the constraint r_{0.05}<0.036 at 95% confidence. Running maximum likelihood search on simulations we obtain unbiased results and find that σ(r)=0.009. These are the strongest constraints to date on primordial gravitational waves.

Discharging patients; does it need to be done by a doctor?

Funding Acknowledgements

None

Background

Patients undergoing angiography and percutaneous coronary intervention (PCI) were historically reviewed post procedure by a member of the medical team who assesses the patient’s suitability for discharge and completes the discharge letter. Over the past 10 years, the number of patients admitted for these procedures as day cases has increased significantly. In addition, there has been an expansion in nursing roles in the UK with the development of a variety of clinical nurse specialist (CNS) posts which have taken over many of the traditional medical roles.

The majority of patients undergoing elective angiography and PCI are admitted to a day case unit at this tertiary cardiac centre. There is no designated medical cover for the unit and medical staff from the acute cardiac unit are called to review patients and complete their discharge paperwork in addition to their other duties. This frequently results in delayed discharge and patients going home without a discharge summary.

It was therefore proposed that suitably qualified CNSs could be trained to discharge these patients and others undergoing day case cardiology procedures.  From June 2017, the CNS team took over the role of reviewing patients post procedure and completing the discharge letter.

Purpose

The aim of the study was to evaluate if CNSs were able to discharge patients and provide a timely and effective service following elective cardiology procedures and to obtain patient feedback.

Method

Data on the number of patients reviewed by the CNSs from June 2017 to the end of December 2019, were prospectively collected in a dedicated database. A pilot study of patient experience was carried out in January 2020. Patients were given a questionnaire which asked about the explanation they received from the CNS regarding the procedure they had undergone, if their medication was reviewed and discussed with them, and if they received a discharge summary to take home.

Results

1287 patients were reviewed by the CNS team during the above period. 811 (63.0%) patients had undergone angiography and 423 (32.9%) PCI.  Informal feedback from the staff working on the day case unit included that patients were discharged earlier, had improved knowledge about their procedure and that the discharge letter was more detailed when completed by the CNS team.

Eight patients completed the pilot questionnaire. Six were discharged by one of the CNS team, one by a doctor and one patient was not sure who did their discharge. All patients were very satisfied with the process and the information they were given.

Conclusion

Experienced CNSs can deliver high-quality, timely discharge of patients following cardiology procedures.  This process is being used as a template to expand nurse-led discharge to other areas in cardiology. Patient experience will continue to be audited with a larger sample size in 2020.

Manipulating the sensation of feeling fat: The role of alexithymia, interoceptive sensibility and perfectionism

OBJECTIVE

Feeling fat reflects difficulties in processing emotions and is an important aspect of body image and eating disorders. The current study aimed to develop a novel social comparison manipulation to induce feeling fat and to explore personality traits that may increase an individual's vulnerability.

METHODS

At time 1254 healthy females (24.14 years, BMI = 23.77) completed the feeling fat subscale of the Body Attitudes Questionnaire, as well as self-report measures of alexithymia, interoceptive sensibility, physical appearance comparison and perfectionism online.

RESULTS

Greater tendency to feel fat was significantly associated with difficulty identifying and describing feelings (alexithymia), poorer interoceptive sensibility, higher socially-prescribed perfectionism, and greater engagement in physical appearance comparisons. At time 2, a subset of 107 participants (22.39 years, BMI = 23.85) were randomly assigned to a condition: negative social comparison, positive social comparison, negative general, or neutral (as a control). Participants in the negative social comparison condition reported significantly greater increases in feeling fat compared to the control condition, but only when they were also high in alexithymia or socially-prescribed perfectionism.

DISCUSSION

Current findings provide new insights into the potential mechanisms underpinning feeling fat and highlight how a novel social comparison manipulation can be used to induce the sensation of feeling fat.

A massive rock and ice avalanche caused the 2021 disaster at Chamoli, Indian Himalaya

On 7 February 2021, a catastrophic mass flow descended the Ronti Gad, Rishiganga, and Dhauliganga valleys in Chamoli, Uttarakhand, India, causing widespread devastation and severely damaging two hydropower projects. More than 200 people were killed or are missing. Our analysis of satellite imagery, seismic records, numerical model results, and eyewitness videos reveals that ~27 × 10⁶ cubic meters of rock and glacier ice collapsed from the steep north face of Ronti Peak. The rock and ice avalanche rapidly transformed into an extraordinarily large and mobile debris flow that transported boulders greater than 20 meters in diameter and scoured the valley walls up to 220 meters above the valley floor. The intersection of the hazard cascade with downvalley infrastructure resulted in a disaster, which highlights key questions about adequate monitoring and sustainable development in the Himalaya as well as other remote, high-mountain environments.

The quality of e-fit notes issued in secondary care

BACKGROUND

Few data are available on the pattern of use of fit notes issued in secondary care settings.

AIMS

To evaluate the pattern and quality of e-fit notes issued in an NHS Trust.

METHODS

Anonymized data on patients admitted to Guy's and St Thomas' NHS Foundation Trust (London, UK) who had an e-fit note issued from 1 January to 31 August 2017 were analysed using descriptive statistical methods. Thematic analysis was used to group the free-text comments into distinct categories and themes.

RESULTS

A total of 815 fit notes were issued during the study period. A total of 659 (81%) fit notes advised that patients were 'not fit' for work, whilst 156 (19%) advised that they 'may be fit' for work. The specialty with the highest proportion of patients assessed as may be fit was plastic surgery 46/104 (44%), whilst the lowest was ear, nose and throat surgery 0/57 (0%). The majority 151/156 (97%) of fit notes which advised that patients may be fit for work used the tick-box sections on the fit note to recommend work modifications. Of the free-text comments in section 4 of the 'may be fit' e-fit notes issued, 91/114 (80%) were related to the functional ability of patients.

CONCLUSIONS

Our study suggests that doctors in secondary care are more willing to use the 'may be fit' option on the fit note than primary care practitioners. Most fit notes, which advised that a patient may be fit for work, suggested workplace modifications.

Impact on outcomes in Europe: a cluster analysis from the ESC-EHRA EORP AF general long-term registry

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

ESC-EHRA EORP AF General Long-Term Registry Investigators

Introduction

Data derived from recent observational studies in atrial fibrillation (AF) show how the complexity of the clinical phenotype, beyond baseline thromboembolic risk, can increase risk of major adverse outcomes. Importantly, risk factors tend to occur in clusters, rather than occur individually in isolation.

Aims

To describe AF patients’ clinical phenotypes among a large contemporary European AF cohort and to analyse the differential impact of these clinical phenotypes on the occurrence of major adverse outcomes.

Methods

We performed a hierarchical cluster analysis based on Ward’s Method and using Squared Euclidean Distance using 22 clinical covariates. All variables were considered as binary. Examining the distances between cluster coefficients and by visual inspection of the dendrogram produced we identified the optimal number of clusters. Patients with data available for all 22 variables were included. We considered occurrence of cardiovascular events and all-cause death.

Results

Among the original 11096 patients included, 9363 (84.4%) were available for this analysis. The cluster analysis identified three clusters: Cluster 1 (n = 3634; 38.8%) characterized by older patients with prevalent noncardiac comorbidities; Cluster 2 (n = 2774; 29.6%) characterized by younger patients mainly admitted for first detected and paroxysmal AF with low prevalence of concomitant conditions; Cluster 3 (n = 2955; 31.6%) included patients with high prevalence of permanent AF, cardiac risk factors and comorbidities. Thromboembolic and bleeding risks were higher in Cluster 3 and progressively lower in Cluster 1 and Cluster 2 (both p &lt; 0.001). Use of oral anticoagulant was significantly lower for Cluster 2 (83.2% vs. 86.5% and 86.7% in Cluster 1 and Cluster 3, respectively; p &lt; 0.001). Over a mean follow-up of 22.5 (SD5.5) months, Cluster 3 had the highest rate of both cardiovascular events (10.0%) and all-cause death (13.2%), compared with Cluster 1 (6.6% and 9.4%, respectively) and Cluster 2 (3.7% and 3.8%, respectively) (both p &lt; 0.001). Kaplan-Meier curves (Figure) show that Cluster 2 (green line) had the lowest cumulative risk of outcomes; risk was progressively higher in Cluster 1 (orange line) and Cluster 3 (yellow line). A Cox multivariable regression analysis, adjusted for type of AF, symptomatic status, CHA2DS2-VASc score and use of oral anticoagulants, showed that both Cluster 3 and Cluster 1 were associated with a significantly increased risk of cardiovascular events (HR: 1.80, 95%CI: 1.39-2.33 and HR: 1.40, 95%CI: 1.09-1.80, respectively) and all-cause death (HR: 1.80, 95%CI: 1.40-2.30 and HR: 1.66, 95%CI: 1.30-2.11) compared to Cluster 2.

Conclusions

In European AF patients, three main clinical clusters were identified, those with non-cardiac comorbidities, low risk and cardiac comorbidities. Both non-cardiac and cardiac comorbidities clusters were found to be associated with an increased risk of cardiovascular events and all-cause death. Abstract Figure. Kaplan-Meier Curves for Outcomes

Associations of exercise-based cardiac rehabilitation with all-cause mortality among patients with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

There is limited evidence of long-term impact of exercise-based CR on clinical endpoints for patients with AF. We therefore compared 18-month all-cause mortality, hospitalisation, stroke, and heart failure in patients with AF and an electronic medical record (EMR) of exercise-based CR to matched controls.

Methods and Results

This retrospective cohort study included patient data obtained on 11 December 2020, from a global federated health research network. AF patients undergoing exercise-based CR were propensity score matched to AF patients without exercise-based CR by age, sex, race, medication, and co-morbidities. We ascertained 18-month incidence of all-cause mortality, hospitalisation, stroke, and heart failure.

Of 1,350,886 patients with AF, 10,625 patients had an EMR of exercise-based CR within 6-months of incident AF. The propensity score matched cohort of 21,250 patients with AF demonstrated that exercise-based CR was associated with 64% lower odds of all-cause mortality (odds ratio 0.36, 95% confidence interval (CI) 0.33-0.40), 41% lower odds of hospitalisation (0.59, 95% CI 0.56-0.63), and 17% lower odds of incident stroke (0.83, 95% CI 0.71-0.98) compared to propensity score matched controls. No significant associations were shown for heart failure at 18-months (0.92, 95% CI 0.81-1.02). The beneficial association of exercise-based CR on all-cause mortality was independent of sex, older age, comorbidities, and AF subtype.

CONCLUSIONS

Exercise-based CR among patients with incident AF was associated with lower odds of all-cause mortality, hospitalisation, and stroke at 18-months follow-up. The longitudinal nature of this retrospective follow-up study strongly supports the provision of exercise programmes for patients with incident AF.

Cardiac rehabilitation and all-cause mortality in patients with heart failure: A retrospective cohort study

Funding Acknowledgements

Type of funding sources: None.

Background

Despite the benefits of exercise training in the secondary prevention of cardiovascular disease, there are conflicting findings for the impact of exercise-based cardiac rehabilitation (CR) on mortality for patients with heart failure (HF).

Methods

A retrospective cohort study was conducted which utilised a global federated health research network. Patients with a diagnosis of HF were compared between those with and without an electronic medical record of exercise-based CR within 6-months of a HF diagnosis. Patients with HF undergoing exercise-based CR were propensity score matched to HF patients without exercise-based CR by age, sex, race, co-morbidities, medications, and procedures. We ascertained 2-year incidence of all-cause mortality, hospitalisation, stroke, and atrial fibrillation.

Results

Following propensity score matching, a total of 40,364 patients with HF were identified. Exercise-based CR was associated with 42% lower odds of all-cause mortality (odds ratio 0.58, 95% confidence interval (CI): 0.54-0.62), 26% lower odds of hospitalisation (0.74, 95% CI 0.71-0.77), 37% lower odds of incident stroke (0.63, 95% CI 0.51-0.79), and 53% lower odds of incident atrial fibrillation (0.47, 95% CI 0.4-0.55) compared to matched controls. The beneficial association of exercise-based CR on all-cause mortality was consistent across stratification for sex, older age, included comorbidities, and HF subtype (all P &lt; 0.0001), including patients with HFpEF (0.65, 95% CI 0.60-0.71).

Conclusions

Exercise-based CR was associated with lower odds of all-cause mortality, hospitalisations, incident stroke and incident atrial fibrillation at 2-years follow-up for patients with HF. The beneficial association of CR and lower mortality was consistent for patients with HFrEF and HFpEF.

The role of the posterior parietal cortex on cognition: An exploratory study

Theta burst stimulation (TBS) is a form of repetitive transcranial magnetic stimulation (rTMS) that can be used to increase (intermittent TBS) or reduce (continuous TBS) cortical excitability. The current study provides a preliminary report of the effects of iTBS and cTBS in healthy young adults, to investigate the causal role of the posterior parietal cortex (PPC) during the performance of four cognitive functions: attention, inhibition, sequence learning and working memory. A 2 × 2 repeated measures design was incorporated using hemisphere (left/right) and TBS type (iTBS/cTBS) as the independent variables. 20 participants performed the cognitive tasks both before and after TBS stimulation in 4 counterbalanced experimental sessions (left cTBS, right cTBS, left iTBS and right iTBS) spaced 1 week apart. No change in performance was identified for the attentional cueing task after TBS stimulation, however TBS applied to the left PPC decreased reaction time when inhibiting a reflexive response. The sequence learning task revealed differential effects for encoding of the sequence versus the learnt items. cTBS on the right hemisphere resulted in faster responses to learnt sequences, and iTBS on the right hemisphere reduced reaction times during the initial encoding of the sequence. The reaction times in the 2-back working memory task were increased when TBS stimulation was applied to the right hemisphere. Results reveal clear differential effects for tasks explored, and more specifically where TBS stimulation on right PPC could provide a potential for further investigation into improving oculomotor learning by inducing plasticity-like mechanisms in the brain.

Impact of physical activity on all-cause mortality in European patients with atrial fibrillation: a report from the ESC-EHRA EORP AF General Long-Term Registry

Background

Physical activity (PA) may have a beneficial contribution for outcomes in patients with atrial fibrillation (AF).

Purpose

We aimed to evaluate the impact of self-reported PA in a large contemporary cohort of European AF patients on the risk of all-cause mortality.

Methods

We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Self-reported PA was categorized, on the basis of reported time spent exercising, as follows: i) No PA; ii) Occasional PA; iii) Regular PA; iv) Intense PA. The primary outcome was all-cause death.

Results

Over 11096, a total of 8699 (78.4%) patients (mean age (SD) 69.1 (11.5); 40.7% female) had available data about PA and follow-up observation and were included in the analysis. Of these, 3703 (42.6%) reported no PA, 2829 (32.5%) occasional PA, 1824 (21.0%) regular PA, with only 343 (3.9%) reporting intense PA. With the 4 increasing PA categories, mean age, proportion of female patients, CHA2DS2-VASc and HAS-BLED scores were progressively lower (all p&lt;0.001). Use of vitamin K antagonist (VKA) declined across the classes of PA (53.1% vs. 52.2% vs. 44.5% vs. 33.9%, p&lt;0.001), while use of non-VKA OACs (NOACs) conversely increased. During a mean (SD) 680.6 (171.5) days of follow-up, there were a total of 848 (9.7%) all-cause death events. Based on Kaplan-Meier analysis, there was a progressively lower cumulative risk for all-cause death according to PA categories [Figure]. A multivariable Cox regression analysis, adjusting for CHA2DS2-VASc score, use of OAC at baseline and type of AF, found a lower risk of all-cause death associated with increasing levels of PA (Hazard ratio [HR]: 0.69, 95% confidence interval [CI]: 0.59–0.81 for occasional PA, HR: 0.45, 95% CI: 0.35–0.58 for regular PA, HR: 0.41, 95% CI: 0.23–0.76 for intense PA, when compared to no PA). In a sensitivity analysis, a regular-intense PA was inversely associated with occurrence of cardiovascular (CV) death, after multivariable adjustments for comorbidities (HR: 0.54, 95% CI: 0.37–0.77).

Conclusions

In a large contemporary cohort of European AF patients, self-reported PA was found to be inversely associated with all-cause death and CV death.

Kaplan-Meier Curves

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Since the start of EORP, several companies have supported the programme with unrestricted grants

The cholesterol paradox in atrial fibrillation: results from the LIPIDOGRAM 2015 study

Background

High blood lipid levels are known risk factors for atherosclerotic cardiovascular events, but associations between lipid levels and atrial fibrillation (AF) are unclear. Some previous studies have suggested an inverse association between lipid levels and AF referred to as the “cholesterol paradox”.

Purpose

To examine the prevalence of AF by differing lipid levels in a large population-based study of almost 14,000 adults in Poland.

Methods

The LIPIDOGRAM 2015 study is a cross-sectional study of adults aged 18 years and older recruited in Poland in 2015/2016 by 438 family physicians. Poisson regression models with robust variance were used to estimate prevalence ratios (PRs) for AF with 95% confidence intervals (CIs) for participants with differing lipid profiles. Lipid measures including low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), total cholesterol (TC) and LDL/HDL ratios were grouped into quartiles with the lowest quartile as the reference group. Models were adjusted for potential confounding factors including age, sex, waist-to-hip ratio, smoking, alcohol intake, regular physical activity, hypertension, antihypertensive medication use and treatment of dyslipidaemia.

Results

13,724 participants were recruited to the study, the median (interquartile range: IQR) age was 58.0 (47.7–65.8) years and 5.2% (n=708) had a diagnosis of AF, with a median (IQR) 3 (1–8) years since diagnosis. After adjusting for potential confounding factors, a statistically significant lower prevalence of AF was estimated for participants in the highest quartile for LDL-C (PR (95% CI): 0.60 (0.48, 0.75) p&lt;0.001), HDL-C (0.58 (0.46, 0.74), p&lt;0.001), TC (0.61 (0.49, 0.75), p&lt;0.001) and LDL/HDL ratio (0.75 (0.61, 0.94), p=0.010). No statistically significant difference in prevalence of AF was observed for participants in the highest quartile for TG levels compared to the lowest quartile for TG levels.

Conclusions

The prevalence of AF was lower for people with higher levels of LDL-C, HDL-C, TC and higher LDL/HDL ratios; some of the difference in prevalence was explained by controlling for confounding factors, but in multivariable models the association remained statistically significant. This research adds to the body of evidence which suggests an inverse relationship between cholesterol levels and AF-the “cholesterol paradox” for AF.

Funding Acknowledgement

Type of funding source: None

Temporal changes in quality of life amongst European atrial fibrillation patients: relationship to all-cause mortality. A report from the ESC-EHRA EORP-AF General Long-Term Registry

Background

Atrial fibrillation (AF) significantly impacts on patients' quality of life (QoL). An impaired QoL has been associated with worse outcomes even in AF patients, but contemporary data in a large-scale pan-European population are limited.

Purpose

We aimed to assess temporal changes in AF patients' QoL across 2 years follow-up observation, and the relationship of QoL changes with all-cause death.

Methods

We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. The EQ-5D-5L questionnaire was used to assess QoL. A Health Utility Score (HUS), indicating the overall health state (1 equals perfect health), was derived. Differences throughout the follow-up (Baseline, 1-Y FU, 2-Y FU) observation were assessed. The study outcome was all-cause mortality.

Results

Out of a total of 11906 patients, 8097 (73.0%) were available for this analysis. Mean (SD) age was 69.1 (11.5) years; 60.8% males; median CHA2DS2-VASc and HASBLED scores were 3 (IQR 2–4) and 1 (1–2), respectively. The mean (SD) HUS at baseline was 0.815 (0.200) and 0.834 (0.196), 0.829 (0.195) at 1-year follow-up and 2-year follow-up, respectively (p&lt;0.0001 for changes over time). Patients with a higher CHA2DS2-VASc score (CHA2DS2-VASc 6–9) reported a significant reduction in the quality of life, compared to the other CHA2DS2-VASc strata, with a mean (SD) HUS decreasing from 0.754 (0.214) at baseline to 0.727 (0.238) at 2-year follow-up (F=6.538, p&lt;0.0001) (Figure). Multivariate analysis demonstrated that age [−0.001 (95% CI [−0.002, −0.121]) and coronary artery disease (CAD) [−0.016 (95% CI [−0.029, −0.004] were independently inversely associated with increasing QoL. Positive changes in HUS over time were inversely associated with an increase in the risk of all-cause death, even after adjusting for chronic kidney disease, liver disease, chronic obstructive pulmonary disease, oral anticoagulants and type of AF (OR:0.24, 95% CI: 0.13–0.45 for increasing HUS difference, as a continuous variable).

Conclusions

In a contemporary European-wide cohort of AF patients, significant temporal changes in QoL were found. Patients at higher stroke risk according to CHA2DS2-VASc score showed a significant reduction in the QoL. Age and CAD were independently associated with changes in QoL. A greater reduction in HUS (i.e. worsening QoL) over time was associated with a higher risk of all-cause death.

Temporal changes in HUS

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Since the start of EORP, several companies have supported the programme with unrestricted grants

Relationship between frailty and all-cause mortality in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational research programme AF general long-term registry

Introduction

Frailty is a major health determinant for cardiovascular disease. Thus far, data on frailty in patients with atrial fibrillation (AF) are limited.

Aims

To evaluate frailty in a large contemporary cohort of European AF patients, the relationship with oral anticoagulant (OAC) prescription and with risk of all-cause death.

Methods

We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. A 38-items frailty index (FI) was derived from baseline characteristics according to the accumulation of deficits model proposed by Rockwood and Mitnitsky. All-cause mortality was the primary study outcome.

Results

Out of the 11096 AF enrolled patients, data for evaluating frailty were available for 6557 (59.1%) patients who have been included in this analysis (mean [SD] age 68.9 [11.5], 37.7% females). Baseline median [IQR] CHA2DS2-VASc and HAS-BLED were 3 [2–4] and 1 [1–2], respectively. At baseline, median [IQR] FI was 0.16 (0.12–0.23), with 1276 (19.5%) patients considered “not-frail” (FI&lt;0.10), 4033 (61.5%) considered “pre-frail” (FI 0.10–0.25) and 1248 (19.0%) considered “frail” (FI≥0.25). Age, female prevalence, CHA2DS2-VASc and HAS-BLED progressively increased across the FI classes (all p&lt;0.001). Use of OAC progressively increased among FI classes; after adjustments FI was not associated with OAC prescription (odds ratio [OR]: 1.09, 95% confidence interval [CI]: 0.98–1.19 for each 0.10 FI increase). Conversely, FI was directly associated with vitamin K antagonist (VKA) use (OR: 1.26, 95% CI: 1.18–1.34 for each 0.10 FI increase) and inversely associated with non-VKA OACs (NOACs) use (OR: 0.82, 95% CI: 0.77–0.88). FI was significantly correlated with CHA2DS2-VASc (Rho= 0.516, p&lt;0.001). Over a median [IQR] follow-up of 731 [704–749] days, there were 569 (8.7%) all-cause death events. Kaplan-Meier curves [Figure] showed an increasing cumulative risk for all-cause death according to FI categories. A Cox multivariable analysis, adjusted for age, sex, type of AF and use of OAC, found that increasing FI as a continuous variable was associated with an increased risk of all-cause death (hazard ratio [HR]: 1.56, 95% CI: 1.40–1.73 for each 0.10 FI increase). An association with all-cause death risk was found across the FI categories (HR: 1.71, 95% CI: 1.23–2.38 and HR: 2.88, 95% CI: 2.02–4.12, respectively for pre-frail and frail patients compared to non-frail ones). FI was also predictive of all-cause death (c-index: 0.660, 95% CI: 0.637–0.682; p&lt;0.001).

Conclusions

In a European contemporary cohort of AF patients the burden of frailty is significant, with almost 1 out of 5 patients found to be “frail”. Frailty influenced significantly the choice of OAC therapy and was associated with (and predictive of) all-cause death at follow-up.

Kaplan-Meier Curves

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Since the start of EORP programme, several companies have supported it with unrestricted grants.

The wider consequences of obesity: estimated social and economic costs from Mendelian Randomization

Background

Obesity is a key public health issue worldwide. Accurate estimates of its full impacts on health, social, and economic outcomes are required, but are difficult to obtain due to bias from confounding and reverse causality (the impact of social and economic factors on obesity).

Methods

Using data from the UK Biobank and ALSPAC, we applied a genetic causal inference approach (Mendelian Randomization, MR) to estimate the impact of body mass index (BMI) on key social and economic outcomes. Because genetic variants are assigned before birth and cannot change, estimates from MR studies are less liable to confounding and reverse causation.

Results

Effects of higher BMI were often larger in MR than conventional (non-genetic) models, suggesting previous studies may have underestimated the impact of BMI. For example, in adolescents, MR models implied a standard deviation increase in BMI led to exam scores around 1/3 of a grade lower in all subjects at age 16, and 8.7% (CI: 1.8% to 16.1%) more school absence. In adults a 5kg/m2 increase in BMI corresponded, among other negative outcomes, to £2,778 less annual household income (CI: £1,864 to £3,693), less chance of owning one's home (-1.6%, CI: -2.4% to -0.8%), and higher chance of being lonely (2.4%, CI: 1.4% to 3.5%). At £21.22 (CI: £14.35 to £28.07) per person per marginal kg/m2 per year, MR estimates for inpatient hospital costs were around 40% higher than conventional estimates.

Conclusions

Findings from causal inference based on genetic variation indicate that high BMI has negative impacts on social and economic outcomes that may be larger than previously estimated. This evidence highlights the potential social and economic value of preventing high BMI across the life course.

Key messages

High BMI has considerable negative impacts not only for health, but for individuals’ education and socioeconomic outcomes, and overall health care costs. Previous attempts to quantify these effects may have underestimated BMI’s full impact.

Low Protein Intake Irrespective of Source is Associated with Higher Mortality Among Older Community-dwelling Men

OBJECTIVES

Our aim was to determine the association between protein intake (overall and by source) and all-cause and cause-specific mortality among older men.

DESIGN

Prospective cohort study.

SETTING

5790 ambulatory community-dwelling older men from multicenter Osteoporotic Fractures in Men (MrOS) study.

MEASUREMENTS

Total energy and protein intake, and protein intake by source (dairy, non-dairy animal, plant) were assessed using a 69-item food frequency questionnaire. We included up to 10-year follow-up with adjudicated cardiovascular, cancer and other mortality outcomes. We used time-to-event analysis with protein exposures, mortality outcome, and adjusted for possible confounders including age, center, education, race, smoking, alcohol use, physical activity, weight, total energy intake (TEI), and comorbidities. Hazard ratios were expressed per each unit=2.9% TEI decrement for all protein intake variables.

RESULTS

The mean (SD) baseline age of 5790 men was 73.6 (5.8) y. There were 1611 deaths and 211 drop-outs prior to 10 years, and 3868 men who were alive at the 10-year follow-up. The mean (SD) total protein intake was 64.7 (25.8) g/d, while the mean (SD) intake expressed as percent of total energy intake (%TEI) was 16.1 (2.9) %TEI. Lower protein intake was associated with an increased risk of death, with unadjusted HR=1.11 (95% CI: 1.06, 1.17) and adjusted HR=1.09 (95% CI: 1.04, 1.14) and the associations for protein intake by source were similar. The adjusted HR for cancer mortality was HR=1.13 (95% CI: 1.03, 1.25) while the association for CVD mortality was HR=1.08 (95% CI: 0.99, 1.18).

CONCLUSIONS

Low protein intake, irrespective of source, was associated with a modest increase in risk of all-cause and cause-specific mortality among older men. Special consideration should be given to level of protein intake among older adults.

Assessing the potential of upper respiratory tract point-of-care testing: a systematic review of the prognostic significance of upper respiratory tract microbes

OBJECTIVES

Microbial point-of-care testing (POCT) has potential to revolutionize clinical care. Understanding the prognostic value of microbes identified from the upper respiratory tract (a convenient sampling site) is a necessary first step to understand potential for upper respiratory tract POCTs in assisting antimicrobial treatment decisions for respiratory infections (RTIs). The aim was to investigate the relationship between upper respiratory tract microbial detection and disease prognosis, including effects of antimicrobial use.

METHODS

Data sources were the MEDLINE and Embase databases. Study eligibility criteria consisted of quantitative studies reporting microbiological and prognostic data from patients of all age groups presenting with RTI. Patients presenting to healthcare or research settings with RTI participated. Interventions included upper respiratory tract swab. The methods used were systematic review and meta-analysis.

RESULTS

Searches identified 5156 articles, of which 754 were duplicates and 4258 excluded on title or abstract. A total of 144 full texts were screened; 21 articles were retained. Studies reported data for 15 microbes and 26 prognostic measures (390 potential associations). One hundred and seven (27%) associations were investigated statistically, of which 38 (36%) were significant. Most studies reported only prognostic value of test positive results. Meta-analyses suggested hospitalization duration was longer for patients with respiratory syncytial virus than adenovirus and influenza, but significant heterogeneity was observed between studies.

CONCLUSIONS

A quarter of potential prognostic associations have been investigated. Of these, a third were significant, suggesting considerable potential for POCT. Future research should investigate prognostic value of positive and negative tests, and interactions between test results, use of antimicrobials and microbial resistance.

P1521In a 36-week placebo-controlled phase 2 trial in patients with non-alcoholic steatohepatitis (NASH), treatment with MGL-3196 (resmetirom) significantly reduces atherogenic lipoprotein particles

Background

MGL-3196 is a liver-directed, orally active, highly selective thyroid hormone receptor-β agonist being developed for the treatment of non-alcoholic steatohepatitis (NASH). In a 36-week Phase 2 NASH study, MGL-3196 treatment compared with placebo (PbO) resulted in significant reductions in hepatic fat, liver enzymes, NASH on liver biopsy, and atherogenic lipids including low-density lipoprotein cholesterol (LDL-C) and triglycerides. Most NASH patients die of cardiovascular disease (CVD), and, in NASH patients, CV risk correlates better with LDL particle than LDL-C levels.

Purpose

To determine the effects of MGL-3196 on lipoprotein particle concentrations in patients with NASH.

Methods

MGL-3196–05 (NCT02912260) is a 36-week multicenter, randomized, double-blind, placebo controlled study of NASH patients assessed with serial liver imaging and liver biopsies. Patients received 2:1 MGL-3196 80 mg (blinded ± 20 mg dose adjustment possible at Week 4 based on Week 2 pharmacokinetic data) or placebo once daily, for 36 weeks. Lipoprotein particle concentrations were assessed in fasting blood samples at baseline and Week (Wk) 36.

Results

As shown (Table), MGL-3196 significantly reduced the level of lipoprotein particles, with greater reductions in patients with baseline (BL) LDL-C ≥100 mg/dL and the patient group with higher MGL-3196 exposures (High exp).

Lipoprotein particles Particles (by NMR) (nmol/L) Time Point Placebo, n=34 MGL-3196 (all), n=73 MGL-3196 BL LDL-C ≥100 mg/dL, n=44; High Exp, n=25 (PbO BL ≥100 mg/dL, n=23 mean data not shown) Total LDL, mean (SD) BL 1234 (276) 1275 (328) 1443 (290) 1407 (267) Wk 36 1251 (323) 1045 (264) 1155 (248) 1090 (216) % change from BL vs PbO (SE), p value −19.6 (4.2), <0.0001 −19.8 (5.6), 0.0008 −22.8 (6.3), 0.0006 Small LDL, mean (SD) BL 746 (295) 835 (294) 887 (329) 916 (314) Wk 36 749 (343) 641 (207) 641 (234) 618 (149) % change from BL vs PbO (SE), p value −27.7 (8.9), 0.002 −34.3 (13.1), 0.01 −39.4 (14.7), 0.009 Total VLDL and Chylomicron, mean (SD) BL 56.8 (23.9) 55.9 (22.9) 61.4 (24.5) 66.0 (24.8) Wk 36 58.8 (24.4) 46.0 (21.1) 47.6 (22.9) 47.4 (23.1) % change from BL vs PbO (SE), p value −22.7 (6.9), 0.001 −27.2 (7.5), 0.0006 −34.7 (8.3), <0.0001 Large VLDL and Chylomicron, mean (SD) BL 6.3 (4.3) 8.7 (5.8) 8.9 (6.1) 10.2 (6.8) Wk 36 7.2 (4.5) 6.6 (3.9) 6.7 (4.1) 7.2 (4.7) % change from BL vs PBO (SE), p value −52.5 (11.8), <0.0001 −65.6 (15.5), <0.0001 −71.3 (17.4), 0.0001 BL, baseline; High exp, high MGL-3196 exposure based on % increase from baseline in sex hormone binding globulin, BL LDL-C ≥100, a prespecified group.

Conclusions

MGL-3196 significantly reduced atherogenic lipoprotein particles, particularly in NASH patients with greater BL hypercholesterolemia. These findings are consistent with a potentially beneficial effect of MGL-3196 on the CV risk profile in NASH patients.

Development and validation of a Brief Diet Quality Assessment Tool in the French-speaking adults from Quebec

Background

The objective of this study was to develop and validate a short, self-administered questionnaire to assess diet quality in clinical settings, using the Alternative Healthy Eating Index (AHEI) as reference.

Methods

A total of 1040 men and women (aged 44.6 ± 14.4 y) completed a validated web-based food frequency questionnaire (webFFQ) and had their height and weight measured (development sample). Participants were categorized arbitrarily according to diet quality (high: AHEI score ≥ 65/110, low: AHEI score < 65/110) based on dietary intake data from the webFFQ. The Brief Diet Quality Assessment Tool was developed using a classification and regression tree (CART) approach and individual answers to the webFFQ among participants considered to have a plausible energy intake (ratio of reported energy intake to basal metabolic rate ≥ 1.2 and < 2.4; n = 1040). A second sample of 3344 older adults (aged 66.5 ± 6.4 y) was used to test the external validity of the Brief Diet Quality Assessment Tool (external validation sample).

Results

The decision tree included sequences of 3 to 6 binary questions, yielding 21 different pathways classifying diet quality as being high or low. In the development sample, the area under the receiver operating characteristic (ROC) curve of the predictive model was 0.92, with sensitivity, specificity and agreement values of 89.5, 83.9 and 87.2%. Compared with individuals having a low-quality diet according to the Brief Diet Quality Assessment Tool (mean AHEI 56.7 ± 11.4), individuals classified as having a high-quality diet (mean AHEI 71.3 ± 11.0) were significantly older, and had lower BMI, percent body fat and waist circumference, and had lower blood pressure, triglycerides, cholesterol/HDL ratio and fasting insulin as well as higher HDL-cholesterol concentrations (all P < 0.05). Similar results were observed in the external validation sample, although overall performance of the Brief Diet Quality Assessment Tool was slightly lower than in the development sample, with an area under the ROC curve of 0.79 and sensitivity, specificity and agreement values of 73.0, 69.0 and 71.3%, respectively.

Conclusion

The CART approach yielded a simple and rapid Brief Diet Quality Assessment Tool that identifies individuals at risk of having a low-quality diet. Further studies are needed to test the performance of this tool in primary care settings.

Electronic supplementary material

The online version of this article (10.1186/s12966-019-0821-6) contains supplementary material, which is available to authorized users.

A site-specific standard for comparing dynamic solar ultraviolet protection characteristics of established tree canopies

A standardised procedure for making fair and comparable assessments of the ultraviolet protection of an established tree canopy that takes into account canopy movement and the changing position of the sun is presented for use by government, planning, and environmental health authorities. The technique utilises video image capture and replaces the need for measurement by ultraviolet radiometers for surveying shade quality characteristics of trees growing in public parks, playgrounds and urban settings. The technique improves upon tree shade assessments that may be based upon single measurements of the ultraviolet irradiance observed from a fixed point of view. The presented technique demonstrates how intelligent shade audits can be conducted without the need for specialist equipment, enabling the calculation of the Shade Protection Index (SPI) and Ultraviolet Protection Factor (UPF) for any discreet time interval and over a full calendar year.

•

Tree shade UPF measurements are presented using video capture analysis of moving canopies

•

A standard method for making accurate assessments of tree shade has been developed

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Tree shade comparisons are made without the need for specialist equipment

Assessment of the American Heart Association's "Life's simple 7" score in French-speaking adults from Québec

BACKGROUND AND AIMS

The "Life's Simple 7" (LS7) metrics were developed by the American Heart Association (AHA) to assess and promote cardiovascular health in the American population. The purpose of this study was to assess the overall cardiovascular health of French-speaking adults from the Province of Quebec using the LS7 score.

METHODS AND RESULTS

A total of 777 age and sex-representative participants of five different administrative regions in the Province of Quebec (387 men and 390 women; mean age ± SEM: 41.9 ± 0.1 years) were included in these analyses. Metrics of the LS7 score (smoking, physical activity, diet, body mass index, blood pressure, fasting total cholesterol and blood glucose) were analysed to generate a final score ranging from 0 to 7. Only 0.5% of participants met all criteria for ideal cardiovascular health. The diet metric showed the lowest prevalence of "ideal" scores (4.8%) whereas not smoking was the metric with the highest prevalence (88.1%). Women had a higher LS7 score than men, while age and education level (negative and positive association, respectively; p < 0.0001) were also associated with the LS7 score.

CONCLUSION

Consistent with studies conducted among other populations, very few French-speaking adults from the Province of Quebec achieve an ideal cardiovascular health. These data indicate that further public health efforts aimed at promoting the LS7 metrics, focusing primarily on diet, are urgently needed. Specific groups, including older adults and those with lower levels of education, should be targeted when developing cardiovascular health promotion interventions.

Climate change and climate change velocity analysis across Germany

Although there are great concerns to what extent current and future climate change impacts biodiversity across different spatial and temporal scales, we still lack a clear information on different climate change metrics across fine spatial scales. Here we present an analysis of climate change and climate change velocity at a local scale (1 × 1 km) across Germany. We focus on seasonal climate variability and velocity and investigate changes in three time periods (1901–2015, 1901–1950 and 1951–2015) using a novel statistical approach. Our results on climate variability showed the highest trends for the 1951–2015 time period. The strongest (positive/negative) and spatially the most dispersed trends were found for Summer maximum temperature and Summer minimum temperatures. For precipitation the strongest positive trends were most pronounced in the summer (1951–2015) and winter (1901–2015). Results for climate change velocity showed that almost 90% of temperature velocities were in the range of 0.5 to 3 km/year, whereas all climate velocities for precipitation were within the range of −3.5 to 4.5 km/year. The key results amplify the need for more local and regional scale studies to better understand species individualistic responses to recent climate change and allow for more accurate future projections and conservation strategies.

Unusual case of transdermal fentanyl in cachexia

Fentanyl has a low molecular weight and is lipophilic making it suitable for transdermal administration. However, multiple factors appear to lead to interindividual variation in absorption via this route. Here we describe an unusual case where a patient was found to have twelve 100 μg/hour fentanyl patches in situ which she was using as background analgesia.

Identification of Cystic Lesions by Secondary Screening of Familial Pancreatic Cancer (FPC) Kindreds Is Not Associated with the Stratified Risk of Cancer

OBJECTIVES

Intraductal papillary mucinous neoplasms (IPMNs) are associated with risk of pancreatic ductal adenocarcinoma (PDAC). It is unclear if an IPMN in individuals at high risk of PDAC should be considered as a positive screening result or as an incidental finding. Stratified familial pancreatic cancer (FPC) populations were used to determine if IPMN risk is linked to familial risk of PDAC.

METHODS

This is a cohort study of 321 individuals from 258 kindreds suspected of being FPC and undergoing secondary screening for PDAC through the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer (EUROPAC). Computerised tomography, endoscopic ultrasound of the pancreas and magnetic resonance imaging were used. The risk of being a carrier of a dominant mutation predisposing to pancreatic cancer was stratified into three even categories (low, medium and high) based on: Mendelian probability, the number of PDAC cases and the number of people at risk in a kindred.

RESULTS

There was a median (interquartile range (IQR)) follow-up of 2 (0-5) years and a median (IQR) number of investigations per participant of 4 (2-6). One PDAC, two low-grade neuroendocrine tumours and 41 cystic lesions were identified, including 23 IPMN (22 branch-duct (BD)). The PDAC case occurred in the top 10% of risk, and the BD-IPMN cases were evenly distributed amongst risk categories: low (6/107), medium (10/107) and high (6/107) (P = 0.63).

CONCLUSIONS

The risk of finding BD-IPMN was independent of genetic predisposition and so they should be managed according to guidelines for incidental finding of IPMN.

The perception of sub-clinical personality disorders by employers, employees and co-workers

This study set out to determine people's perceptions of different dark-side personality types in the workplace. A total of 240 adults with at least one year's work experience rated vignettes describing job candidates with sub-clinical PDs. PDs were grouped into (Hogan and Hogan's 1997) personality clusters 'Moving Away from', 'Moving Against' and 'Moving Toward' others. PDs in the Moving Toward cluster were rated as the most desirable employees. Participants were least willing to work with or for PDs in the Moving Against cluster. Moving Against candidates were perceived as less successful than Moving Towards candidates, suggesting that people believe the costs of working with people with many PDs (e.g. psychopathy and narcissism) outweigh any benefits there may be. Implications and limitations are noted.

Constraints on Primordial Gravitational Waves Using Planck, WMAP, and New BICEP2/Keck Observations through the 2015 Season

We present results from an analysis of all data taken by the bicep2/Keck CMB polarization experiments up to and including the 2015 observing season. This includes the first Keck Array observations at 220 GHz and additional observations at 95 and 150 GHz. The Q and U maps reach depths of 5.2, 2.9, and 26  μK_{CMB} arcmin at 95, 150, and 220 GHz, respectively, over an effective area of ≈400 square degrees. The 220 GHz maps achieve a signal to noise on polarized dust emission approximately equal to that of Planck at 353 GHz. We take auto and cross spectra between these maps and publicly available WMAP and Planck maps at frequencies from 23 to 353 GHz. We evaluate the joint likelihood of the spectra versus a multicomponent model of lensed-ΛCDM+r+dust+synchrotron+noise. The foreground model has seven parameters, and we impose priors on some of these using external information from Planck and WMAP derived from larger regions of sky. The model is shown to be an adequate description of the data at the current noise levels. The likelihood analysis yields the constraint r_{0.05}<0.07 at 95% confidence, which tightens to r_{0.05}<0.06 in conjunction with Planck temperature measurements and other data. The lensing signal is detected at 8.8σ significance. Running a maximum likelihood search on simulations we obtain unbiased results and find that σ(r)=0.020. These are the strongest constraints to date on primordial gravitational waves.

Exploring Variations in the Content of Cancer-Specific Treatment Guidelines: An International Cancer Benchmarking Partnership (ICBP) Study

Background: Cancer-specific treatment guidelines aim to provide robust evidence-based recommendations for clinicians to ensure optimal disease management for patients. The content of these guidelines can greatly affect a patients' access to optimal treatment. However, the extent of international variation in guideline content remains understudied. Aim: Phase 2 of ICBP explores several factors that may be contributing to differences in cancer survival outcomes. Module 7 investigates differences in 'access to treatment' across seven participating countries (Canada, Australia, New Zealand, the UK, Ireland, Norway and Denmark). This project specifically aims to explore how variation in guideline content for cancer-specific treatment modalities may be contributing to differences in international survival outcomes. Methods: We reviewed cancer treatment guidelines across the seven ICBP countries that fulfill standard methodological criteria and are widely used in clinical care. This study includes a selected range of national and international guidelines recognizing that some participating countries do not produce their own site-specific guidelines and instead draw on international bodies (e.g., ESMO oncology clinical practice guidelines). We reviewed treatment guidelines for three cancer sites (stomach, pancreas and lung), recording points of content variation that were considered clinically significant and relevant to emerging findings from the ICBP survival benchmarking study. Results: Differences in the content of guidelines were found for each cancer site to varying degrees. Some guidelines showed a large degree of similarity which reflects strong consensuses in the evidence base. Others exhibited stark differences in recommendations for the type of surgical technique implemented, when to administer chemotherapy, use and type of radiotherapy and the extent of palliative care. Some differences may partly be explained by differences in the timeliness of some bodies to produce new guidelines, while others may stem from differences in how bodies evaluate the robustness and validity of high-profile phase III trials. Conclusion: This study found variation in the content of treatment guidelines. The extent to which this variation contributes to differences in international cancer outcomes warrants further exploration, as does additional content analyses of national guidelines for low- and middle-income countries. Our findings may prompt a move by clinical and policy stakeholders toward the standardization of international treatment guidelines, particularly in cases where content variation is marginal and given that guideline development processes are highly labor- and resource-intensive. This study also highlights the need to improve communications between national and international guideline bodies, when recommendations vary significantly, to reach international consensuses on areas of controversy regarding cancer site-specific treatment modalities.