bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessing the effects of changes in care commissioning guidelines at a tertiary centre in London on the provision of NHS-funded procedures of limited clinical effectiveness: an 11-year retrospective database analysis
Authors: Rahman Shafiq , Langridge Benjamin , Hachach-Haram Nadine , Hansen Esther , Bootle Anna , Bystrzonowski Nicola , Hamilton Stephen , Mosahebi Afshin
Published: July 2017

Objectives

The main objective of this study was to assess the impact of changes in care commissioning policies on National Health Service (NHS)-funded cosmetic procedures over an 11-year period at our centre.

Setting

The setting was a tertiary care hospital in London regulated by the North Central London Hospitals NHS Trust care commissioning group.

Participants

We included all patients logged on to our database at the time of the study which was 2087 but later excluded 61 from analysis due to insufficient information.

Primary and secondary outcome measures

The main outcome measures were the results of tribunal assessment for different cosmetic surgeries which were either accepted, rejected or inconclusive based on the panel meeting.

Results

There were a total of 2087 patient requests considered between 2004 and 2015, of which 715 (34%) were accepted, 1311 (63%) were declined and 61 (3%) had inconclusive results. The implementation of local care commissioning guidelines has reduced access to cosmetic surgeries. Within this period, the proportion of procedures accepted has fallen from 36% in 2004 to 21% in 2015 (χ2; p<0.05, 95% CI).

Conclusion

Local guidance on procedures of limited clinical effectiveness is a useful, although not evidence-based selection process to reduce access to cosmetic surgery in line with increasing financial constraints. However, patients with a physical impairment may not receive treatment in comparison to previous years, and this can have a negative impact on their quality of life.
Relationship between initial therapy and blood pressure control for high-risk hypertension patients in the UK: a retrospective cohort study from the THIN general practice database
Authors: Weir Sharada , Juhasz Attila , Puelles Jorge , Tierney Travis S
Published: July 2017

Objective

To examine the UK practice patterns in treating newly diagnosed hypertension and to determine whether subgroups of high-risk patients are more or less likely to follow particular therapeutic protocols and to reach blood pressure goals.

Design

Retrospective cohort study.

Setting

This study examined adults in The Health Improvement Network (THIN) UK general practice medical records database who were initiated on medication for hypertension.

Participants

48 131 patients with essential hypertension diagnosed between 2008 and 2010 who were registered with a participating practice for a minimum of 13 months prior to, and 6 months following, initiation of therapy. We excluded patients with gestational hypertension or secondary hypertension. Patients were classified into risk groups based on blood pressure readings and comorbid conditions.

Primary and secondary outcome measures

Odds of receiving single versus fixed or free-drug combination therapy and odds of achieving blood pressure control were assessed using multivariable logistic regression.

Results

The vast majority of patients (95.8%) were initiated on single drug therapy. Patients with high cardiovascular risk (patients with grade 2–3 hypertension or those with high normal/grade 1 hypertension plus at least one cardiovascular condition pretreatment) had a statistically significant benefit of starting immediately on combination therapy when blood pressure control was the desired goal (OR: 1.23; 95% CI: 1.06 to 1.42) but, surprisingly, were less likely than patients with no risk factors to receive combination therapy (OR: 0.53; 95% CI: 0.47 to 0.59).

Conclusions

Our results suggest that combination therapy may be indicated for patients with high cardiovascular risk, who accounted for 60.6% of our study population. The National Institute for Health and Care Excellence guideline CG34 of 2006 (in effect during the study period) recommended starting with single drug class therapy for most patients, and this advice does seem to have been followed even in cases where a more aggressive approach might have been considered.
Treatment and clinicopathological characteristics of lupus nephritis with anti-neutrophil cytoplasmic antibody positivity: a case–control study
Authors: Li Cui , Zhou Min-Lin , Liang Dan-Dan , Wang Jing-Jing , Yang Jing , Zeng Cai-Hong , Liu Zhi-Hong , Zhang Hai-Tao
Published: July 2017

Objective

To assess the clinical features, pathological presentations, treatments and outcomes of lupus nephritis (LN) with anti-neutrophil cytoplasmic antibody (ANCA) positivity.

Design

A case–control study.

Methods

Patients (n=49) were retrospectively included from Jinling Hospital in China if presenting with biopsy-proven ANCA-positive LN between 1985 and 2008. Clinicopathological characteristics and outcomes were analysed and compared with those of a control group (n=1279). We further compared treatment responses and outcomes of ANCA-positive LN patients based on the treatment issued.

Results

The study included 40 women and 9 men (median age 33 years at biopsy): 38 with myeloperoxidase (MPO)-ANCA, 7 with proteinase 3(PR3)-ANCA and 4 with double positivity. ANCA-positive LN patients exhibited higher haematuria, serum creatinine levels and systemic lupus erythematosus disease activity index scores. On pathological evaluation, class IV LN was predominant, accounting for 61.22% of cases. Light microscopy revealed significantly higher activity index and chronicity index scores, including cellular crescents, interstitial inflammation, tubular atrophy and interstitial fibrosis. ANCA-positive LN patients receiving mycophenolate mofetil as induction therapy had a higher remission rate and better renal outcomes than those receiving cyclophosphamide. During follow-up, end-stage renal disease developed in seven (14.29%) ANCA-positive LN patients, all of them were MPO-ANCA positive.

Conclusions

The characteristics of ANCA-positive LN were massive haematuria and advanced renal insufficiency. We observed a higher remission rate and better prognoses when using mycophenolate mofetil than when using cyclophosphamide as induction therapy.
Impact of intrapatient variability (IPV) in tacrolimus trough levels on long-term renal transplant function: multicentre collaborative retrospective cohort study protocol
Authors: Goldsmith Petra M , Bottomley Matthew J , Okechukwu Okidi , Ross Victoria C , Ghita Ryan , Wandless David , Falconer Stuart J , Papachristos Stavros , Nash Philip , Androshchuk Vitaliy , Clancy Marc
Published: July 2017

Introduction

High intrapatient variability (IPV) in tacrolimus trough levels has been shown to be associated with higher rates of renal transplant failure. There is no consensus on what level of IPV constitutes a risk of graft loss. The establishment of such a threshold could help to guide clinicians in identifying at-risk patients to receive targeted interventions to improve IPV and thus outcomes.

Methods and analysis

A multicentre Transplant Audit Collaborative has been established to conduct a retrospective study examining tacrolimus IPV and renal transplant outcomes. Patients in receipt of a renal transplant at participating centres between 2009 and 2014 and fulfilling the inclusion criteria will be included in the study. The aim is to recruit a minimum of 1600 patients with follow-up spanning at least 2 years in order to determine a threshold IPV above which a renal transplant recipient would be considered at increased risk of graft loss. The study also aims to determine any national or regional trends in IPV and any demographic associations.

Ethics and dissemination

Consent will not be sought from patients whose data are used in this study as no additional procedures or information will be required from participants beyond that which would normally take place as part of clinical care. The study will be registered locally in each participating centre in line with local research and development protocols. It is anticipated that the results of this audit will be disseminated locally, in participating NHS Trusts, through national and international meetings and publications in peer-reviewed journals.
Study on factors inducing workplace violence in Chinese hospitals based on the broken window theory: a cross-sectional study
Authors: Zhou Chenyu , Mou Huitong , Xu Wen , Li Zhe , Liu Xin , Shi Lei , Peng Boshi , Zhao Yan , Gao Lei , Fan Lihua
Published: July 2017

Objectives

To explore the potential components of hospital workplace violence (HWPV) from the perspectives of hospital administrators and patients, and put forward corresponding strategies for its prevention and control.

Setting

Using convenience sampling methods, 116 hospitals in 14 provinces of China were surveyed using a self-designed questionnaire.

Methods

A cross-sectional study was used.

Participants

Hospital administrators and patients from 116 hospitals in 14 provinces of China.

Results

First, hospital administrators point of workplace factors included six factors, with the following weighting coefficients: hospital administrator factors (29.40%), patient-related factors (20.08%), hospital environmental factors (19.45%), policy and institutional factors (11.92%), social psychological factors (10.26%), objective events factors (8.89%). Second, patients from the hospital workplace predisposing factors included three common factors. The weight coefficients of these were hospital-related factors (60.27%), social and governmental factors (23.64%) and patient-related factors (16.09%).

Conclusions

A wide range of factors according to hospital administrators, patients and in the hospital environment play important roles in HWPV. From the perspectives of hospital administrators, communication skills and attitude to the service are important factors for inducing HWPV. From the perspective of patients, the characteristics of staff personalities and medical cognition are more important inducing factors. As far as social factors are concerned, economic compensation of medical malpractice is an important inducing factor for HWPV. In terms of environmental factors, management of Chinese medical hospitals, medical procedures and the layout of departments are all potential factors for the occurrence of violence. Corresponding defects were exposed in the health legal system and the supervision system for influencing public opinion.
EntericSalmonellain humans and food in the Middle East and North Africa: protocol of a systematic review
Authors: Chaabna Karima , Alali Walid
Published: July 2017

Introduction

Non-typhoidalSalmonellais considered one of the leading causes of foodborne disease worldwide. This protocol provides methods that will be used to synthesise available epidemiological data on non-typhoidal entericSalmonellain humans and food in Middle East and North Africa (MENA) region and to characterise the morbidity of human salmonellosis in this region.

Methods and analysis

A systematic review will be conducted based on the Cochrane Collaboration handbook and will be reported following the items outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We will search PubMed, Embase, CAB Direct and Global Health Library (WHO) databases in order to identify relevant reports. Additionally, the literature search will be supplemented by checking references of the included reports and the identified reviews. Furthermore, we will hand-search conference proceedings and Ministry of Health's website of each country of the MENA region. We will use comprehensive search criteria with no time and no language restrictions. We will extract data on report and study characteristics, biological assay characteristics, individuals’ demographic characteristics and on primary and secondary outcomes of interest. If appropriate, meta-analysis will be conducted in order to estimate pooled prevalence measures using DerSimonian and Laird random-effects models. We will conduct meta-regression analysis to explore the effect of study-level characteristics as potential sources of heterogeneity.

Ethics and dissemination

The results of the systematic review will be disseminated in a peer-reviewed journal and presented at relevant conferences.

Trial registration number

The trial registration number is CRD42016046360.
Drug-eluting stents in clinical routine: a 1-year follow-up analysis based on German health insurance administrative data from 2008 to 2014
Authors: Jeschke Elke , Searle Julia , Günster Christian , Baberg Henning Thomas , Dirschedl Peter , Levenson Benny , Malzahn Jürgen , Mansky Thomas , Möckel Martin
Published: July 2017

Objectives

To describe the use of drug-eluting stents (DESs) in the largest population of statutory health insurance members in Germany, including newly developed bio-resorbable vascular scaffolds (BVSs), and to evaluate 1-year complication rates of DES as compared with bare metal stents (BMSs) in this cohort.

Design

Routine data analysis of statutory health insurance claims data from the years 2008 to 2014.

Setting

The German healthcare insurance Allgemeine Ortskrankenkasse covers approximately 30% of the German population and is the largest nationwide provider of statutory healthcare insurance in Germany.

Participants and interventions

We included all patients with a claims record for a percutaneous coronary intervention (PCI) with either DES or BMS and additionally, from 2013, BVS. Patients with acute myocardial infarction (AMI) were excluded. Main outcome measure: major adverse cerebrovascular and cardiovascular event (MACCE, defined as mortality, AMI, stroke and transient ischaemic attack), bypass surgery, PCI and coronary angiography) at 1 year after the intervention.

Results

A total of 243 581 PCI cases were included (DES excluding BVS: 143 765; BVS: 1440; BMS: 98 376). The 1-year MACCE rate was 7.42% in the DES subgroup excluding BVS and 11.29% in the BMS subgroup. The adjusted OR for MACCE was 0.72 (95% CI 0.70 to 0.75) in patients with DES excluding BVS as compared with patients with BMS. In the BVS group, the proportion of 1-year MACCE was 5.0%.

Conclusion

The analyses demonstrate a lower MACCE rate for PCI with DES. BVSs are used in clinical routine in selected cases and seem to provide a high degree of safety, but data are still sparse.
Rapid decline in lung function in healthy adults predicts incident excess urinary albumin excretion later in life
Authors: Bhatia Sapna , Qualls Clifford , Crowell Thomas A , Arynchyn Alexander , Thyagarajan Bharat , Smith Lewis J , Kalhan Ravi , Jacobs David R , Kramer Holly , Duprez Daniel , Celli Bartolome , Sood Akshay
Published: July 2017

Introduction

Chronic lung disease, often characterised by rapid decline in lung function, is associated with vascular endothelial dysfunction (characterised by moderate to severe excess urinary albumin excretion (eUAE) but their longitudinal relationship is inadequately studied. In a bidirectional longitudinal examination of healthy adults, we analysed the following two hypotheses: (1) rapid decline (ie, highest tertile of lung function decline) predicts eUAE and (2) eUAE predicts rapid decline.

Methods

We performed a secondary data analysis from 3052 eligible participants from the Coronary Artery Risk Development in Young Adults (CARDIA) study. For analysis 1, the predictor was rapid decline in lung function between the peak value (attained at or before CARDIA visit year 10 or Y10 at a mean age of 35 years) and Y20; and the outcome was incident eUAE at Y20 and/or Y25. For analysis 2, the predictor was eUAE at Y10 and the outcome was rapid decline between Y10 and Y20.

Results

After adjustment for covariates in analysis 1, rapid decline in FEV1or FVC between peak and Y20 predicted incident eUAE at Y20 and/or Y25 (OR 1.51 and 1.44, respectively; p≤0.05 for both analyses). In analysis 2, eUAE at Y10 did not predict subsequent rapid decline.

Conclusions

Healthy adults with rapid decline in lung function are at risk for developing vascular endothelial dysfunction, as assessed by incident eUAE, later in life.
Evaluation of the current landscape of respiratory nurse specialists in the UK: planning for the future needs of patients
Authors: Yorke Janelle , Prigmore Sam , Hodson Matt , Stonham Carol , Long Hannah , Bellhouse Sarah , Fletcher Monica , Edwards Sheila
Published: July 2017

Introduction

The National Health Service currently faces significant challenges and must optimise effective workforce planning and management. There are increasing concerns regarding poor workforce planning for respiratory medicine; a greater understanding of the role of respiratory nurse specialists will inform better workforce planning and management.

Methods

This was a survey study. Two surveys were administered: an organisational-level survey and an individual respiratory nurse survey.

Results

There were 148 and 457 respondents to the organisational and individual nurse survey, respectively. Four main themes are presented: (1) breadth of service provided; (2) patient care; (3) work environment; and (4) succession planning. The majority of work conducted by respiratory nurse specialists relates to patient care outside the secondary care setting including supporting self-management in the home, supporting patients on home oxygen, providing hospital-at-home services and facilitating early discharge from acute care environments. Yet, most respiratory nursing teams are employed by secondary care trusts and located within acute environments. There was evidence of multidisciplinary working, although integrated care was not prominent in the free-text responses. High workload was reported with one-quarter of nursing teams short-staffed. Respiratory nurses reported working unpaid extra hours and a lack of administrative support that often took them away from providing direct patient care. Nearly half of the present sample either plan to retire or are eligible for retirement within 10 years.

Conclusions

This survey report provides a current snapshot of the respiratory nurse specialist workforce in the UK. This workforce is an ageing population; the results from this survey can be used to inform succession planning and to ensure a viable respiratory nurse specialist workforce in future.
Singing for Lung Health: a qualitative assessment of a British Lung Foundation programme for group leaders
Authors: Lewis Adam , Cave Phoene , Hopkinson Nicholas S
Published: July 2017

Introduction

Singing for Lung Health (SLH) groups are an increasingly popular intervention for people with respiratory disease. There are limited data as to how these groups should be developed and run. We aimed to evaluate the experience of singing leaders both to assess the training provided by the British Lung Foundation (BLF) and to provide information to guide future development of programmes.

Methods

A convenience sample of 15 leaders who had received BLF SLH training participated in the BLF service evaluation. Fifteen singing groups were observed, and singing leader interviews and questionnaires were collected. Inductive themes from the qualitative data were the primary outcome. The content of observed singing groups was also rated against the training leaders had received.

Results

Singing leaders valued the BLF training but felt that a significant level of expertise is required before joining. Singing leaders often found setting up groups challenging and some found clinician support beneficial. There were important technical aspects of running a lung health group including issues around content, for example, choice of repertoire to suit breathing pattern, and delivery, for example, pace, rhythm and management of group dynamics. Leaders said that group participants reported physical health improvements such as reduced breathlessness on activity. The content and delivery of singing classes observed displayed a good level of fidelity, suggesting that SLH training is effective.

Conclusion

The experience of the leaders highlights the requirements, support and technical skills needed to run SLH groups, which have features distinct from generic community singing groups.
Description of the protocol for the PRACTICAL study: a randomised controlled trial of the efficacy and safety of ICS/LABA reliever therapy in asthma
Authors: Fingleton James , Hardy Jo , Baggott Christina , Pilcher Janine , Corin Andrew , Hancox Robert J , Harwood Matire , Holliday Mark , Reddel Helen K , Shirtcliffe Philippa , Snively Suzanne , Weatherall Mark , Beasley Richard
Published: July 2017

Introduction

In adult asthma, combination inhaled corticosteroid (ICS)/fast-onset long-acting beta agonist (LABA) used solely as reliever therapy may represent an effective and safe alternative to ICS maintenance and short-acting beta agonist (SABA) reliever therapy.

Objective

To compare the efficacy and safety of ICS/fast-onset LABA reliever therapy with ICS maintenance and SABA reliever therapy in adults with asthma.

Methods and analysis

A 52-week, open-label, parallel group, multicentre, phase III randomised controlled trial with 1:1 randomisation to either budesonide/formoterol Turbuhaler 200/6 µg, one actuation as required for symptom relief, or budesonide Turbuhaler 200 µg, one actuation twice daily and terbutaline Turbuhaler 250 µg, two actuations as required for symptom relief. 890 adults aged 18–75 years with asthma for whom maintenance ICS and SABA reliever therapy is indicated by current guidelines will be recruited in New Zealand. The primary outcome variable is the rate of severe exacerbations per patient per year. This study will investigate a novel treatment regimen that might lead to a paradigm shift in asthma management for adults for whom guidelines currently recommend maintenance ICS and SABA reliever therapy.

Ethics and dissemination

Ethical approval has been granted (15/NTB/178). Study findings will be published according to Iinternational Committee of Medical Journal Editors' recommendations.

Trial registration number

ACTRN12616000377437; Pre-results.
Adjuncts for sputum clearance in COPD: clinical consensus versus actual use
Authors: Barker Ruth , Laverty Anthony A , Hopkinson Nicholas S
Published: July 2017

Introduction

Oscillatory positive pressure devices (OPEP) can be used as adjuncts to improve sputum clearance in chronic obstructive pulmonary disease (COPD), though the evidence base is incomplete. The attitudes of physiotherapists towards these devices in the care of patients with COPD is unknown. In addition, actual use compared with the prescription of medications has not been studied.

Methods

We analysed English prescribing data, obtained from OpenPrescribing.net, for a 3-year period from 2013. In addition, we conducted an online survey of members of the Association of Chartered Physiotherapists in Respiratory Care regarding awareness of devices, thresholds for treatment and device preference.

Results

Out of a potential 3.2 million COPD patient-years of treatment between 2013 and 2015, 422 744 patient-years of treatment with carbocisteine, at a cost of £73 million, were prescribed, as well as 1.1 million years treatment with tiotropium. In the same period, only 4989 OPEP devices were prescribed. There were 116 responses to the survey (12% response rate), 72% in hospital practice, 28% based in the community. There were variations in respondents’ threshold for treatment with sputum adjuncts in COPD, and when asked to select either the Acapella, Flutter or positive expiratory pressure mask, preferences were 69%, 24% or 6%, respectively.

Conclusions

There is a 100-fold difference between use of carbocisteine and OPEP devices in COPD, with far fewer devices prescribed than are included in the phenotypes clinicians believe them to be effective in. Variation in physiotherapist attitudes to treatment thresholds highlights the need for research into the effectiveness of OPEP devices in specific patient phenotypes.
The waterpolo shoulder paradigm: results of ultrasound surveillance at poolside
Authors: Galluccio Felice , Bellucci Eleonora , Porta Francesco , Tofani Lorenzo , De Paulis Amato , Bianchedi Diana , Barskova Tatiana , Matucci-Cerinic Marco
Published: July 2017

Background

Waterpolo consists of a combination of swimming and throwing with close contact between players. The shoulder is the most frequently injured joint, with a combination of rotator cuff tear and tendinopathy, long head biceps tendinopathy, superior labral lesions and shoulder impingement. This unique combination is a challenge for the clinician who must determine which of these shoulder pathologies is responsible for the onset of pain and the best strategy to rehabilitate the joint and prevent recurrence.

Aim

The aim of this study was to estimate with ultrasound the frequency and characteristics of shoulder injuries in waterpolo players competing in different leagues.

Methods

Forty-two players from two clubs in the premier and second Italian league were enrolled in the study. Standard and dynamic shoulder ultrasound scans were performed on all athletes.

Results

Ultrasound investigation showed that almost all players had injuries of the shoulders; only four players did not show any shoulder modification. Thirteen athletes who had shoulder pain during the ultrasound examination showed subacromion deltoid bursitis and/or long head biceps tendinitis. No statistically significant differences in the frequency and characteristics of shoulder modifications or injuries were detected between players of the premier or second league.

Conclusion

Shoulder injuries are very common in waterpolo players and comprise a peculiar and complex combination of rotator cuff tendinopathy and tears, long head biceps tendinopathy, impingement, subacromion deltoid bursitis and superior labral lesions. The use of ultrasound has been shown to be of considerable help in highlighting the modifications of the shoulder structures at an early asymptomatic stage. The ability to perform real-time scanning at the poolside makes ultrasound a useful tool in the rapid management and regular follow-up of shoulder modifications in everyday practice in sport medicine.
The training type influence on male elite athletes’ ventilatory function
Authors: Durmic Tijana , Lazovic Popovic Biljana , Zlatkovic Svenda Mirjana , Djelic Marina , Zugic Vladimir , Gavrilovic Tamara , Mihailovic Zoran , Zdravkovic Marija , Leischik Roman
Published: July 2017

Background/aim

To assess and compare measured ventilatory volumes (forced expiratory volume in 1 s (FEV1), peak expirium flow (PEF) and maximal voluntary ventilation (MVV)), ventilatory function capacities (forced vital capacity (FVC) and vital capacity (VC)) and FEV1/VC ratio in a sample of power and endurance elite athletes and their age-matched and sex-matched sedentary control group.

Methods

A cross-sectional study was applied on male elite athletes (n=470) who were classified according to the type of the predominantly performed exercise in the following way: group 1: endurance group (EG=270), group 2: power athletes group (SG=200) and group 3: sedentary control group (CG=100). The lung VC, FVC, FEV1, FEV1/FVC ratio, PEF and MVV were measured in all of the observed subjects, who were also classified with regard to body mass index (BMI) and the percentage of the body fat (BF%).

Results

The CG had the highest BF% value, while the endurance group had the lowest BMI and BF% value, which is significantly different from the other two groups (p<0.05). The observed values of VC, FVC and FEV1in the EG were significantly higher than those from the other two groups (p<0.05). There were no differences concerning the observed FEV1/FVC ratio.

Conclusions

A continued endurance physical activity leads to adaptive changes in spirometric parameters (VC, FVC and FEV1), highlighting the fact that there is a need for specific consideration of different respiratory ‘pattern’ development in different types of sport, which also has to be further evaluated.
Exergaming can be an innovative way of enjoyable high-intensity interval training
Authors: Moholdt Trine , Weie Stian , Chorianopoulos Konstantinos , Wang Alf Inge , Hagen Kristoffer
Published: July 2017

Objectives

Exergames can replace sedentary time spent on computer gaming with physical activity. Previous research has found exergaming to elicit light-to-moderate exercise intensity. Our primary aim was to examine the exercise intensity of a newly developed biking exergame.

Methods

Eight males (23.9±0.6 years) played the exergame (PLAY) and walked (WALK) on three separate occasions, with the condition counterbalanced and in random sequence within each day. They were asked to PLAY and WALK for a minimum of 15 min and then continue for as long as they wanted. We measured heart rate (HR), activity duration, caloric expenditure and subject-rated exertion and enjoyment (based on 0–10 Visual Analogue Scale, VAS). We used an average of each outcome variable across the 3 days in the analysis.

Results

The average intensity during PLAY (73%±10% of HRmax) was significantly higher than that during WALK (57%±7% of HRmax, p=0.01). Participants spent 12.5±5.3 min at 80%–89% of HRmaxand 5.5±4.6 min at ≥90% of HRmaxduring PLAY, whereas intensity during WALK was ≤72% of HRmax. The duration of PLAY was 44.3±0.7 min and of WALK 17.0±0.7 min (p=0.01). The relative energy expenditure during PLAY was 7.6±0.7 kcal/min and during WALK 6.2±0.3 kcal/min (p<0.01). The enjoyment of PLAY (VAS 8.7±0.1) was higher than that of WALK (VAS 3.9±1.8, p=0.01).

Conclusions

Exergaming can be an innovative way of enjoyable high-intensity training.
Simulated death enhances learner attitudes regarding simulation
Authors: Park Chang H , Wetmore Douglas , Katz Daniel , DeMaria Samuel , Levine Adam I , Goldberg Andrew T
Published: July 2017

Introduction

Despite the widespread use of simulated death in healthcare education, some view it as a controversial learning tool due to potential psychological harm. Others believe that allowing death during simulation enhances participant learning. Sparse data exist in the literature about learner attitudes towards simulated death. Our objective was to establish a link between exposure to simulated death and learner attitudes regarding simulation. Our hypothesis was that exposure to simulated death will positively affect learner attitudes towards simulation.

Methods

Anonymous surveys were distributed to participants of simulations conducted by our department from January 2014 to December 2015. Collected survey data included total number of simulation scenarios, exposure to death and participants’ views towards simulation afterwards. Participants also rated the simulation on a Likert scale. We compared demographic and simulation data for participants who experienced simulated death versus participants who did not. Exposure to death and clinical level were included as predictor variables in logistic regressions using the simulator experience variables as outcomes.

Results

250 survey responses were analysed. 64% of participants were attendings. 82% of participants experienced death during simulation. The group that experienced simulated death gave significantly higher ratings (4.77 vs 4.50, p=0.004) and a higher percentage of maximum ratings on the Likert scale (83% vs 59%, p=0.0002). More participants who experienced death thought that simulated death could enhance learning (76% vs 59%, p=0.021). When adjusted for training level, those who experienced death in simulation were nearly twice as likely to think that death can enhance learning (p=0.049) and 133% more likely to give the simulation the highest rating (p=0.036).

Conclusions

Survey participants who experienced simulated death were more likely to think that death can enhance learning and more likely to give the simulation the highest rating, thereby demonstrating that exposure to simulated death positively affects learner attitudes regarding simulation.
Cancer risk and survival in path_MMR carriers by gene and gender up to 75 years of age: a report from the Prospective Lynch Syndrome Database
Authors: Møller Pål , Seppälä Toni T , Bernstein Inge , Holinski-Feder Elke , Sala Paulo , Gareth Evans D , Lindblom Annika , Macrae Finlay , Blanco Ignacio , Sijmons Rolf H , Jeffries Jacqueline , Vasen Hans F A , Burn John , Nakken Sigve , Hovig Eivind , Rødland Einar Andreas , Tharmaratnam Kukatharmini , de Vos tot Nederveen Cappel Wouter H , Hill James , Wijnen Juul T , Jenkins Mark A , Green Kate , Lalloo Fiona , Sunde Lone , Mints Miriam , Bertario Lucio , Pineda Marta , Navarro Matilde , Morak Monika , Renkonen-Sinisalo Laura , Valentin Mev Dominguez , Frayling Ian M , Plazzer John-Paul , Pylvanainen Kirsi , Genuardi Maurizio , Mecklin Jukka-Pekka , Moeslein Gabriela , Sampson Julian R , Capella Gabriel
Published: July 2017

Background

Most patients with path_MMR gene variants (Lynch syndrome (LS)) now survive both their first and subsequent cancers, resulting in a growing number of older patients with LS for whom limited information exists with respect to cancer risk and survival.

Objective and design

This observational, international, multicentre study aimed to determine prospectively observed incidences of cancers and survival in path_MMR carriers up to 75 years of age.

Results

3119 patients were followed for a total of 24 475 years. Cumulative incidences at 75 years (risks) for colorectal cancer were 46%, 43% and 15% in path_MLH1, path_MSH2 and path_MSH6 carriers; for endometrial cancer 43%, 57% and 46%; for ovarian cancer 10%, 17% and 13%; for upper gastrointestinal (gastric, duodenal, bile duct or pancreatic) cancers 21%, 10% and 7%; for urinary tract cancers 8%, 25% and 11%; for prostate cancer 17%, 32% and 18%; and for brain tumours 1%, 5% and 1%, respectively. Ovarian cancer occurred mainly premenopausally. By contrast, upper gastrointestinal, urinary tract and prostate cancers occurred predominantly at older ages. Overall 5-year survival for prostate cancer was 100%, urinary bladder 93%, ureter 85%, duodenum 67%, stomach 61%, bile duct 29%, brain 22% and pancreas 0%. Path_PMS2 carriers had lower risk for cancer.

Conclusion

Carriers of different path_MMR variants exhibit distinct patterns of cancer risk and survival as they age. Risk estimates for counselling and planning of surveillance and treatment should be tailored to each patient’s age, gender and path_MMR variant. We have updated our open-access website www.lscarisk.org to facilitate this.
Shock-absorbing aggregates beneath playground equipment: grain properties and moisture content
Authors: Jäniskangas Tapani , Pylkkänen Kari P K , Kolisoja Pauli
Published: July 2017

Objectives

To assess the influence of grain size distribution and moisture condition on aggregates’Setting and methods

Impact attenuation of sands and gravels was tested using a guided headform with a uniaxial accelerometer inside. The result for impact attenuation was the acceleration value of the headform measured from four different drop heights and the Head Injury Criterion (HIC) calculated from it. The acceptable HIC value of a shock-absorbing layer is <1000, that is, less than the critical fall height. Tests were conducted with both dry and wet materials.

Results

The impact attenuation of a shock-absorbing layer made of loose aggregate is determined mainly by the following material factors: maximum grain size, median grain size, uniformity coefficient, fines content, grain shape and moisture content. In addition, the moisture content of aggregate, especially sands, has a major impact on its impact attenuation capacity. Of the studied sands, coarse and gravelly ones had the best impact attenuation properties. Most of the examined sands were uniformly graded. None of the grain properties of gravels proved more significant than the others. Yet, open-graded gravel (dominant grain size 4–8 mm) containing a small amount (about10%) of sand fraction 0.06–0.6 mm, but with hardly any coarse sand (0.6–2 mm), was found to have good impact attenuation.

Conclusions

This study shows that the aggregates for shock-absorbing layer should always be tested wet in laboratory conditions corresponding the most critical situation. Standards should include a procedure for wet testing of aggregates.
Reducing chemical exposures at home: opportunities for action
Authors: Zota Ami R , Singla Veena , Adamkiewicz Gary , Mitro Susanna D , Dodson Robin E
Published: July 2017

Indoor environments can influence human environmental chemical exposures and, ultimately, public health. Furniture, electronics, personal care and cleaning products, floor coverings and other consumer products contain chemicals that can end up in the indoor air and settled dust. Consumer product chemicals such as phthalates, phenols, flame retardants and per- and polyfluorinated alkyl substances are widely detected in the US general population, including vulnerable populations, and are associated with adverse health effects such as reproductive and endocrine toxicity. We discuss the implications of our recent meta-analysis describing the patterns of chemical exposures and the ubiquity of multiple chemicals in indoor environments. To reduce the likelihood of exposures to these toxic chemicals, we then discuss approaches for exposure mitigation: targeting individual behaviour change, household maintenance and purchasing decisions, consumer advocacy and corporate responsibility in consumer markets, and regulatory action via state/federal policies. There is a need to further develop evidence-based strategies for chemical exposure reduction in each of these areas, given the multi-factorial nature of the problem. Further identifying those at greatest risk; understanding the individual, household and community factors that influence indoor chemical exposures; and developing options for mitigation may substantially improve individuals’ exposures and health.
The impact of bivalent HPV vaccine on cervical intraepithelial neoplasia by deprivation in Scotland: reducing the gap
Authors: Cameron Ross L , Kavanagh Kimberley , Cameron Watt D , Robertson Chris , Cuschieri Kate , Ahmed Syed , Pollock Kevin G
Published: July 2017

Background

Cervical cancer disproportionately affects women from lower socioeconomic backgrounds. A human papillomavirus (HPV) vaccination programme was introduced in Scotland in 2008 with uptake being lower and inequitable in a catch-up cohort run for the first three years of the programme compared with the routine programme. The socioeconomic differences in vaccine uptake have the potential to further increase the inequality gap in regards to cervical disease.

Methods

Vaccination status was linked to demographic, cytological and colposcopic data, which are routinely collected by the Scottish HPV surveillance system. Incidence rates and relative risk of cervical intraepithelial neoplasia (CIN) 1, 2 and 3 in unvaccinated and vaccinated women were stratified by birth year and deprivation status using Poisson regression.

Results

Women who received three doses of HPV vaccine have significantly decreased risk of CIN 1, 2 and 3. Vaccine effectiveness was greater in those women from the most deprived backgrounds against CIN 2 and 3 lesions. Compared with the most deprived, unvaccinated women, the relative risk of CIN 3 in fully vaccinated women in the same deprivation group was 0.29 (95% CI 0.2 to 0.43) compared with 0.62 (95% CI 0.4 to 0.97) in vaccinated women in the least-deprived group.

Conclusions

The HPV vaccine is associated with significant reductions in both low-grade and high-grade CIN for all deprivation categories. However, the effect on high-grade disease was most profound in the most-deprived women. These data are welcoming and allay the concern that inequalities in cervical cancer may persist or increase following the introduction of the vaccine in Scotland.
Identification of biomarkers of response to abatacept in patients with SLE using deconvolution of whole blood transcriptomic data from a phase IIb clinical trial
Authors: Bandyopadhyay Somnath , Connolly Sean E , Jabado Omar , Ye June , Kelly Sheila , Maldonado Michael A , Westhovens Rene , Nash Peter , Merrill Joan T , Townsend Robert M
Published: July 2017

Objective

To characterise patients with active SLE based on pretreatment gene expression-defined peripheral immune cell patterns and identify clusters enriched for potential responders to abatacept treatment.

Methods

This post hoc analysis used baseline peripheral whole blood transcriptomic data from patients in a phase IIb trial of intravenous abatacept (~10 mg/kg/month). Cell-specific genes were used with a published deconvolution algorithm to identify immune cell proportions in patient samples, and unsupervised consensus clustering was generated. Efficacy data were re-analysed.

Results

Patient data (n=144: abatacept: n=98; placebo: n=46) were grouped into four main clusters (C) by predominant characteristic cells: C1—neutrophils; C2—cytotoxic T cells, B-cell receptor-ligated B cells, monocytes, IgG memory B cells, activated T helper cells; C3—plasma cells, activated dendritic cells, activated natural killer cells, neutrophils; C4—activated dendritic cells, cytotoxic T cells. C3 had the highest baseline total British Isles Lupus Assessment Group (BILAG) scores, highest antidouble-stranded DNA autoantibody levels and shortest time to flare (TTF), plus trends in favour of response to abatacept over placebo: adjusted mean difference in BILAG score over 1 year, −4.78 (95% CI −12.49 to 2.92); median TTF, 56 vs 6 days; greater normalisation of complement component 3 and 4 levels. Differential improvements with abatacept were not seen in other clusters, except for median TTF in C1 (201 vs 109 days).

Conclusions

Immune cell clustering segmented disease severity and responsiveness to abatacept. Definition of immune response cell types may inform design and interpretation of SLE trials and treatment decisions.

Trial registration number

NCT00119678; results.
Penile transplantation as an appropriate response to botched traditional circumcisions in South Africa: an argument against
Authors: Moodley Keymanthri , Rennie Stuart
Published: July 2017

Traditional male circumcision is a deeply entrenched cultural practice in South Africa. In recent times, there have been increasing numbers of botched circumcisions by untrained and unscrupulous practitioners, leading to genital mutilation and often, the need for penile amputation. Hailed as a world’s first, a team of surgeons conducted the first successful penile transplant in Cape Town, South Africa in 2015. Despite the euphoria of this surgical victory, concerns about the use of this costly intervention in a context of severe resource constraints have been raised. In this paper, we explore some of the ethical implications of penile transplants as a clinical and public health response to the adverse consequences of traditional male circumcision. Given the current fiscal deficits in healthcare and public health sectors, how can one justify costly, high-technology interventions for conditions affecting a small section of the population? Since botched traditional male circumcisions are preventable, is a focus on penile transplantation as a form of treatment reasonable? Finally, do such interventions create undue expectations and false hope among a highly vulnerable and stigmatised group of young men? In this paper, we argue that given limited healthcare resources in South Africa and competing healthcare needs, prevention is a more appropriate response to botched traditional circumcisions than penile transplants.
Freedom of conscience in Europe? An analysis of three cases of midwives with conscientious objection to abortion
Authors: Fleming Valerie , Ramsayer Beate , Škodič Zakšek Teja
Published: July 2017

While abortion has been legal in most developed countries for many years, the topic remains controversial. A major area of controversy concerns women’s rights vis-a-vis the rights of health professionals to opt out of providing the service on conscience grounds. Although scholars from various disciplines have addressed this issue in the literature, there is a lack of empirical research on the topic. This paper provides a documentary analysis of three examples of conscientious objection on religious grounds to performing abortion-related care by midwives in different Member States of the European Union, two of which have resulted in legal action. These examples show that as well as the laws of the respective countries and the European Union, professional and church law each played a part in the decisions made. However, support from both professional and religious sources was inconsistent both within and between the examples. The authors conclude that there is a need for clear guidelines at both local and pan-European level for health professionals and recommend a European-wide forum to develop and test them.
Heartfelt images: learning cardiac science artistically
Authors: Courneya Carol Ann
Published: July 2017

There are limited curricular options for medical students to engage in art-making during their training. Yet, it is known that art-making confers a variety of benefits related to learning. This qualitative study utilises a visual methodology to explore students’ art-making in the context of the cardiovascular sciences. The existence of a multiyear repository of medical/dental student generated, cardiac-inspired art, collected over 6 years, provided the opportunity to explore the nature of the art made. The aim was to categorise the art produced, as well as the depth and breadth of understanding required to produce the art. The data set included a wide variety of titled art (paintings, photographs, sketches, sculptures, collages, poetry and music/dance). Systematic curation of the collection, across all media, yielded three main categories: anatomical renderings, physiology/pathophysiology renderings and kinesthetic creations (music/dance/tactile). Overall (medical and dental) student-generated art suggested a high level of content/process understanding, as illustrated by attention to scientific detail, integration of form and function as well as the sophisticated use of visual metaphor and word play. Dental students preferentially expressed their understanding of anatomy and physiology kinesthetically, creating art that required manual dexterity as well as through choreography and dance. Combining art-making with basic science curricular learning invited the medical and dentistry students to link their understanding to different modes of expression and a non-biomedical way of knowing. Subsequent incorporation of the student-generated cardiac art into lectures exposed the entire class to creative pictorial expressions of anatomy, physiology and pathophysiology.