bluuebunny/crossref_metadata_2025 huggingface dataset:
Is elevation of N-terminal pro-B-type natriuretic peptide at discharge associated with 2-year composite endpoint of all-cause mortality and heart failure hospitalisation after transcatheter aortic valve implantation? Insights from a multicentre prospective OCEAN-TAVI registry in Japan
Authors: Mizutani Kazuki , Hara Masahiko , Nakao Mana , Okai Tsukasa , Kajio Keiko , Murakami Takashi , Shibata Toshihiko , Yoshiyama Minoru , Naganuma Toru , Yamanaka Futoshi , Higashimori Akihiro , Tada Norio , Takagi Kensuke , Araki Motoharu , Ueno Hiroshi , Tabata Minoru , Shirai Shinichi , Watanabe Yusuke , Yamamoto Masanori , Hayashida Kentaro
Published: August 2018

Objectives

The aim of this study was to investigate the 2-year prognostic impact of N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels at discharge following transcatheter aortic valve implantation (TAVI).

Design

Multicentre prospective observational study.

Settings

Seven institutions from multicentre, observational registry of symptomatic patients with severe aortic stenosis who undergo TAVI.

Participants

We enrolled 500 consecutive patients who underwent TAVI with measurements of NT-proBNP at discharge between 2013 and 2016. Study patients were stratified into two groups according to survival classification and regression tree (CART) analysis: high versus low NT-proBNP groups.

Interventions

The impact of high NT-proBNP on a 2-year composite endpoint consisting of all-cause mortality and heart failure hospitalisation was evaluated using a multivariable Cox model.

Results

Median age was 86 years (quartile 82–89), and 24.2% of the study population were men. Median Society of Thoracic Surgeon score was 7.1 (5.1–9.8), and NT-proBNP at discharge was 1381 (653–3136) pg/mL. The composite endpoint incidence was 13.0% (95% CI 9.5% to 16.3%) at 1 year and 22.3% (95% CI 16.1%–27.9%) at 2 years. The survival CART analysis revealed that the NT-proBNP level required to discern the 2-year composite endpoint was 4288 pg/mL. Elevated NT-proBNP had a statistically significant impact on outcomes, with adjusted HR of 2.21 (95% CI 1.21 to 4.04, p=0.010), and with a significant sex difference (Pfor interaction=0.003).

Conclusion

Elevation of NT-proBNP at discharge is associated with higher incidence of the 2-year composite endpoint after TAVI.

Trial registration number

000020423
Ethnic differences in cardiovascular morbidity and mortality among patients with breast cancer in the Netherlands: a register-based cohort study
Authors: Deen Laura , Buddeke Josefien , Vaartjes Ilonca , Bots Michiel L , Norredam Marie , Agyemang Charles
Published: August 2018

Objectives

Cardiovascular disease (CVD) is of increasing concern among breast cancer survivors. However, evidence on ethnic differences in CVD among women with breast cancer is sparse. We assessed ethnic differences in cardiovascular morbidity and mortality among patients with breast cancer in the Netherlands.

Methods

A nationwide register-based cohort study comprising all women with a first admission for breast cancer (n=127 714) between 1996 and 2010 in the Netherlands was conducted. Differences in CVD admission, CVD mortality and overall CVD event, which comprised a CVD admission and/or CVD mortality, between the largest ethnic minority groups (Surinamese, Moroccan, Turkish, Antillean and Indonesian) and the Dutch general population (henceforth, Dutch) were investigated using Cox proportional hazard models.

Results

The incidence of cardiovascular outcomes varied by the ethnic group. The incidence of an overall cardiovascular event was significantly higher for women with breast cancer from Suriname (HR 1.46; 95% CI 1.29 to 1.64) and Turkey (HR 1.25; 95% CI 1.03 to 1.51), compared with Dutch women with breast cancer. In contrast, Indonesian women with breast cancer had a significantly lower risk (HR 0.88; 95% CI 0.81 to 0.96) of a cardiovascular event compared with Dutch women with breast cancer. The risk of a cardiovascular event did not differ between Moroccan and Dutch women with breast cancer, whereas for Antillean women the risk was not significantly higher.

Conclusions

Our findings suggest that Surinamese and Turkish women with breast cancer are disadvantaged in terms of cardiovascular outcomes compared with Dutch women with breast cancer. More work is needed to unravel the potential factors contributing to these differences.
Reuse of intermittent catheters: a qualitative study of IC users’ perspectives
Authors: Avery Miriam , Prieto Jacqui , Okamoto Ikumi , Cullen Samantha , Clancy Bridget , Moore Katherine N , Macaulay Margaret , Fader Mandy
Published: August 2018

Objectives

To explore the views of intermittent catheter (IC) users regarding the advantages and disadvantages of single-use or reuse of catheters.

Design

Qualitative study with semi-structured interviews. The interviews were recorded, transcribed and analysed thematically.

Setting

Participant’s own homes in Hampshire and Dorset, UK.

Participants

A convenience sample of 39 IC users, aged 23–86 years, using IC for at least 3 months.

Results

The analysis revealed four main themes: concerns regarding risk of urinary tract infection (UTI); cleaning, preparation and storage; social responsibility; practicalities and location. The main concern was safety, with the fear that reuse could increase risk of UTI compared with single-use sterile catheters. If shown to be safe then around half of participants thought they might consider reusing catheters. The practicalities of cleaning methods (extra products, time and storage) were considered potentially burdensome for reuse; but for single-use, ease of use and instant usability were advantages. Always having a catheter without fear of ‘running out’ was considered an advantage of reuse. Some participants were concerned about environmental impact (waste) and cost of single-use catheters. The potential for reuse was usually dependent on location. The analysis showed that often the disadvantages of single-use could be off-set by the advantages of reuse and vice versa, for example, the need to take many single-use catheters on holiday could be addressed by reuse, while the burden of cleaning would be obviated by single-use.

Conclusions

If shown to be safe with a practical cleaning method, some participants would find reuse an acceptable option, alongside their current single-use method. The choice to use a mixture of single-use and reuse of catheters for different activities (at home, work or holiday) could optimise the perceived advantages and disadvantages of both. The safety and acceptability of such an approach would require testing in a clinical trial.
Is time to progression associated with post-progression survival in previously treated metastatic non-small cell lung cancer with BRAF V600E mutation? A secondary analysis of phase II clinical trial data
Authors: Li Junlong , Sasane Medha , Zhang Jie , Zhao Jing , Ricculli Marie Louise , Yao Zhiwen , Redhu Suman , Signorovitch James
Published: August 2018

Objective

Longer time to progression (TTP) is associated with prolonged post-progression survival (PPS) in anaplastic lymphoma kinase+non-small cell lung cancer (NSCLC). This study evaluated whether TTP is associated with PPS among previously treated patients with metastatic v-Raf murine sarcoma viral oncogene homolog B V600E NSCLC receiving dabrafenib as monotherapy or in combination with trametinib.

Design

Secondary analysis of phase II clinical trial data.

Setting

Patients who experienced disease progression treated with dabrafenib monotherapy or in combination with trametinib as second line or later in an open-label, non-randomised, phase II study.

Primary outcome measures

The primary outcome was the TTP–PPS association. PPS was assessed with Kaplan-Meier analysis among patients with shorter versus longer TTP (< or ≥6 months). The TTP–PPS association was quantified in the Cox models adjusting for clinical covariates.

Results

Of the 84 included patients who progressed on dabrafenib monotherapy (n=57) or combination therapy (n=27), 60 (71%) died during post-progression follow-up. Patients with TTP ≥6 months experienced significantly longer PPS compared with those with TTP <6 months (median PPS: 9.5 vs 2.7 months, log-rank p<0.001). Each 3 months of longer TTP was associated with a 32% lower hazard of death following progression (HR 0.68, 95% CI 0.52 to 0.88) in the multivariable Cox model. Similar associations were seen in each treatment arm.

Conclusion

A longer TTP duration after treatment with dabrafenib monotherapy or combination therapy was associated with significantly longer PPS duration.

Trial registration number

NCT01336634; Post-results.
Escalation-related decision making in acute deterioration: a retrospective case note review
Authors: Campling Natasha , Cummings Amanda , Myall Michelle , Lund Susi , May Carl R , Pearce Neil W , Richardson Alison
Published: August 2018

Aim

To describe how decision making inter-relates with the sequence of events in individuals who die during admission and identify situations where formal treatment escalation plans (TEPs) may have utility.

Design and methods

A retrospective case note review using stratified sampling. Two data analysis methods were applied concurrently: directed content analysis and care management process mapping via annotated timelines for each case. Analysis was followed by expert clinician review (n=7), contributing to data interpretation.

Sample

45 cases, age range 38–96 years, 23 females and 22 males. Length of admission ranged from <24 hours to 97 days.

Results

Process mapping led to a typology of care management, encompassing four trajectories: early de-escalation due to catastrophic event; treatment with curative intent throughout; treatment with curative intent until significant point; and early treatment limits set. Directed content analysis revealed a number of contextual issues influencing decision making. Three categories were identified: multiple clinician involvement, family involvement and lack of planning clarity; all framed by clinical complexity and uncertainty.

Conclusions

The review highlighted the complex care management and related decision-making processes for individuals who face acute deterioration. These processes involved multiple clinicians, from numerous specialities, often within hierarchical teams. The review identified the need for visible and clear management plans, in spite of the frame of clinical uncertainty. Formal TEPs can be used to convey such a set of plans. Opportunities need to be created for patients and their families to request TEPs, in consultation with the clinicians who know them best, outside of the traumatic circumstances of acute deterioration.
Measuring health-related quality of life of care home residents, comparison of self-report with staff proxy responses for EQ-5D-5L and HowRu: protocol for assessing proxy reliability in care home outcome testing
Authors: Usman Adeela , Lewis Sarah , Hinsliff-Smith Kathryn , Long Annabelle , Housley Gemma , Jordan Jake , Gage Heather , Dening Tom , Gladman John R F , Gordon Adam L
Published: August 2018

Introduction

Research into interventions to improve health and well-being for older people living in care homes is increasingly common. Health-related quality of life (HRQoL) is frequently used as an outcome measure, but collecting both self-reported and proxy HRQoL measures is challenging in this setting. This study will investigate the reliability of UK care home staff as proxy respondents for the EQ-5D-5L and HowRu measures.

Methods and analysis

This is a prospective cohort study of a subpopulation of care home residents recruited to the larger Proactive Healthcare for Older People in Care Homes (PEACH) study. It will recruit residents ≥60 years across 24 care homes and not receiving short stay or respite care. The sample size is 160 participants. Resident and care home staff proxy EQ-5D-5L and HowRu responses will be collected monthly for 3 months. Weighted kappa statistics and intraclass correlation adjusted for clustering at the care home level will be used to measure agreement between resident and proxy responses. The extent to which staff variables (gender, age group, length of time caring, role, how well they know the resident, length of time working in care homes and in specialist gerontological practice) influence the level of agreement between self-reported and proxy responses will be considered using a multilevel mixed-effect regression model.

Ethics and dissemination

The PEACH study protocol was reviewed by the UK Health Research Authority and University of Nottingham Research Ethics Committee and was determined to be a service development project. We will publish this study in a peer-reviewed journal with international readership and disseminate it through relevant national stakeholder networks and specialist societies.
‘Adding another spinning plate to an already busy life’.Benefits and risks in patient partner–researcher relationships: a qualitative study of patient partners’ experiences in a Canadian health research setting
Authors: Leese Jenny , Macdonald Graham , Kerr Sheila , Gulka Lianne , Hoens Alison M , Lum Wendy , Tran Bao Chau , Townsend Anne F , Li Linda C
Published: August 2018

Objective

To better understand, based on patient partners’ experiences, benefits and risks in patient partner–researcher relationships in a health research setting.

Design

Qualitative interviews with thematic analysis informed by a relational ethics lens.

Setting

A multidisciplinary health research centre in Vancouver, Canada. This study was codeveloped by patient partners and researchers at the centre.

Participants

22 people living with arthritis, with experience as members of a patient advisory board at the research centre from 1 month to 10 years.

Results

We identified three main themes: (1) Being Heard: Participants had experienced uncomfortable emotions (eg, feelings of insecurity) in their relationships with researchers. The discomfort, however, was minimised by the demonstration of mutual respect in their interactions. Specifically, participants valued environments without a hierarchy between patient partners and researchers, where contributions of each party were considered equally important, and where patients’ voices were heard; (2) Cobuilding social relations: Participants valued building social relations with researchers beyond their expected interactions as partners in research and (3) Adding another spinning plate to an already busy life: Participants valued relationships with researchers who had cocreated environments that minimised the risks of physical and emotional impacts (eg, fatigue, stress, guilt) on them while juggling multiple obligations, priorities and their health.

Conclusions

Findings provide valuable insights to guide relationship building between patient partners and researchers. Informed by a relational ethics lens, these findings are a critical step in supporting an ethically sound practice of patient engagement in research that prioritises patients’ perspectives.
Psychiatry as a career choice among medical students: a cross-sectional study examining school-related and non-school factors
Authors: Seow Lee Seng Esmond , Chua Boon Yiang , Mahendran Rathi , Verma Swapna , Ong Hui Lin , Samari Ellaisha , Chong Siow Ann , Subramaniam Mythily
Published: August 2018

Objectives

Given the low recruitment to psychiatry worldwide, the current study aimed to examine how premedical and intramedical school factors, perception of career aspects, attitudes towards psychiatry, stigma towards mental illness and personality traits may affect the likelihood of psychiatry as a career choice.

Design

Cross-sectional online study.

Participants

502 medical students from two public medical institutions in Singapore.

Methods

We critically examined existing literature for factors identified to influence psychiatry as a career choice and explored their effects in a group of medical students in Singapore. To avoid overloading the regression model, this analysis only included variables shown to have significant association (p<0.05) with the outcome variable from the initial Χ2test and independent t-test analyses.

Results

A considerable number of non-medical school factors such as preschool influence and interest, personality traits and importance of a high status specialty in medicine were found to affect students’ choice of psychiatry as a career. Among medical school factors, attending a psychiatry/mental health club was the only influential factor. Negative attitudes towards psychiatry, but not stigma towards people with mental illness, significantly predicted the likelihood of not choosing psychiatry as a career.

Conclusions

Improving educational environment or teaching practice in psychiatric training may aid in future recruitment for psychiatrists. While the changing of premedical school influences or personality factors may be infeasible, medical schools and psychiatry institutes could play a more critical role by enhancing enrichment activities or clerkship experience to bring about a more positive attitudinal change towards psychiatry among students who did consider a career in psychiatry.
Systematic review to identify proxy indicators to quantify the impact of eHealth tools on maternal and neonatal health outcomes in low-income and middle-income countries including Delphi consensus
Authors: Perrin Caroline , Hounga Lothaire , Geissbuhler Antoine
Published: August 2018

Objective

To identify interventions that could serve as reliable proxy indicators to measure eHealth impact on maternal and neonatal outcomes.

Design

Systematic review and Delphi study.

Methods

We searched PubMed, Embase and Cochrane from January 1990 to May 2016 for studies and reviews that evaluated interventions aimed at improving maternal/neonatal health and reducing mortality. Interventions that are not low-income and middle-income context appropriate and that cannot currently be diagnosed, managed or impacted by eHealth (eg, via telemedicine distance diagnostic or e-learning) were excluded. We used the Cochrane risk of bias, Risk Of Bias In Non- randomised Studies - of Interventions and ROBIS tool to assess the risk of bias. A three-step modified Delphi method was added to identify additional proxy indicators and prioritise the results, involving a panel of 13 experts from different regions, representing obstetricians and neonatologists.

Results

We included 44 studies and reviews, identifying 40 potential proxy indicators with a positive impact on maternal/neonatal outcomes. The Delphi experts completed and prioritised these, resulting in a list of 77 potential proxy indicators.

Conclusions

The proxy indicators propose relevant outcome measures to evaluate if eHealth tools directly affect maternal/neonatal outcomes. Some proxy indicators require mapping to the local context, practices and available resources. The local mapping facilitates the utilisation of the proxy indicators in various contexts while allowing the systematic collection of data from different projects and programmes. Based on the mapping, the same proxy indicator can be used for different contexts, allowing it to measure what is locally and temporally relevant, making the proxy indicator sustainable.

PROSPERO registration number

CRD42015027351.
Utilisation willingness for institutional care by the elderly: a comparative study of empty nesters and non-empty nesters in Shandong, China
Authors: Qian Yangyang , Qin Wen , Zhou Chengchao , Ge Dandan , Zhang Li , Sun Long
Published: August 2018

Introduction

Institutional care has been strongly promoted in China to meet seniors’ long-term care needs. Empty-nest elderly, in comparison with their counterparts, have less social support and fewer caring networks. This study aimed to compare the utilisation willingness for institutional care and its predictors between empty-nest and non-empty-nest seniors.

Methods

A total of 3923 seniors were included in the analysis. Binary logistic regression models were used to understand the association between the living arrangements of the elderly households and willingness for institutional care and to identify the predictors of the utilisation willingness for institutional care among empty nesters and non-empty nesters.

Results

Our study found that approximately 8.5% of the seniors had a willingness for institutional care in Shandong, China. Empty-nest singles (OR 5.301; 95% CI 2.838 to 9.904) and empty-nest couples (OR 1.547; 95% CI 1.135 to 2.107) were found to be more willing to receive institutional care. Our results also showed that residence was a key determinant for institutionalisation willingness in empty-nest and non-empty-nest elderly. Among empty-nest singles, psychological stress was a positive determinant for institutional care. Factors, including education attainment, relationship with adult children, household income and per capita living space, were determinants for empty-nest couple willingness for institutionalisation. Age, number of children and self-reported health status were found to be associated factors for willingness among non-empty nesters.

Conclusions

The government should pay more attention to institutional care in rural areas where there is still a gap in elder care compared with that in urban areas. Targeted policies should be made for different types of seniors to offer appropriate institutional care.
Impact of adverse media reporting on public perceptions of the doctor–patient relationship in China: an analysis with propensity score matching method
Authors: Sun Jing , Liu Shiyang , Liu Qiannan , Wang Zijuan , Wang Jun , Hu Cecile Jia , Stuntz Mark , Ma Jing , Liu Yuanli
Published: August 2018

Objectives

Numerous studies indicate that the doctor–patient relationship in China is facing serious challenges. This study examined the impact of China Central Television’s negative coverage of high medicines prices on both doctors’ and patients’ opinions of the doctor–patient relationship.

Setting

Data were collected in a national survey conducted during 19 December 2016 to 11 January 2017 which targeted 136 public tertiary hospitals across the country.

Participants

All patients and doctors who submitted completed questionnaire were retrieved from the survey database.

Intervention

The study used propensity score matching method to match the respondents before and after China Central Television’s news report about high medicines prices which was given at 00:00 hours on 24 December 2016.

Outcome measure

Perception scores were calculated based on the five-point Likert scales to measure the opinions of the doctor–patient relationship.

Results

The perception scores of the doctor–patient relationship were significantly affected by the negative media coverage for hospitalised patients, who scored 1.18 lower on the doctor–patient relationship following the report (p=0.006, 95% CI 0.34 to 2.02), and doctors who scored 5.96 points lower on the same scale (p<0.001, 95% CI 4.11 to 7.82). Score for the ambulatory patients was unaffected by exposure to the adverse news report (p=0.05).

Conclusion

Chinese national media’s reporting of adverse news negatively affected the perceptions of the doctor–patient relationship among both inpatients and doctors. A better understanding of the role of mass media in the formation of opinion and trust between doctors and patients may permit strategies for managing the media, in order to improve public perceptions of the doctor–patient relationship.
Small volume plasma exchange for Guillain-Barré syndrome in resource-limited settings: a phase II safety and feasibility study
Authors: Islam Badrul , Islam Zhahirul , Rahman Shafiqur , Endtz Hubert P , Vos Margreet C , van der Jagt Mathieu , van Doorn Peter A , Jacobs Bart C , Mohammad Quazi Deen
Published: August 2018

Objective

To assess the safety and feasibility of small volume plasma exchange (SVPE) for patients with Guillain-Barré syndrome (GBS).

Design

Non-randomised, single-arm, interventional trial.

Setting

National Institute of Neurosciences and Hospital, Dhaka, Bangladesh.

Participants

Twenty adult (>18 years) patients with GBS presented within 2 weeks of onset of weakness who were unable to walk unaided for more than 10 m.

Interventions

SVPE involves blood cell sedimentation in a blood bag and removal of supernatant plasma after blood cells are retransfused. This procedure was repeated three to six times a day, for eight consecutive days. Fresh frozen plasma (FFP) and normal saline were used as replacement fluid.

Outcome measures

Serious adverse events (SAEs) were defined as severe sepsis and deep venous thrombosis related to the central venous catheter (CVC) used during SVPE. SVPE was considered safe if less than 5/20 patients experienced an SAE, and feasible if 8 L plasma could be removed within 8 days in at least 15/20 patients.

Results

Median patient age 33 years (IQR 23–46; range 18–55); 13 (65%) were male. Median Medical Research Council (MRC) sum score was 20 (IQR 0–29; range 0–36); three (15%) patients required mechanical ventilation. One patient developed SAE (severe sepsis, possibly related to CVC). The median plasma volume exchanged was 140 mL/kg (range 110–175) and removal of 8 L plasma was possible in 15 (75%) patients. Patients received a median 1 g/kg IgG via FFP although a substantial proportion of IgG was probably removed again by the SVPE sessions. GBS disability score improved by at least one grade in 14 (70%) patients 4 weeks after SVPE started. No patients died.

Conclusion

SVPE seems a safe and feasible alternative treatment to standard plasma exchange (PE) or intravenous immunoglobulin (IVIg) for GBS; further studies of clinical efficacy in low-income and middle-income countries are warranted.

Trial registration number

NCT02780570.
Utilisation of primary care before a childhood cancer diagnosis: do socioeconomic factors matter?: A Danish nationwide population-based matched cohort study
Authors: Friis Abrahamsen Christina , Ahrensberg Jette Møller , Vedsted Peter
Published: August 2018

Objectives

Early diagnosis of childhood cancer is critical. Nevertheless, little is known about the potential role of inequality. This study aims to describe the use of primary care 2 years before a childhood cancer diagnosis and to investigate whether socioeconomic factors influence the use of consultations and diagnostic tests in primary care.

Design

A national population-based matched cohort study.

Setting and participants

This study uses observational data from four Danish nationwide registers. All children aged 0–15 diagnosed with cancer during 2008–2015 were included (n=1386). Each case was matched based on gender and age with 10 references (n=13 860).

Primary and secondary outcome measures

The primary outcome was additional rates for consultations and for invoiced diagnostic tests for children with cancer according to parental socioeconomic factors. Furthermore, we estimated the association between socioeconomic factors and frequent use of consultations, defined as at least four consultations, and the odds of receiving a diagnostic test within 3 months of diagnosis.

Results

Children with cancer from families with high income had 1.46 (95% CI 1.23 to 1.69) additional consultations 3 months before diagnosis, whereas children from families with low income had 1.85 (95% CI 1.60 to 2.11) additional consultations. The highest odds of frequent use of consultations was observed among children from low-income families (OR: 1.94, 95% CI 1.24 to 3.03). A higher odds of receiving an invoiced diagnostic test was seen for children from families with mid-educational level (OR: 1.46, 95% CI 1.09 to 1.95).

Conclusion

We found a socioeconomic gradient in the use of general practice before a childhood cancer diagnosis. This suggests that social inequalities exist in the pattern of healthcare utilisation in general practice.
An exploration of how women in the UK perceive the provision of care received in an early pregnancy assessment unit: an interpretive phenomenological analysis
Authors: Norton Wendy , Furber Lynn
Published: August 2018

Objective

The objective of the study was to explore how women experience care within an early pregnancy assessment unit (EPAU) and how they are helped to understand, reconcile and make sense of their loss and make informed decisions about how their care will be managed following a first trimester miscarriage.

Design

This was a single centre, prospective qualitative study. An interpretive phenomenological analysis approach was used to interpret the participants’ meanings of their experiences. It is an ideographic approach that focuses in depth on a small set of cases to explore how individuals make sense of a similar experience.

Setting

An EPAU in a large teaching hospital in the Midlands that provides care to women in their early pregnancy, including those experiencing pregnancy loss.

Participants

A purposive sample of 10 women were recruited to this study. All of the women were either miscarrying at the time of this study or had miscarried within the previous few weeks.

Results

Six superordinate themes in relation to women’s experiences of miscarriage were identified: (1) the waiting game, (2) searching for information, (3) management of miscarriage: no real choice, (4) the EPAU environment, (5) communication: some room for improvement and (6) moving on.

Conclusions

This study found that improvements are required to ensure women and their partners receive a streamlined, informative, supportive and continuous package of care from the point they first see their general practitioner or midwife for support to being discharged from the EPAU. The provision of individualised care, respect for women’s opinions and appropriate clinical information is imperative to those experiencing miscarriage to help them gain a degree of agency within an unfamiliar situation and one in which they feel is out of their control.
Recognising the importance of informal communication events in improving collaborative care
Authors: Burm Sarah , Boese Kaitlyn , Faden Lisa , DeLuca Sandy , Huda Noureen , Hibbert Kathy , Goldszmidt Mark
Published: August 2018

Background

While the concept of collaboration is highly touted in the literature, most descriptions of effective collaboration highlight formal collaborative events; largely ignored are the informal collaborative events and none focusing on the frequent, ‘seemingly’ by chance communication events that arise and their role in supporting patient safety and quality care.

Objective

To identify the types of informal communication events that exist in the inpatient setting and better understand the barriers contributing to their necessity.

Methods

We undertook a constructivist grounded theory study in an inpatient internal medicine teaching unit in Ontario, Canada. Interview and observational data were collected across two phases; in total, 56 participants were consented for the study. Data collection and analysis occurred iteratively; themes were identified using constant comparison methods.

Results

Several types of informal communication events were identified and appeared valuable in three ways: (1) providing a better sense of a patient’s baseline function in comparison to their current function; (2) gaining a more holistic understanding of the patient’s needs; and (3) generating better insight into a patient’s wishes and goals of care. Participants identified a number of organisational and communication challenges leading to the need for informal communication events. These included: scheduling, competing demands and the spatial and temporal organisation of the ward. As a result, nursing staff, allied health professionals and caregivers had to develop strategies for interacting with the physician team.

Conclusion

We highlight the importance of informal communication in supporting patient care and the gaps in the system contributing to their necessity. Changes at the system level are needed to ensure we are not leaving important collaborative opportunities to chance alone.
Patient healthcare passports in community specialist palliative care: a mixed methods study
Authors: White Clare , Sproule Jenny , Brogan Paula , Watson Max
Published: August 2018

Background

Patient held records need to be evaluated in palliative care settings.

Objectives

To evaluate how patients, families and professionals in a specialist palliative setting use a patient held record created through close consultation with patients and carers.

Methods

A mixed methods prospective longitudinal cohort study in the UK—adult patients under community specialist palliative care nurse review or attending day hospice were given questionnaires at record introduction and after 4–6 weeks. Hospice staff completed a questionnaire and focus group after 8 months.

Results

From Sept 2016 to June 2017, 550 patients were screened, 347 (63.1%) were offered records and 259 accepted (74.6%). 238 accepted a research pack, 105 returned questionnaire 1 (44.1% response rate) and 26 returned questionnaire 2 (24.8% of initial respondents). Questionnaire 1 (patients): 40% found it burdensome repeating information, and almost 70% were interested in a record to reduce this. Questionnaire 2 (patients): 74% found the record easy to use, but few (4, 15.4%) used it regularly. Over 60% stated the record was useful and would recommend it to others, despite not using it themselves. Professionals indicated that it was mainly patients and relatives who used the record, not non-palliative professionals.

Conclusions

While initial uptake of the record was high, use appeared low. While people saw real value in the record for others, they did not generally use it themselves. This evaluation demonstrates that patient held records are unlikely to be used by palliative care patients even though they see value in the concept.
Alcohol inhibits T-cell glucose metabolism and hepatitis in ALDH2-deficient mice and humans: roles of acetaldehyde and glucocorticoids
Authors: Gao Yanhang , Zhou Zhou , Ren Tianyi , Kim Seung-Jin , He Yong , Seo Wonhyo , Guillot Adrien , Ding Yanhua , Wu Ruihong , Shao Shuang , Wang Xiaomei , Zhang Hong , Wang Wei , Feng Dechun , Xu Mingjiang , Han Elaine , Zhong Wei , Zhou Zhanxiang , Pacher Pal , Niu Junqi , Gao Bin
Published: August 2018

Objective

Aldehyde dehydrogenase 2 (ALDH2), a key enzyme to detoxify acetaldehyde in the liver, exists in both active and inactive forms in humans. Individuals with inactive ALDH2 accumulate acetaldehyde after alcohol consumption. However, how acetaldehyde affects T-cell hepatitis remains unknown.

Design

Wild-type (WT) and Aldh2 knockout (Aldh2-/-) mice were subjected to chronic ethanol feeding and concanavalin A (ConA)-induced T-cell hepatitis. Effects of acetaldehyde on T-cell glucose metabolism were investigated in vitro. Human subjects were recruited for binge drinking and plasma cortisol and corticosterone measurement.

Results

Ethanol feeding exacerbated ConA-induced hepatitis in WT mice but surprisingly attenuated it in Aldh2-/- mice despite higher acetaldehyde levels in Aldh2-/- mice. Elevation of serum cytokines and their downstream signals in the liver post-ConA injection was attenuated in ethanol-fed Aldh2-/- mice compared to WT mice. In vitro exposure to acetaldehyde inhibited ConA-induced production of several cytokines without affecting their mRNAs in mouse splenocytes. Acetaldehyde also attenuated interferon-γ production in phytohaemagglutinin-stimulated human peripheral lymphocytes. Mechanistically, acetaldehyde interfered with glucose metabolism in T cells by inhibiting aerobic glycolysis-related signal pathways. Finally, compared to WT mice, ethanol-fed Aldh2-/- mice had higher levels of serum corticosterone, a well-known factor that inhibits aerobic glycolysis. Blockade of corticosterone partially restored ConA-mediated hepatitis in ethanol-fed Aldh2-/- mice. Acute alcohol drinking elevated plasma cortisol and corticosterone levels in human subjects with higher levels in those with inactive ALDH2 than those with active ALDH2.

Conclusions

ALDH2 deficiency is associated with elevated acetaldehyde and glucocorticoids post-alcohol consumption, thereby inhibiting T-cell activation and hepatitis.
Switchable CAR-T cells mediate remission in metastatic pancreatic ductal adenocarcinoma
Authors: Raj Deepak , Yang Ming-Hsin , Rodgers David , Hampton Eric N , Begum Julfa , Mustafa Arif , Lorizio Daniela , Garces Irene , Propper David , Kench James G , Kocher H M , Young Travis S , Aicher Alexandra , Heeschen Christopher
Published: August 2018

Objective

Pancreatic ductal adenocarcinoma (PDAC) is a disease of unmet medical need. While immunotherapy with chimeric antigen receptor T (CAR-T) cells has shown much promise in haematological malignancies, their efficacy for solid tumours is challenged by the lack of tumour-specific antigens required to avoid on-target, off-tumour effects. Switchable CAR-T cells whereby activity of the CAR-T cell is controlled by dosage of a tumour antigen-specific recombinant Fab-based ‘switch’ to afford a fully tunable response may overcome this translational barrier.

Design

In this present study, we have used conventional and switchable CAR-T cells to target the antigen HER2, which is upregulated on tumour cells, but also present at low levels on normal human tissue. We used patient-derived xenograft models derived from patients with stage IV PDAC that mimic the most aggressive features of PDAC, including severe liver and lung metastases.

Results

Switchable CAR-T cells followed by administration of the switch directed against human epidermal growth factor receptor 2 (HER2)-induced complete remission in difficult-to-treat, patient-derived advanced pancreatic tumour models. Switchable HER2 CAR-T cells were as effective as conventional HER2 CAR-T cells in vivo testing a range of different CAR-T cell doses.

Conclusion

These results suggest that a switchable CAR-T system is efficacious against aggressive and disseminated tumours derived from patients with advanced PDAC while affording the potential safety of a control switch.
Prediagnostic circulating markers of inflammation and risk of oesophageal adenocarcinoma: a study within the National Cancer Institute Cohort Consortium
Authors: Cook Michael B , Barnett Matthew J , Bock Cathryn H , Cross Amanda J , Goodman Phyllis J , Goodman Gary E , Haiman Christopher A , Khaw Kay-Tee , McCullough Marjorie L , Newton Christine C , Boutron-Ruault Marie-Christine , Lund Eiliv , Rutegård Martin , Thornquist Mark D , Spriggs Michael , Giffen Carol , Freedman Neal D , Kemp Troy , Kroenke Candyce H , Le Marchand Loïc , Park Jin Young , Simon Michael , Wilkens Lynne R , Pinto Ligia , Hildesheim Allan , Campbell Peter T
Published: August 2018

Objective

Cross-sectional data indicate that systemic inflammation is important in oesophageal adenocarcinoma. We conducted a prospective study to assess whether prediagnostic circulating markers of inflammation were associated with oesophageal adenocarcinoma and to what extent they mediated associations of obesity and cigarette smoking with cancer risk.

Design

This nested case–control study included 296 oesophageal adenocarcinoma cases and 296 incidence density matched controls from seven prospective cohort studies. We quantitated 69 circulating inflammation markers using Luminex-based multiplex assays. Conditional logistic regression models estimated associations between inflammation markers and oesophageal adenocarcinoma, as well as direct and indirect effects of obesity and smoking on risk of malignancy.

Results

Soluble tumour necrosis factor receptor 2 (sTNFR2) (ORsquartile 4 vs 1=2.67, 95% CI 1.52 to 4.68) was significantly associated with oesophageal adenocarcinoma. Additional markers close to the adjusted significance threshold included C reactive protein, serum amyloid A, lipocalin-2, resistin, interleukin (IL) 3, IL17A, soluble IL-6 receptor and soluble vascular endothelial growth factor receptor 3. Adjustment for body mass index, waist circumference or smoking status slightly attenuated biomarker–cancer associations. Mediation analysis indicated that sTNFR2 may account for 33% (p=0.005) of the effect of waist circumference on oesophageal adenocarcinoma risk. Resistin, plasminogen activator inhibitor 1, C reactive protein and serum amyloid A were also identified as potential mediators of obesity–oesophageal adenocarcinoma associations. For smoking status, only plasminogen activator inhibitor 1 was a nominally statistically significant (p<0.05) mediator of cancer risk.

Conclusion

This prospective study provides evidence of a link between systemic inflammation and oesophageal adenocarcinoma risk. In addition, this study provides the first evidence that indirect effects of excess adiposity and cigarette smoking, via systemic inflammation, increase the risk of oesophageal adenocarcinoma.
Potential spironolactone effects on collagen metabolism biomarkers in patients with uncontrolled blood pressure
Authors: Ferreira João Pedro , Rossignol Patrick , Pizard Anne , Machu Jean-Loup , Collier Timothy , Girerd Nicolas , Huby Anne-Cécile , Gonzalez Arantxa , Diez Javier , López Begoña , Sattar Naveed , Cleland John G , Sever Peter S , Zannad Faiez
Published: August 2018

Background

An increase in myocardial collagen content may contribute to the development of heart failure; this might be inhibited or reversed by mineralocorticoid receptor antagonists (MRAs). We investigated changes in serum concentrations of the collagen synthesis biomarkers N-terminal propeptide of procollagen type III (PIIINP) (primary outcome) and C-terminal propeptide of procollagen type I (PICP) (secondary outcome) after non-randomised initiation of spironolactone as add-on therapy among patients with resistant hypertension enrolled in the ‘Anglo-Scandinavian Cardiac Outcomes’ trial (ASCOT).

Methods

An age/sex matching plus propensity-scored logistic regression model incorporating variables related to the outcome and spironolactone treatment was created to compare patients treated with spironolactone for a 9-month period versus matched controls. A within-person analysis comparing changes in serum biomarker concentrations in the 9 months before versus after spironolactone treatment was also performed.

Results

Patients included in the between-person analysis (n=146) were well matched: the mean age was 63±7 years and 11% were woman. Serum concentrations of PIIINP and PICP rose in ‘controls’ and fell during spironolactone treatment (adjusted means +0.52 (−0.05 to 1.09) vs −0.41 (−0.97 to 0.16) ng/mL, p=0.031 for PIIINP and +4.54(−1.77 to 10.9) vs −6.36 (−12.5 to −0.21) ng/mL, p=0.023 for PICP). For the within-person analysis (n=173), spironolactone treatment was also associated with a reduction in PICP (beta estimate=−11.82(−17.53 to −6.10) ng/mL, p<0.001) but not in PIIINP levels.

Conclusions

Treatment with spironolactone was associated with a reduction in serum biomarkers of collagen synthesis independently of blood pressure in patients with hypertension, suggesting that spironolactone might exert favourable effects on myocardial collagen synthesis and fibrosis. Whether this effect might contribute to slowing the progression to heart failure is worth investigating.
Malnutrition, congestion and mortality in ambulatory patients with heart failure
Authors: Sze Shirley , Pellicori Pierpaolo , Zhang Jufen , Clark Andrew L
Published: August 2018

Background

In patients with chronic heart failure (CHF), malnutrition might be related to right heart dysfunction and venous congestion, which predispose to bowel oedema and malabsorption, thereby leading to malnutrition. We explored the relation between congestion, malnutrition and mortality in a large cohort of ambulatory patients with CHF.

Methods

We assessed malnutrition using the Geriatric Nutritional Risk Index (GNRI). Congestion was defined by echocardiography (raised right atrial pressure (RAP)=dilated inferior vena cava≥21 mm/raised pulmonary artery systolic pressure (PAsP)=transtricuspid gradient of ≥36 mm Hg/right ventricular systolic dysfunction (RVSD)=tricuspid annular plane systolic excursion <17 mm).

Results

Of the 1058 patients enrolled, CHF was confirmed in 952 (69% males, median age 75 (IQR: 67–81) years, median N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) 1141 (IQR: 465–2562) ng/L). 39% had HF with -reduced ejection fraction (left ventricular ejection fraction, LVEF <40%) and 61% had HF with normal (HeFNEF, LVEF ≥40% and NT-pro-BNP >125 ng/L) ejection fraction. Overall, 14% of patients were malnourished (GNRI ≤98). 35% had raised RAP, 23% had raised PAsP and 38% had RVSD. Congestion was associated with malnutrition. During a median follow-up of 1683 days (IQR: 1096–2230 days), 461 (44%) patients died. Malnutrition was an independent predictor of mortality. Patients who were malnourished with both RVSD and increased RAP had much worse outcome compared with non-malnourished patients without RVSD who had normal RAP.

Conclusion

Malnutrition and congestion are modestly correlated and each is independently associated with increased mortality in patients with CHF. Patients with HF with both malnutrition and congestion as evidenced by right heart dysfunction should be managed with additional vigilance.
Patient survival and therapeutic outcome in the UK bridge to transplant left ventricular assist device population
Authors: Parameshwar Jayan , Hogg Rachel , Rushton Sally , Taylor Rhiannon , Shaw Steven , Mehew Jenny , Simon Andre , MacGowan Guy A , Dalzell Jonathan R , Al Attar Nawwar , Venkateswaran Rajamiyer , Lim Hoong Sern , Schueler Stephan , Tsui Steven , Banner Nicholas Robert
Published: August 2018

Objective

To study the survival and patient outcome in a population of UK patients supported by an implantable left ventricular assist device (LVAD) as a bridge to heart transplantation.

Methods

Data on all adult patients (n=342) who received a HeartMate II or HVAD as a first long-term LVAD between January 2007 and 31 December 2013 were extracted from the UK Ventricular Assist Device (VAD) Database in November 2015. Outcomes analysed include survival on a LVAD, time to urgent listing, heart transplantation and complications including those needing a pump exchange.

Results

112 patients were supported with the Thoratec HeartMate II and 230 were supported with the HeartWare HVAD. Median duration of support was 534 days. During the study period, 81 patients required moving to the UK urgent waiting list for heart transplantation. Of the 342 patients, 85 (24.8%) received a heart transplant, this included 63 on the urgent list. Thirty-day survival was 88.9%, while overall patient survival at 3 years from LVAD implant was 49.6%. 156 patients (46%) died during LVAD support; the most common cause of death on a VAD was a cerebrovascular accident. There was no significant difference between the two devices used in any outcome.

Conclusions

In a population of patients with advanced heart failure, who have a very poor prognosis, support with an implantable LVAD allowed a quarter to receive a heart transplant in a 3-year period. Overall survival of the cohort was about 50%. With improvement in technology and in post-LVAD management, it is likely that outcomes will improve further.