bluuebunny/crossref_metadata_2025 huggingface dataset:
Dietary Regulation of Memory T Cells
Authors: Collins Nicholas
Published: June 2020

Memory T cells are a fundamental component of immunological memory, providing rapid and potent host protection against secondary challenges. As such, memory T cells are key targets in the design of vaccination strategies and cancer immunotherapies, making it critical to understand the factors and mechanisms that regulate their biology. Diet is an environmental feature that impacts virtually all aspects of host physiology. However, the influence of specific dietary regiments and nutritional components on the immune system is only just starting to be uncovered. This article will review literature regarding the impact of diet and nutrition on memory T cell development, maintenance and function. It was recently shown that caloric restriction without undernutrition enhances memory T cell function, while diets high in fiber are also beneficial. However, memory T cell responses are dysfunctional in extreme nutritional states, such as undernutrition and diet-induced obesity. Therefore, diet and host nutritional status are major regulators of memory T cell biology and host fitness. To define the dietary balance required to promote optimal memory T cell responses could allow for the implementation of rational diet-based therapies that prevent or treat disease. Furthermore, that certain dietary regiments can enhance memory T cell function indicates the possibility of harnessing the underlying mechanisms in the design of novel vaccination strategies and cancer immunotherapies.
Using Orthogonal Combined Signals in Broadband ADCP for Improving Velocity Measurement
Authors: Lin Yujing , Yuan Fei , Cheng En
Published: June 2020

Broadband Acoustic Doppler Current Profiler (BBADCP) is a widely used technology in velocity measurements. To adapt to the varied water environment and different measurement requirements, flexible tuning of transmitted signal parameters will improve the feasibility and accuracy of velocity measurement. Compared with the conventional signal, the orthogonal combined signal designed in this paper can generate a wealth of signal combination examples and improve the accuracy of the velocity measurement under the same conditions. The proposed orthogonal combined signal consists of two orthogonal sub-signals with a symmetrical spectrum. Each is designed based on time delay to eliminate or weaken the current velocity ambiguity. Then, the processing method of the received signal when the pulse signals are the same or different coded signal is discussed. The numerical simulation results show that, when using the proposed method, the standard deviation of the estimated current velocity has different degrees of reduction at different current velocities. Our simulation also shows that, compared to the convention method, the proposed method can improve the SNR by 10 dB. This can help significantly increase the scope of the configuration.
Electrochemical Recycling of Platinum Group Metals from Spent Catalytic Converters
Authors: Diac Cornelia , Maxim Florentina Iuliana , Tirca Radu , Ciocanea Adrian , Filip Valeriu , Vasile Eugeniu , Stamatin Serban N.
Published: June 2020

Platinum group metals (PGMs: Pt, Pd, and Rh) are used extensively by the industry, while the natural resources are limited. The PGM concentration in spent catalytic converters is 100 times larger than in natural occurring ores. Traditional PGM methods use high temperature furnaces and strong oxidants, thus polluting the environment. Electrochemical studies showed that platinum can be converted to their chloride form. The amount of dissolved PGM was monitored by inductively coupled plasma-optical emission spectroscopy and the structure was identified by ultraviolet-visible spectroscopy. An electrochemistry protocol was designed to maximize platinum dissolution, which was then used for a spent catalytic converter. A key finding is the use of potential step that enhances the dissolution rate by a factor of 4. Recycling rates as high as 50% were achieved in 24 h without any pretreatment of the catalyst. The method developed herein is part of a current need to make the PGM recycling process more sustainable.
Isolation and Characterization of a New Endophytic Actinobacterium Streptomyces californicus Strain ADR1 as a Promising Source of Anti-Bacterial, Anti-Biofilm and Antioxidant Metabolites
Authors: Singh Radha , Dubey Ashok
Published: June 2020

In view of the fast depleting armamentarium of drugs against significant pathogens, like methicillin-resistant Staphylococcus aureus (MRSA) and others due to rapidly emerging drug-resistance, the discovery and development of new drugs need urgent action. In this endeavor, a new strain of endophytic actinobacterium was isolated from the plant Datura metel, which produced secondary metabolites with potent anti-infective activities. The isolate was identified as Streptomyces californicus strain ADR1 based on 16S rRNA gene sequence analysis. Metabolites produced by the isolate had been investigated for their antibacterial attributes against important pathogens: S. aureus, MRSA, S. epidermis, Enterococcus faecium and E. faecalis. Minimum inhibitory concentration (MIC90) values against these pathogens varied from 0.23 ± 0.01 to 5.68 ± 0.20 μg/mL. The metabolites inhibited biofilm formation by the strains of S. aureus and MRSA (Biofilm inhibitory concentration [BIC90] values: 0.74 ± 0.08–4.92 ± 0.49 μg/mL). The BIC90 values increased in the case of pre-formed biofilms. Additionally, the metabolites possessed good antioxidant properties, with an inhibitory concentration (IC90) value of 217.24 ± 6.77 µg/mL for 1, 1-diphenyl-2-picrylhydrazyl (DPPH) free radical scavenging. An insight into different classes of compounds produced by the strain ADR1 was obtained by chemical profiling and GC-MS analysis, wherein several therapeutic classes, for example, alkaloids, phenolics, terpenes, terpenoids and glycosides, were discovered.
Preconcentration and Detection of Gefitinib Anti-Cancer Drug Traces from Water and Human Plasma Samples by Means of Magnetic Nanoparticles
Authors: Borg Hadeer , Zámbó Dániel , Elmansi Heba , Hashem Heba M. , Nasr Jenny Jehan , Walash Mohammed I. , Bigall Nadja C. , Belal Fathalla
Published: June 2020

Along of widespread application of anti-cancer drug Gefitinib (GEF), it appears in human body fluids as well as clinical wastewater. Consequently, a reliable and easy-to-adapt detection technique is of essential importance to quantify the drug in different media. The extraction and quantitative detection of anti-cancer drug Gefinitib (GEF) is demonstrated based on a straightforward and efficient magnetic nanoparticle-assisted preconcentration route from water and human plasma samples. Iron oxide magnetic nanoparticles (Fe3O4) have been prepared with an average particle size of 15 nm and utilized as extractible adsorbents for the magnetic solid-phase extraction (MSPE) of GEF in aqueous media. The method is based on MSPE and preconcentration of GEF followed by High-Performance Liquid Chromatography-Ultraviolet Detection (HPLC-UV). The yield of GEF extraction under the optimum MSPE conditions were 94% and 87% for water and plasma samples, respectively. The chromatographic separation was carried out isocratically at 25 °C on a Phenomenex C8 reversed phase column (150 mm × 4.6 mm, with 5 µm particle size). The proposed method was linear over concentration ranges of 15.0–300.0 and 80.0–600.0 ng/mL for water and plasma samples with limits of detection of 4.6 and 25.0 ng/mL in a respective order. Relative standard deviations (%RSD) for intra-day and inter-day were 0.75 and 0.94 for water samples and 1.26 and 1.70 for plasma samples, respectively. Using the magnetic nanoparticles (MNPs) as loaded drug-extractors made the detection of the anti-cancer drug environmentally friendly and simple and has great potential to be used for different drug-containing systems.
Carbon Nanomaterial-Based Nanofluids for Direct Thermal Solar Absorption
Authors: Trong Tam Nguyen , Viet Phuong Nguyen , Hong Khoi Phan , Ngoc Minh Phan , Afrand Masoud , Van Trinh Pham , Hung Thang Bui , Żyła Gaweł , Estellé Patrice
Published: June 2020

Recently, many scientists have been making remarkable efforts to enhance the efficiency of direct solar thermal absorption collectors that depends on working fluids. There are a number of heat transfer fluids being investigated and developed. Among these fluids, carbon nanomaterial-based nanofluids have become the candidates with the most potential by the heat absorbing and transfer properties of the carbon nanomaterials. This paper provides an overview of the current achievements in preparing and exploiting carbon nanomaterial-based nanofluids to direct thermal solar absorption. In addition, a brief discussion of challenges and recommendations for future work is presented.
Improvement of Learning and Memory in Senescence-Accelerated Mice by S-Allylcysteine in Mature Garlic Extract
Authors: Hashimoto Masakazu , Nakai Tsuyoshi , Masutani Teruaki , Unno Keiko , Akao Yukihiro
Published: June 2020

S-allylcysteine (SAC), a major thioallyl compound contained in mature garlic extract (MGE), is known to be a neuroactive compound. This study was designed to investigate the effects of SAC on primary cultured hippocampal neurons and cognitively impaired senescence-accelerated mice prone 10 (SAMP10). Treatment of these neurons with MGE or SAC significantly increased the total neurite length and number of dendrites. SAMP10 mice fed MGE or SAC showed a significant improvement in memory dysfunction in pharmacological behavioral analyses. The decrease of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor, N-methyl-d-aspartate (NMDA) receptor, and phosphorylated α-calcium/calmodulin-dependent protein kinase II (CaMKII) in the hippocampal tissue of SAMP10 mice fed MGE or SAC was significantly suppressed, especially in the MGE-fed group. These findings suggest that SAC positively contributes to learning and memory formation, having a beneficial effect on brain function. In addition, multiple components (aside from SAC) contained in MGE could be useful for improving cognitive function by acting as neurotrophic factors.
The PK/PD Integration and Resistance of Tilmicosin against Mycoplasma hyopneumoniae
Authors: Huang Zilong , Hu Zixuan , Zheng Haorui , Xia Xirui , Gu Xiaoyan , Shen Xiangguang , Yang Hong , Ding Huanzhong
Published: June 2020

Mycoplasma hyopneumoniae is the major pathogen causing enzootic pneumonia in pigs. M. hyopneumoniae infection can lead to considerable economic losses in the pig-breeding industry. Here, this study established a first-order absorption, one-compartment model to study the relationship between the pharmacokinetics/pharmacodynamics (PK/PD) index of tilmicosin against M. hyopneumoniae in vitro. We simulated different drug concentrations of timicosin in the fluid lining the lung epithelia of pigs. The minimum inhibitory concentration (MIC) of tilmicosin against M. hyopneumoniae with an inoculum of 106 CFU/mL was 1.6 μg/mL using the microdilution method. Static time–kill curves showed that if the drug concentration >1 MIC, the antibacterial effect showed different degrees of inhibition. At 32 MIC, the amount of bacteria decreased by 3.16 log10 CFU/mL, thereby achieving a mycoplasmacidal effect. The M. hyopneumoniae count was reduced from 3.61 to 5.11 log10 CFU/mL upon incubation for 96 h in a dynamic model with a dose of 40–200 mg, thereby achieving mycoplasmacidal activity. The area under the concentration-time curve over 96 h divided by the MIC (AUC0–96 h/MIC) was the best-fit PK/PD parameters for predicting the antibacterial activity of tilmicosin against M. hyopneumoniae (R2 = 0.99), suggesting that tilmicosin had concentration-dependent activity. The estimated value for AUC0–96 h/MIC for 2log10 (CFU/mL) reduction and 3log10 (CFU/mL) reduction from baseline was 70.55 h and 96.72 h. Four M. hyopneumoniae strains (M1–M4) with reduced sensitivity to tilmicosin were isolated from the four dose groups. The susceptibility of these strains to tylosin, erythromycin and lincomycin was also reduced significantly. For sequencing analyses of 23S rRNA, an acquired A2058G transition in region V was found only in resistant M. hyopneumoniae strains (M3, M4). In conclusion, in an in vitro model, the effect of tilmicosin against M. hyopneumoniae was concentration-dependent and had a therapeutic effect. These results will help to design the optimal dosing regimen for tilmicosin in M. hyopneumoniae infection, and minimize the emergence of resistant bacteria.
Iron Oxide/Salicylic Acid Nanoparticles as Potential Therapy for B16F10 Melanoma Transplanted on the Chick Chorioallantoic Membrane
Authors: Predoi Maria Cristina , Mîndrilă Ion , Buteică Sandra Alice , Purcaru Ștefana Oana , Mihaiescu Dan Eduard , Mărginean Ovidiu Marcel
Published: June 2020

Unfavorable prognoses and low survival rates are specific features of metastatic melanoma that justify the concern for the development of new therapeutic strategies. Lately, nanotechnology has become an attractive field of study due to recent advances in nanomedicine. Using a chick chorioallantoic membrane (CAM) implanted with xenografts harvested from C57BL/6 mice with B16F10 melanoma cells, we studied the effects of iron oxide nanoparticles functionalized with salicylic acid (SaMNPs) as a form of therapy on the local development of xenotransplants and CAM vessels. The SaMNPs induced an anti-angiogenic effect on the CAM vessels, which accumulated preferentially in the melanoma cells and induced apoptosis and extensive xenograft necrosis. As a result, this slowed the increase in the xenograft volume and reduced the melanoma cells’ ability to metastasize locally and distally. Further, we demonstrate the use of the chick CAM model as a tool for testing the action of newly synthesized nanocomposites on melanoma xenotransplants. The SaMNPs had a therapeutic effect on B16F10 melanoma due to the synergistic action of the two components of its structure: the coating of the salicylic acid with antiangiogenic and chemotherapeutic action and the core of iron oxides with cytotoxic action.
Immunogenicity Measures of Influenza Vaccines: A Study of 1164 Registered Clinical Trials
Authors: Domnich Alexander , Manini Ilaria , Panatto Donatella , Calabrò Giovanna Elisa , Montomoli Emanuele
Published: June 2020

Influenza carries an enormous burden each year. Annual influenza vaccination is the best means of reducing this burden. To be clinically effective, influenza vaccines must be immunogenic, and several immunological assays to test their immunogenicity have been developed. This study aimed to describe the patterns of use of the various immunological assays available to measure the influenza vaccine-induced adaptive immune response and to determine its correlates of protection. A total of 76.5% of the studies included in our analysis measured only the humoral immune response. Among these, the hemagglutination-inhibition assay was by far the most widely used. Other, less common, humoral immune response assays were: virus neutralization (21.7%), enzyme-linked immunosorbent (10.1%), single radial hemolysis (4.6%), and assays able to quantify anti-neuraminidase antibodies (1.7%). By contrast, cell-mediated immunity was quantified in only 23.5% of studies. Several variables were significantly associated with the use of single assays. Specifically, some influenza vaccine types (e.g., adjuvanted, live attenuated and cell culture-derived or recombinant), study phase and study sponsorship pattern were usually found to be statistically significant predictors. We discuss the principal findings and make some suggestions from the point of view of the various stakeholders.
IFN-I Independent Antiviral Immune Response to Vesicular Stomatitis Virus Challenge in Mouse Brain
Authors: Mishra Anurag R. , Byrareddy Siddappa N. , Nayak Debasis
Published: June 2020

Type I interferon (IFN-I) plays a pivotal role during viral infection response in the central nervous system (CNS). The IFN-I can orchestrate and regulate most of the innate immune gene expression and myeloid cell dynamics following a noncytopathic virus infection. However, the role of IFN-I in the CNS against viral encephalitis is not entirely clear. Here we have implemented the combination of global differential gene expression profiling followed by bioinformatics analysis to decipher the CNS immune response in the presence and absence of the IFN-I signaling. We observed that vesicular stomatitis virus (VSV) infection induced 281 gene changes in wild-type (WT) mice primarily associated with IFN-I signaling. This was accompanied by an increase in antiviral response through leukocyte vascular patrolling and leukocyte influx along with the expression of potent antiviral factors. Surprisingly, in the absence of the IFN-I signaling (IFNAR−/− mice), a significantly higher (1357) number of genes showed differential expression compared to the WT mice. Critical candidates such as IFN-γ, CCL5, CXCL10, and IRF1, which are responsible for the recruitment of the patrolling leukocytes, are also upregulated in the absence of IFN-I signaling. The computational network analysis suggests the presence of the IFN-I independent pathway that compensates for the lack of IFN-I signaling in the brain. The analysis shows that TNF-α is connected maximally to the networked candidates, thus emerging as a key regulator of gene expression and recruitment of myeloid cells to mount antiviral action. This pathway could potentiate IFN-γ release; thereby, synergistically activating IRF1-dependent ISG expression and antiviral response.
Water Supply Delivery Failures—A Scenario-Based Approach to Assess Economic Losses and Risk Reduction Options
Authors: Sjöstrand Karin , Lindhe Andreas , Söderqvist Tore , Rosén Lars
Published: June 2020

Access to a reliable water supply is central for a well-functioning society. However, water supply systems are subject to a wide range of threats which may affect their ability to provide water to society. This paper presents a novel risk assessment approach that enables thorough analyses of economic losses and associated uncertainties under a range of water supply disruption scenarios. The purpose is to avoid sub-optimization when prioritizing between risk reduction measures, by integrating the full range of possible outcomes from low to high probability events. By combining risk analysis with cost-benefit analysis, additional information is provided on measures for leveraging investments in managing and reducing the risks. This enables the identification of the most economically profitable risk reduction alternatives and enables decision makers to build strategic capacity for operating in difficult and uncertain futures. The presented approach is exemplified on the island of Gotland, one of the most water scarce areas of Sweden.
Assessment of Future Water Demand and Supply under IPCC Climate Change and Socio-Economic Scenarios, Using a Combination of Models in Ourika Watershed, High Atlas, Morocco
Authors: Ayt Ougougdal Houssam , Yacoubi Khebiza Mohamed , Messouli Mohammed , Lachir Asia
Published: June 2020

Climate change will affect the water resources system, on global and regional levels. Over the past thirty years, the High Atlas Mountains in Morocco have experienced severe droughts, which causes a decrease in water supply that affects both agriculture and the urban water system. In this paper, we assess the impact of climate change and socio-economic activities on water supply and demand in the Ourika watershed (High Atlas of Morocco), then we evaluate the efficiency and sustainability of regional adaptation strategies for water supply management. For this, we simulate and analyze the future water situation using the statistical downscaling model (SDSM) and the water assessment and planning tool (WEAP). After the model’s calibration and validation, the precipitation, minimum (Tmin) and maximum (Tmax) temperatures, water demand and unmet water demand were projected for 2100 horizon, using different climate change scenarios. The results revealed that the model’s performance, calibration and validation were found to be satisfactory. The analysis shows that the mean precipitation will decrease by 49.25% and 34.61% by 2100, under A2 and B2 emission scenarios of the Intergovernmental Panel on Climate Change (IPCC). The projected mean Tmax and Tmin will be warmer than the baseline period, with Tmax increasing by 4.2 °C (A2) and 3.6 °C (B2), and Tmin by 3.5 °C (A2) and 2.9 °C (B2) by 2100. The results also show that water demand and the unmet water demand will increase in all scenarios, the pressure on water resources will increase, leading to water scarcity. The results reveal that, under the influence of climate change, future unmet water demand is expected to reach 64 million cubic meters (MCM) by 2100. The results demonstrate that the assessments of the proposed adaptation strategies are effective, but not sufficient to ensure water sustainability for the Ourika watershed.
The annual dementia review: exploring current practice in primary care
Authors: Dow Johanne , Wheatley Alison , Exley Catherine , Robinson Louise
Published: June 2020

Background

Dementia is a global public health challenge, the significant consequences of which are recognised in global and national health policies. Despite approaches to improve the implementation of evidence-based dementia care in primary care and the inclusion of indicators for dementia in the Quality and Outcomes Framework (QOF), there is consistent evidence that people with dementia and their family carers lack access to care which meets their needs.

Aim

This study aims to explore current practice regarding the annual dementia review in primary care by investigating: 1) what ‘should’ be happening in annual dementia reviews; 2) how dementia reviews are delivered in a sample of general practices; 3) the barriers and facilitators to the implementation of evidence-based care in dementia reviews; and 4) the experience of these reviews from the perspectives of people with dementia and their informal carer(s).

Method

Qualitative methods will be used. In the first stage, semi-structured interviews with national and regional experts in dementia policy and healthcare will be used to explore what ‘should’ be happening in an annual dementia review. In the second stage, interviews with primary healthcare team members will explore how annual dementia reviews are delivered in a sample of practices in North East England. Interviews with people with dementia and their carers will then be used to explore how reviews are experienced by service users. Thematic analysis will be used to analyse data.

Results

Key themes from the first stage will be presented and their implications in primary care discussed.

Conclusion

The research plan for the second stage will be presented.
Improving access to appointments at Laurie Pike Health Centre
Authors: Moxey Jordan , Murdoch Will
Published: June 2020

Background

Rising demand makes it increasingly difficult for patients to access appointments. Laurie Pike Health Centre (LPHC) operates a predominantly same-day booking policy in order to manage appointment requests from its 18 000 patients. We sought to quantify the number of requests, in order to estimate the unmet demand.

Aim

1) To estimate the met and unmet demand for same-day appointments; 2) To assess how capacity for same-day appointments compares to demand; 3) To analyse how well LPHC is utilising its available appointment slots.

Method

We created a data collection tool to count the total number of patient requests by type. We grouped types into four categories: 1) medical appointment requests; 2) sick notes and results requests; 3) other appointment requests (such as healthcare assistant, nurse); and 4) admin/other. Category-specific percentages were applied to call log data to estimate the number of appointment requests per category. Capacity was measured by counting the total number of same-day GP/advanced nurse practitioner (ANP) appointment slots. Consultation records for GP/ANP appointments were analysed to assess the appropriateness of the booking.

Results

Estimated average demand for same-day GP/ANP appointments was 222 per day. Average same-day capacity was 112 slots. After introducing pharmacist and video consultations, average capacity increased to 194 slots per day, a shortfall of 28 appointments. Consultation records indicated that 41% of GP/ANP appointments could have been seen by other practitioners; for example, musculoskeletal practitioners (14%).

Conclusion

GP/ANP appointments alone cannot meet patient demand but a diversified workforce might. Alongside this, efforts to improve care navigation may free up to 41% of GP/ANP appointment slots.
What influences Roma women attending NHS cervical screening? Knowledge, fear, and passive consent
Authors: Lehane David , Kandrac David , Walton Elizabeth , Mitchell Caroline
Published: June 2020

Background

Recent immigration from Eastern Europe poses new challenges in engaging with women eligible to have smears. The Roma population have low socioeconomic status, low educational status, and a life expectancy 10 years lower than other EU citizens. An audit of smear uptake in four ‘Deep End’ Sheffield practices identified as having >1000 registered Roma Slovak patients, demonstrated smear uptakes between 53% to 40%, all of which are below the Sheffield CCG average of 73.5%.

Aim

To establish the barriers, facilitators and attitudes of Roma women towards accessing the NHS cervical screening.

Method

Semi-structured interviews were recorded, transcribed, and analysed thematically using an iterative, with independent verification of emergent themes. Interviews continued to data saturation. Interviews were carried out in the patient’s home or a community centre, facilitated by a trained interpreter.

Results

Sixteen women who self-identified as Roma, were interviewed. The overarching themes of ‘language discordance’, ‘poor educational attainment’, and ‘passivity in receiving care’, influenced the women’s likelihood of smear uptake or the need for screening. These emergent themes underpinned a longstanding distrust of the role of the state in relation to the health needs of the community.

Conclusion

It is vital that we develop and evaluate appropriate interventions to increase smear uptake in migrant and other vulnerable populations. There is a need for the UK to adapt screening programmes to maximise uptake within ‘hard to reach’ groups, such as the ‘Roma’, who are likely to be at the highest risk of cancer and late presentation of the disease.
Workforce Race Equality Standard survey in general practice: Lewisham 2019
Authors: Kalwij Sebastian
Published: June 2020

Background

The NHS Workforce Race Equality Standard (WRES) was introduced in 2015 and is mandatory for NHS trusts. Nine indicators have been created to evaluate the experiences of black and minority ethnic (BME) staff compared with the rest of the workforce. The trust data published showed a poor experience of BME staff compared with non BME staff.

Aim

To introduce the concept of WRES into general practice and create a baseline from which improvement can be made. A diverse workforce will better serve its population and this will improve health outcomes.

Method

We conducted a survey among all general practice staff members, clinicians, and non-clinicians and asked open-ended questions built around four WRES indicators most applicable to general practice, over a 6-week period in August and September 2019.

Results

We collected 151 responses out of a total workforce of around 550. The response rate between clinicians and non-clinicians was equal 50.6% versus 49.4%. The distribution of non BME staff 51% versus BME staff 49% mirrors the diverse population of Lewisham. 54% of BME staff experienced bullying from patients, their relatives, and members of the public. 25% experienced bullying from a colleague or staff member in the workplace and 22% of BME staff changed jobs as a result of this.

Conclusion

BME staff in general practice report high levels of racism, especially from service users. In 22% this led to a career change. A zero-tolerance policy needs to be enforced and a multi-pronged approach is required to address this.
Identification and management of frailty in English primary care: a qualitative study of national policy
Authors: van Marwijk Harm , Blakeman Tom , Reeves David , Alharbi Khulud
Published: June 2020

Background

Policymakers are directing attention to addressing the needs of an ageing population. Since 2017, general practices in England have been contractually required to identify and code ‘frailty’ as a new clinical concept and, in doing so, support targeted management for this population with the aim of improving outcomes. However, embedding frailty policies into routine practice is not without challenges and little is currently known about the success or otherwise of the programme.

Aim

To explore the implementation of a national policy on frailty identification and management in English primary care.

Method

Semi-structured interviews were conducted with GPs (n = 10), nurses (n = 6), practice managers (n = 3) and health advisors (n = 3). Normalisation Process Theory (NPT) and System Thinking provided sensitizing frameworks to support data collection and analysis.

Results

Primary care professionals were starting to use the concept of frailty to structure care both within practices and across organisations, however, there was widespread concern about the challenge of providing expanded care for the identified needs within existing resources. Concerns were also expressed around how best to identify the frail subpopulation and the limitations of current tools for this, and there was a professional reticence to use the term ‘frailty’ with patients.

Conclusion

Findings suggest that additional focused resources and the development of a stronger evidence base are essential to facilitate professional engagement in policies to improve the targeted coding and management of frailty in primary care.
Study design of the Fasting In diabetes Treatment (FIT) trial: a randomised, controlled, assessor blinded intervention trial which examines the effect of intermittent use of a fasting mimicking diet in patients with type 2 diabetes
Authors: van den Burg Elske , Schoonakker Marjolein , van den Akker Elske , van Dijk Ko Willems , Lamb Hildo , Pijl Hanno , Numans Mattijs , van Peet Petra
Published: June 2020

Background

Caloric restriction is an effective way to treat type 2 diabetes (DM2). However, chronic restriction of food intake is difficult to sustain. Intermittent total fasting exerts similar metabolic effects, but may be even more challenging for most patients. A fasting mimicking diet (FMD) was designed to achieve the metabolic benefits of total fasting, despite considerable calorie content. The effects of a FMD in DM2 patients are still unknown.

Aim

To determine the effect of intermittent use (5 consecutive days a month during a year) of a FMD in DM2 patients on metabolic parameters and DM2 medication use compared to usual care.

Method

One hundred DM2 patients from general practices in the Netherlands with a BMI ≥ 27 kg/m2, treated with lifestyle advice only or metformin, will be randomised to receive the FMD plus usual care or usual care only. Primary outcomes are HbA1c and DM2 medication dosage. Secondary outcomes are anthropometrics, blood pressure, plasma lipid profiles, quality of life, treatment satisfaction, metabolomics, microbiome, MRI (for example, cardiac function and fat distribution), cost-effectiveness, and feasibility in clinical practice.

Results

The first 70 patients are included. Follow up will be completed in April 2021.

Conclusion

Our results will show whether monthly cycles of a FMD are feasible in clinical practice, if they improve metabolic parameters and/or reduce the need for medication in DM2 and if this is a cost-effective intervention.
Emergency Admission Risk Prediction (EARP) tools in primary care to reduce emergency admissions to hospital: clash of evidence and practice
Authors: Snooks Helen , Kingston Mark , Porter Alison , Hutchings Hayley , Russell Ian
Published: June 2020

Background

Policy initiatives have incentivised use of EARP tools in primary care to reduce emergency admissions. A recently published trial in South Wales found that EARP increased emergency admissions and emergency department attendances without clear benefits. This cost the NHS an additional £76 per patient per year. But the use of EARP in primary care across the UK was unknown.

Aim

To assess implementation and facilitators use of EARP tools in primary care across the UK.

Method

Structured email survey of 235 UK primary care commissioners across the UK.

Results

There were 148 (87%) of 171 responders (73%) who reported that EARP tools were available in their areas. We identified 39 different EARP tools in use. Access to EARP tools varied widely by country: Northern Ireland (100%), Scotland (91%), England (76%) and Wales (14%). Promotion by NHS commissioners, and engagement of clinical leaders and practice managers were identified as the most important factors in encouraging use of EARP tools. Research evidence was seen as less important. Nearly 40% of areas using EARP reported that they had revised services as a result, but few reported use of EARP for service evaluation.

Conclusion

Though EARP tools are widely available in primary care, new evidence shows that they are counter-productive. We estimate that by delaying the dissemination of EARP for evaluation NHS Wales saved >£200 million per year. We encourage further research and discussion about next steps in use of EARP tools in emergency admission prevention in the UK.
Vitamin D deficiency is associated with increased risk of postural hypotension in older men: a cross-sectional analysis from The British Regional Heart Study
Authors: Gilani Artaza , Ramsay Sheena , Welsh Paul , Papacosta Olia , Lennon Lucy , Whincup Peter , Wannamethee S Goya
Published: June 2020

Background

There is growing interest in the role of vitamin D in extra-skeletal health, including postural hypotension. Postural hypotension is found in 1 in 5 community-dwelling adults aged 60 years and above. It increases risk of falls, fractures, cardiovascular disease and all-cause mortality. Better understanding of the aetiology of postural hypotension may help yield more effective treatment options than those that are currently available.

Aim

The aim of this study was to investigate the association between circulating vitamin D, parathyroid hormone and postural hypotension.

Method

This was a cross-sectional analysis of 3620 community-dwelling men living in the UK (mean age 68.6 years; standard deviation 5.5 years). Vitamin D status (nmol/L) was categorised as sufficient (≥50), insufficient (≥25 – <50), or deficient (<25). Parathyroid hormone levels were categorised by quintiles. Postural hypotension was defined by consensus criteria as a decrease in systolic blood pressure ≥20 mmHg and/or diastolic blood pressure ≥10 mmHg that occurred within three minutes of standing.

Results

Compared to sufficient levels of vitamin D, vitamin D deficiency increased risk of postural hypotension that specifically occurred within one minute of standing (OR 1.51, 95% CI = 1.06 to 2.15) in multinomial, multiple logistic regression. Neither vitamin D insufficiency, nor elevated parathyroid hormone, were associated with postural hypotension.

Conclusion

In this study, vitamin D deficiency was associated with increased risk of postural hypotension. Further research may help clarify whether treating vitamin D deficiency can reduce the degree of postural hypotension, or if preventing the progression to vitamin D deficiency can reduce the incidence of postural hypotension.
If GPs who teach medical students were assisted to be good role models might this influence the medical career the students choose?
Authors: White Jonathan
Published: June 2020

Background

Most patients are cared for in the community by GPs, and workforce planning for the UK NHS suggests that 50% of medical school graduates need to train as GPs. While there is pressure on medical schools to provide more student teaching in general practice, general practice must be prepared for this increase in workload and teachers should have appropriate training.

Aim

This study examined the influence that teachers as role models can have on the development and career choices of medical students and whether GPs who teach medical students might benefit from assistance in developing positive attributes.

Method

A literature search was carried out. Relevant papers were those that examined the influence of a doctor as teacher role model for medical students, both in assisting in professional development and clinical skills, and in influencing career choice.

Results

The review identified eleven papers. There was evidence of association between a student having an influential role model as teacher and choosing specialty training in that area, although evidence of a causative connection is less convincing. A recurring theme is the recommendation that teachers should be aware of the influence they can have as role models, both positive and negative.

Conclusion

As medical student teaching moves into general practice GPs who teach will need to be helped to understand and develop positive role model attributes, to promote general practice as an attractive career to the students. Further research needs to identify the extent of assistance required and whether medical schools are prepared for this extra responsibility.
In situ deteriorating patient simulation in general practice
Authors: Lawrence Joanna , Eastwick-Field Petronelle , Maloney Anne , Higham Helen
Published: June 2020

Background

GP practices have limited access to medical emergency training and basic life support is often taught out of context as a skills-based event.

Aim

To develop and evaluate a whole team integrated simulation-based education, to enhance learning, change behaviours and provide safer care.

Method

Phase 1: 10 practices piloted a 3-hour programme delivering 40 minutes BLS and AED skills and 2-hour deteriorating patient simulation. Three scenarios where developed: adult chest pain, child anaphylaxis and baby bronchiolitis. An adult simulation patient and relative were used and a child and baby manikin. Two facilitators trained in coaching and debriefing used the 3D debriefing model. Phase 2: 12 new practices undertook identical training derived from Phase 1, with pre- and post-course questionnaires. Teams were scored on: team working, communication, early recognition and systematic approach. The team developed action plans derived from their learning to inform future response. Ten of the 12 practices from Phase 2 received an emergency drill within 6 months of the original session. Three to four members of the whole team integrated training, attended the drill, but were unaware of the nature of the scenario before. Scoring was repeated and action plans were revisited to determine behaviour changes.

Results

Every emergency drill demonstrated improved scoring in skills and behaviour.

Conclusion

A combination of: in situ GP simulation, appropriately qualified facilitators in simulation and debriefing, and action plans developed by the whole team suggests safer care for patients experiencing a medical emergency.
2017 Cancer Prevalence Dashboard for London
Authors: Zalin Amy , Jose Sophie , Petit Jason , Price Liz , Anastasiadis Tania
Published: June 2020

Background

As cancer incidence increases and survival improves, the number of people living with a cancer diagnosis is increasing. People living with cancer have 50% more contact with GPs 15 months after diagnosis than a population of similar age, sex and locality; 70% have another long-term condition.

Aim

To aid service providers’ understanding of the cancer prevalent population by creating a publicly available visualisation tool that both describes patients’ demographics and length of time lived with cancer, and compares counts of nationally registered cancer survivors to GP-maintained registers.

Method

Using National Cancer Registration and Analysis Service (NCRAS) data, prevalence rates and counts were generated for London patients diagnosed 1995–2017 and alive 31 December 2017, overall and for lower-level geographies. GP-recorded Quality and Outcomes Framework (QOF) prevalence at Clinical Commissioning Group (CCG) level was compared to NCRAS counts for the same period.

Results

On 31 December 2017, 231 740 (2.6%) people were living with cancer in London; 33% were diagnosed 5–9 years prior and 31% were diagnosed ≥10 years prior. Prevalence was higher in women (P<0.001) and dramatically increased with age for London (P<0.001); >12% of >75 year olds were living with a cancer diagnosis in every lower-level geography. Completeness of GP QOF cancer registers against NCRAS prevalence counts ranged from 75–108% across CCGs.

Conclusion

Local understanding of the cancer prevalent population is needed, with a concerted effort to interpret large discrepancies between QOF and NCRAS registers, which may arise from differences in coding practice. Ensuring patients are identified in primary care is a first key step to managing cancer as a long-term condition.
The prevalence of musculoskeletal presentations in general practice: an epidemiological study
Authors: Keavy Ruairi
Published: June 2020

Background

It is estimated that 28.9% (17.8 million) of the UK population live with a musculoskeletal (MSK) condition. They are a major cause of morbidity, and a significant reason for presentation to primary care.

Aim

The primary aim of this study was to determine the prevalence of MSK conditions presenting for consultation in general practice. The secondary aim was to determine specifically which MSK conditions present most frequently in general practice.

Method

A total of 545 consultations were reviewed at an urban community general practice, which included evaluating morning consultations over a 1-week period taken from each of January, April, July and October 2018. This encompassed all morning consultations from all GPs present. The number of MSK consultations were recorded and, within that, the different presentations and their management plan.

Results

A total of 115 of all consultations were regarding an MSK presentation yielding an overall prevalence of 21.1%. The commonest MSK presentations included the lumbosacral spine (18.3%) and the knee (17.4%). Re-presentations of original condition accounted for 73.9% of all MSK consultations. Steroid injections were administered in 33% of knee related consultations.

Conclusion

This study demonstrates that MSK presentations account for a large proportion of GP workload. There are no current mandatory training requirements in orthopaedics as part of the GP curriculum. Structured MSK education for GPs is important and would reduce the burden of re-presentations, particularly that of the lumbosacral spine and knee. Competency in joint injection is also a valuable skill for GPs.
A scoping review of community holistic interventions for older people with multimorbidity
Authors: Smith Timothy , Patel Tahera , Akpan Asangaedem , Clegg Andrew , Watkins Dame Caroline , Lightbody Catherine Elizabeth , Chauhan Umesh
Published: June 2020

Background

In many areas, new regional community-based services have been established to provide holistic care to patients with high physical, mental and social needs. Older people represent a group with multimorbidity and high healthcare needs that may benefit from holistic care, although uncertainty remains whether such an approach is effective.

Aim

To review evidence for community holistic interventions in older people with multimorbidity.

Method

The authors screened studies referenced by an earlier Cochrane Review and Academy of Medical Sciences report, both of which looked at interventions and populations more broadly, and their own searches of Medline, EMBASE, trial registration databases and hand-searching of journals since 2015. The authors included controlled community-based studies of holistic interventions with data for people aged at least 60 years.

Results

Studies found (five published, two ongoing) were heterogeneous. The only significant improvement relating to physical or mental outcomes occurred in self-rated health scores, seen in two studies. One consisting entirely of diabetics showed developing a self-management plan improved self-rated health (P = 0.023), and Mental Component Summary (P = 0.03). The other used a multidisciplinary-team-guided personal care plan and found self-rated overall health improved (P = 0.02). Three studies looked at service usage, only one seeing a benefit, and only in the second year.

Conclusion

Community-based holistic interventions for people with multimorbidity tended to focus on disease management or medication modification, and resulted in few significant benefits, almost entirely in self-rated health measures. Research into interventions focused on those with the highest needs, for example, multimorbidity with frailty; high number of comorbidities may be more likely to demonstrate meaningful benefits.
A case study evaluation of a community multidisciplinary team in South East England using a mixed-method approach
Authors: Muscat Jessica Wyatt
Published: June 2020

Background

Community multidisciplinary teams (MDTs) represent a model of integrated care comprising health, social care, and the voluntary sector where members work collaboratively to coordinate care for those patients most at risk.

Aim

The evaluation will answer the question, ‘What are the enablers and what are the restrictors to the embedding of the case study MDT into the routine practice of the health and social care teams involved in the project?’

Method

The MDT was evaluated using a mixed-method approach with normalisation process theory as a methodological tool. Both quantitative and qualitative data were gathered through a questionnaire consisting of the NoMAD survey followed by free-form questions.

Results

The concepts of the MDT were generally clear, and participants could see the potential benefits of the programme, though this was found to be lower in GPs. Certain professionals, particularly mental health and nursing professionals, found it difficult to integrate the MDT into normal working patterns because of a lack of resources. Participants also felt there was a lack of training for MDT working. A lack of awareness of evidence supporting the programme was shown particularly within management, GP, and nursing roles.

Conclusion

Specific recommendations have been made in order to improve the MDT under evaluation. These include adjustments to IT systems and meeting documentation, continued education as to the purpose of the MDT, and the engagement of GPs to enable better buy-in. Recommendations were made to focus the agenda with specialist attendance when necessary, and to expand the MDT remit, particularly in mental health and geriatrics.