bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of the Efficacy of Mycotoxin Modifiers and Mycotoxin Binders by Using an In Vitro Rumen Model as a First Screening Tool
Authors: Debevere Sandra , Schatzmayr Dian , Reisinger Nicole , Aleschko Markus , Haesaert Geert , Rychlik Michael , Croubels Siska , Fievez Veerle
Published: June 2020

Ruminal microbiota of cattle are not able to detoxify all mycotoxins. In addition, detoxification can be hampered by adverse ruminal conditions (e.g., low ruminal pH). Hence, in the cattle husbandry, mycotoxin binders and modifiers could be used to prevent animal exposure to mycotoxins. In this study, an in vitro rumen model, including feed matrix, was established as first screening tool to test the efficacy of five products claiming to detoxify mycotoxins. The detoxifiers had different modes of action: (a) binding (three products); (b) enzymatic detoxification of zearalenone (ZEN; one product, ZenA); and (c) bacterial transformation of trichothecenes (one product, BBSH 797). For the mycotoxin binders, the binding to the mycotoxins enniatin B (ENN B), roquefortine C (ROQ-C), mycophenolic acid (MPA), deoxynivalenol (DON), nivalenol (NIV), and zearalenone (ZEN) were tested at a dose recommended by the manufacturers. The in vitro model demonstrated that all binders adsorbed ENN B to a certain extent, while only one of the binders also partially adsorbed ROQ-C. The binders did not change the concentrations of the other mycotoxins in the ruminal fluid. The enzyme ZenA detoxified ZEN very quickly and prevented the formation of the more toxic metabolite α-zearalenol (α-ZEL), both at normal (6.8) and low ruminal pH (5.8). The addition of BBSH 797 enhanced detoxification of DON and NIV, both at normal and low ruminal pH. The in vitro rumen model demonstrated that the addition of ZenA seems to be a very promising strategy to prevent estrogenic effects of ZEN contaminated feed, and BBSH 797 is efficient in the detoxification of trichothecenes.
The Southeast Alaska Tribal Ocean Research (SEATOR) Partnership: Addressing Data Gaps in Harmful Algal Bloom Monitoring and Shellfish Safety in Southeast Alaska
Authors: Harley John R. , Lanphier Kari , Kennedy Esther G. , Leighfield Tod A. , Bidlack Allison , Gribble Matthew O. , Whitehead Christopher
Published: June 2020

Many communities in Southeast Alaska harvest shellfish such as mussels and clams as an important part of a subsistence or traditional diet. Harmful algal blooms (HABs) of phytoplankton such as Alexandrium spp. produce toxins that can accumulate in shellfish tissues to concentrations that can pose a hazard for human health. Since 2013, several tribal governments and communities have pooled resources to form the Southeast Alaska Tribal Ocean Research (SEATOR) network, with the goal of minimizing risks to seafood harvest and enhancing food security. SEATOR monitors toxin concentrations in shellfish and collects and consolidates data on environmental variables that may be important predictors of toxin levels such as sea surface temperature and salinity. Data from SEATOR are publicly available and are encouraged to be used for the development and testing of predictive algorithms that could improve seafood risk assessment in Southeast Alaska. To date, more than 1700 shellfish samples have been analyzed for paralytic shellfish toxins (PSTs) in more than 20 locations, with potentially lethal concentrations observed in blue mussels (Mytilus trossulus) and butter clams (Saxidomus gigantea). Concentrations of PSTs exhibit seasonality in some species, and observations of Alexandrium are correlated to sea surface temperature and salinity; however, concentrations above the threshold of concern have been found in all months, and substantial variation in concentrations of PSTs remain unexplained.
Epidemiological and Clinical Evidence for the Role of Toxins in S. aureus Human Disease
Authors: Bennett Monique R. , Thomsen Isaac P.
Published: June 2020

Staphylococcus aureus asymptomatically colonizes approximately 30–50% of the population and is a leading cause of bacteremia, bone/joint infections, and skin infections in the US. S. aureus has become a major public health threat due to antibiotic resistance and an increasing number of failed vaccine attempts. To develop new anti-staphylococcal preventive therapies, it will take a more thorough understanding of the current role S. aureus virulence factors play in contributing to human disease. This review focuses on the clinical association of individual toxins with S. aureus infection as well as attempted treatment options. Further understanding of these associations will increase understanding of toxins and their importance to S. aureus pathogenesis.
Forced Zika Virus Infection of Culex pipiens Leads to Limited Virus Accumulation in Mosquito Saliva
Authors: Abbo Sandra R. , Vogels Chantal B. F. , Visser Tessa M. , Geertsema Corinne , van Oers Monique M. , Koenraadt Constantianus J. M. , Pijlman Gorben P.
Published: June 2020

Zika virus (ZIKV) is a mosquito-borne pathogen that caused a large outbreak in the Americas in 2015 and 2016. The virus is currently present in tropical areas around the globe and can cause severe disease in humans, including Guillain-Barré syndrome and congenital microcephaly. The tropical yellow fever mosquito, Aedes aegypti, is the main vector in the urban transmission cycles of ZIKV. The discovery of ZIKV in wild-caught Culex mosquitoes and the ability of Culex quinquefasciatus mosquitoes to transmit ZIKV in the laboratory raised the question of whether the common house mosquito Culex pipiens, which is abundantly present in temperate regions in North America, Asia and Europe, could also be involved in ZIKV transmission. In this study, we investigated the vector competence of Cx. pipiens (biotypes molestus and pipiens) from the Netherlands for ZIKV, using Usutu virus as a control. After an infectious blood meal containing ZIKV, none of the tested mosquitoes accumulated ZIKV in the saliva, although 2% of the Cx. pipiens pipiens mosquitoes showed ZIKV–positive bodies. To test the barrier function of the mosquito midgut on virus transmission, ZIKV was forced into Cx. pipiens mosquitoes by intrathoracic injection, resulting in 74% (molestus) and 78% (pipiens) ZIKV–positive bodies. Strikingly, 14% (molestus) and 7% (pipiens) of the tested mosquitoes accumulated ZIKV in the saliva after injection. This is the first demonstration of ZIKV accumulation in the saliva of Cx. pipiens upon forced infection. Nevertheless, a strong midgut barrier restricted virus dissemination in the mosquito after oral exposure and we, therefore, consider Cx. pipiens as a highly inefficient vector for ZIKV.
Phylogenetic and Geospatial Evidence of Canine Parvovirus Transmission between Wild Dogs and Domestic Dogs at the Urban Fringe in Australia
Authors: Kelman Mark , Harriott Lana , Carrai Maura , Kwan Emily , Ward Michael P. , Barrs Vanessa R.
Published: June 2020

Canine parvovirus (CPV) is an important cause of disease in domestic dogs. Sporadic cases and outbreaks occur across Australia and worldwide and are associated with high morbidity and mortality. Whether transmission of CPV occurs between owned dogs and populations of wild dogs, including Canis familiaris, Canis lupus dingo and hybrids, is not known. To investigate the role of wild dogs in CPV epidemiology in Australia, PCR was used to detect CPV DNA in tissue from wild dogs culled in the peri-urban regions of two Australian states, between August 2012 and May 2015. CPV DNA was detected in 4.7% (8/170). There was a strong geospatial association between wild-dog CPV infections and domestic-dog CPV cases reported to a national disease surveillance system between 2009 and 2015. Postcodes in which wild dogs tested positive for CPV were 8.63 times more likely to also have domestic-dog cases reported than postcodes in which wild dogs tested negative (p = 0.0332). Phylogenetic analysis of CPV VP2 sequences from wild dogs showed they were all CPV-2a variants characterized by a novel amino acid mutation (21-Ala) recently identified in CPV isolates from owned dogs in Australia with parvoviral enteritis. Wild-dog CPV VP2 sequences were compared to those from owned domestic dogs in Australia. For one domestic-dog case located approximately 10 km from a wild-dog capture location, and reported 3.5 years after the nearest wild dog was sampled, the virus was demonstrated to have a closely related common ancestor. This study provides phylogenetic and geospatial evidence of CPV transmission between wild and domestic dogs in Australia.
Extracellular Vesicle Activation of Latent HIV-1 Is Driven by EV-Associated c-Src and Cellular SRC-1 via the PI3K/AKT/mTOR Pathway
Authors: Barclay Robert A. , Mensah Gifty A. , Cowen Maria , DeMarino Catherine , Kim Yuriy , Pinto Daniel O. , Erickson James , Kashanchi Fatah
Published: June 2020

HIV-1 is a global health crisis that has infected more than 37 million people. Latent reservoirs throughout the body are a major hurdle when it comes to eradicating the virus. In our previous study, we found that exosomes, a type of extracellular vesicle (EV), from uninfected cells activate the transcription of HIV-1 in latent infected cells, regardless of combination antiretroviral therapy (cART). In this study, we investigated the specific mechanism behind the EV activation of latent HIV-1. We found that phosphorylated c-Src is present in EVs of various cell lines and has the ability to activate downstream proteins such as EGFR, initiating a signal cascade. EGFR is then able to activate the PI3K/AKT/mTOR pathway, resulting in the activation of STAT3 and SRC-1, culminating in the reversal of HIV-1 latency. This was verified by examining levels of HIV-1 TAR, genomic RNA and HIV-1 Gag p24 protein in cell lines and primary cells. We found that EVs containing c-Src rescued HIV-1 despite the presence of inhibitors, validating the importance of EV-associated c-Src in latent HIV-1 activation. Lastly, we discovered an increased recruitment of p300 and NF-κB in the nucleus of EV-treated infected cells. Collectively, our data suggest that EV-associated c-Src is able to activate latent HIV-1 via the PI3K/AKT/mTOR pathway and SRC-1/p300-driven chromatin remodeling. These findings could aid in designing new strategies to prevent the reactivation of latent HIV-1 in patients under cART.
Seroprevalence of Neutralizing Antibodies against Japanese Encephalitis Virus among Adolescents and Adults in Korea: A Prospective Multicenter Study
Authors: Kwak Byung Ok , Kwon Young Se , Hong Young Jin , Nahm Chung Hyun , Jang Woori , Uh Young , Cho Yong Gon , Kim Jimyung , Kim Myungshin , Kim Dong Hyun
Published: June 2020

The immunization schedule for the Japanese encephalitis (JE) vaccine in Korea is a two-dose primary series at 12–24 months of age, followed by booster doses 12 months after the second dose and at the ages of 6 and 12 years. Although the number of JE cases has markedly decreased after the universal vaccination program, JE predominantly occurs in adults. The aim of this study was to assess the age-specific prevalence of the JE-neutralizing antibody (NTAb) among adolescents and adults in Korea. A total of 1603 specimens were collected from a healthy Korean population above 15 years old in five provinces. The JE-NTAb titers were measured with the pseudotyped virus assay and considered to be positive at ≥ 1:50. The seropositivity of JE-NTAb was the highest in the 15–29 years category (>95%) and gradually began to decrease in the age group of 30–44 years (89.42%). The lowest and second lowest JE-NTAb seropositive rates were observed among those aged 70 years or older (59.77%) and those aged 55–59 years (75.24%), respectively. Subjects from Seoul exhibited the highest JE-NTAb titer in all age groups compared to other provinces. In conclusion, the JE-NTAb seropositive rates and titers have maintained appropriate levels in the general Korean population. We propose that adult immunization and boosters at 12 years of age against JE are not strongly recommended in Korea.
Kinetics and Isotherm Modeling for the Treatment of Rubber Processing Effluent Using Iron (II) Sulphate Waste as a Coagulant
Authors: Ngteni Rahmat , Hossain Md. Sohrab , Ab Kadir Mohd Omar , Asis Ahmad Jaril , Tajudin Zulhafiz
Published: June 2020

There is increasing concern to determine an alternative coagulant for treating industrial effluent with minimal environmental impact and operational cost. In this study, iron (II) sulphate heptahydrate (FeSO4·7H2O) waste, an industrial byproduct from a titanium oxide processing industry, was used as a coagulant for the removal of ammonia (NH3), chemical oxygen demand (COD), biochemical oxygen demand (BOD), and suspended solid (SS) from secondary rubber processing effluent (SRPE). The highest percentage removal of BOD, COD, SS, and NH3 achieved was approximately 97%, 99%, 98%, and 95%, respectively, at pH 5.0, coagulant dose of 1 g/L, coagulation time of 60 min, sedimentation time of 60 min, and at an elevated temperature of 70 °C. The best described adsorption isotherm model was found to be the Brunauer–Emmett–Teller (BET) model, indicated that the FeSO4·7H2O adsorption took placed on the surface of iron hydroxide precipitates with multilayer formation and random distribution. The kinetics analysis showed that the adsorption mechanism was well fitted with the pseudo-second-order kinetic model. The findings of the present study show that the FeSO4·7H2O waste has the potential to be used as a coagulant for the treatment of industrial effluents, including the secondary rubber processing effluent.
Using Chlorophyll a Fluorescence Imaging to Select Desiccation-Tolerant Native Moss Species for Water-Sustainable Green Roofs
Authors: Cruz de Carvalho Ricardo , Afonso do Paço Teresa , Branquinho Cristina , Marques da Silva Jorge
Published: June 2020

Green roofs have been more thoroughly investigated in the last few years due to the potential benefits they offer to ecosystems in urban areas (e.g., carbon sequestration, particle retention, heat island effect attenuation). However, current climate change models predict an increase in desertification, with an increase in temperature and decrease in rainfall, which means there is an increasing demand for green roofs with lower water consumption. Vegetation with very little water requirements, such as desiccation-tolerant mosses, has shown a potential to complement or substitute for vascular species, increasing the sustainability of lower water use in green roofs. In this study, we use chlorophyll a fluorescence imaging to screen for bryophytes with adequate physiology to be used in green roofs placed in at-risk areas with prolonged drought episodes. Apart from Hypnum cupressiforme, all selected species presented a high potential for use in those conditions, particularly Didymodon fallax, Grimmia lisae, Pleurochaete squarrosa, and Targionia hypophylla. Chlorophyll a fluorescence imaging technology proved to be a simple and non-invasive tool for a fast screening of these poikilohydric organisms, to be used in future studies of bryophyte biology, but more importantly in the green roof industry.
Experimental, Numerical and Field Approaches to Scour Research
Authors: Chiew Yee-Meng , Lai Jihn-Sung , Link Oscar
Published: June 2020

Scour, which represents a fascinating and complex engineering problem involving a number of physical mechanisms and interactions, has motivated a vast amount of research following different but complementary methodological approaches such as experimental, numerical, and field methods. Far from being completely understood, scour remains one of the main hazards for many structures such as bridges, submarine pipelines, offshore wind turbines, etc. Thus, scour is currently a very active field of research with important open questions that are unanswered and practical challenges to be tackled. This Special Issue aims to bridge knowledge gaps by collecting fourteen papers to provide a wide view of scour types and different research approaches, with innovative ideas and inferences.
Improving Inter-Laboratory Reproducibility in Measurement of Biochemical Methane Potential (BMP)
Authors: Hafner Sasha D. , Fruteau de Laclos Hélène , Koch Konrad , Holliger Christof
Published: June 2020

Biochemical methane potential (BMP) tests used to determine the ultimate methane yield of organic substrates are not sufficiently standardized to ensure reproducibility among laboratories. In this contribution, a standardized BMP protocol was tested in a large inter-laboratory project, and results were used to quantify sources of variability and to refine validation criteria designed to improve BMP reproducibility. Three sets of BMP tests were carried out by more than thirty laboratories from fourteen countries, using multiple measurement methods, resulting in more than 400 BMP values. Four complex but homogenous substrates were tested, and additionally, microcrystalline cellulose was used as a positive control. Inter-laboratory variability in reported BMP values was moderate. Relative standard deviation among laboratories (RSDR) was 7.5 to 24%, but relative range (RR) was 31 to 130%. Systematic biases were associated with both laboratories and tests within laboratories. Substrate volatile solids (VS) measurement and inoculum origin did not make major contributions to variability, but errors in data processing or data entry were important. There was evidence of negative biases in manual manometric and manual volumetric measurement methods. Still, much of the observed variation in BMP values was not clearly related to any of these factors and is probably the result of particular practices that vary among laboratories or even technicians. Based on analysis of calculated BMP values, a set of recommendations was developed, considering measurement, data processing, validation, and reporting. Recommended validation criteria are: (i) test duration at least 1% net 3 d, (ii) relative standard deviation for cellulose BMP not higher than 6%, and (iii) mean cellulose BMP between 340 and 395 NmLCH4 gVS−1. Evidence from this large dataset shows that following the recommendations—in particular, application of validation criteria—can substantially improve reproducibility, with RSDR < 8% and RR < 25% for all substrates. The cellulose BMP criterion was particularly important. Results show that is possible to measure very similar BMP values with different measurement methods, but to meet the recommended validation criteria, some laboratories must make changes to their BMP methods. To help improve the practice of BMP measurement, a new website with detailed, up-to-date guidance on BMP measurement and data processing was established.
A primary care network analysis: natural communities of general practices in London
Authors: Beaney Thomas , Clarke Jonathan , Barahona Mauricio , Majeed Azeem
Published: June 2020

Background

Primary care networks (PCNs) are a new organisational hierarchy introduced in the NHS Long Term Plan with wide-ranging responsibilities. The vision is that they represent ‘natural’ communities of general practices with boundaries that make sense to practices, other healthcare providers, and local communities.

Aim

Our study aims to identify natural communities of general practices based on patient registration patterns, using network analysis methods and unsupervised clustering to create catchments for these communities.

Method

Patients resident in and attending GP practices in London were identified from Hospital Episode Statistics from 2017 to 2018. We used a series of novel methods for unsupervised graph clustering. A cosine similarity matrix was constructed representing similarities between each general practice to each other, based on registration of patients in each Lower Super Output Area (LSOA). Unsupervised graph partitioning using Markov Multiscale Community Detection was conducted to identify communities of general practices. Catchments were assigned to each PCN based on the majority attendance from an LSOA.

Results

In total 3 428 322 unique patients attended 1334 GPs in general practices LSOAs in London. The model grouped 1291 general practices (96.8%) and 4721 LSOAs (97.6%), into 165 mutually exclusive PCNs. The median PCN list size was 53 490 and a median of 70.1% of patients attended a general practice within their allocated PCN, ranging from 44.6% to 91.4%.

Conclusion

With PCNs expected to take a role in population health management and with community providers expected to reconfigure around them, it is vital we recognise how PCNs represent their communities. This method may be used by policymakers to understand the populations and geography shared between networks.
Anticipatory care planning for older adults: a trans-jurisdictional feasibility study
Authors: Corry Dagmar , Doherty Julie , McCann Adrienne , Doyle Frank , Cardwell Christopher , Carter Gillian , Clarke Mike , Fahey Tom , Gillespie Paddy , McGlade Kieran , O’Halloran Peter , Wallace Emma , Brazil Kevin
Published: June 2020

Background

As the population of older adults’ increases, the complexity of care required to support those who choose to remain in the community has also increased. Anticipatory Care Planning (ACP) through earlier identification of healthcare needs is evidenced to improve quality of life, decrease the number of aggressive futile interventions, and even to prolong life.

Aim

To determine the feasibility of a cluster randomised trial to evaluate the implementation and outcomes of Anticipatory Care Planning (ACP) in primary care to assist older adults identified as at risk for functional decline by developing a personalised support plan.

Method

GP practices were randomised into control/intervention groups stratified by jurisdiction [Northern Ireland (UK) and the Republic of Ireland (RoI)], and by setting (urban and rural). Participants were included if they were a) aged ≥70 years, b) 2 or more chronic medical conditions, c) 4 or more prescribed medications. The Anticipatory Care Plan consisted of home visits where the study nurse discussed patients’ goals and plans. An action plan was put in place following consultation with patient’s GPs and study Pharmacist.

Results

Eight primary care practices participated; four in the UK and four in the RoI. Sample n = 64. Data was collected pertaining to patient quality of life, mental health, healthcare utilisation, costs, perception of person-centred care, and the use of potentially inappropriate medication.

Conclusion

Unique insights relating to the trans-jurisdictional delivery of healthcare services in the UK and RoI were observed which has implications on service delivery for older adults.
How can referrals of patients who are obese to the local exercise referral scheme be increased? A UK based primary care quality improvement study
Authors: Zaver Vasudev , Wormall Stephen , Prasad Vibhore , Perera Keshara
Published: June 2020

Background

Obesity is classified as a body mass index (BMI) >30kg/m2 and contributes to poor health outcomes in the UK. In 2017–18, obesity resulted in 711,000 hospital admissions. The National Institute for Health and Care Excellence (NICE) recommends GPs educate patients who are obese and refer them to exercise programmes. Our practice, Brierley Park Medical Centre, (NHS Mansfield and Ashfield CCG) is in a 4th decile most deprived region of North Nottinghamshire (UK) and serves a population of 9,288. The local exercise referral scheme (ERS) allows clinicians to refer patients to the local gym for a reduced fee at the point of access.

Aim

To calculate and increase the number of adult patients who are obese in our practice who are referred to the local ERS.

Method

The number of adult obese patients who were referred to the local ERS scheme from October 2018 to September 2019 was calculated. An intervention comprising internal system alerts, GP education utilising Making Every Contact Count framework and targeted patient group text alerts was designed and delivered. Pre (cycle 1) and post (cycle 2) intervention data from November to February were generated and compared.

Results

In total, 2766 adult obese patients (29.8% of practice population) were identified: 16 (0.2%) patients were referred to ERS during cycle 1.96 (1%) patients were referred during cycle 2.

Conclusion

The interventions that we have designed and implemented have increased the number of referrals to ERS and may be applied to similar primary care settings.
MULTIPAP Study: Improving healthcare for patients with multimorbidity
Authors: Prados-Torres Alexandra , Cura-González Isabel del , Prados-Torres Juan Daniel , Muth Christiane , Leiva-Fernández Francisca , Lopez-Rodriguez Juan A , González-Rubio Francisca
Published: June 2020

Background

The steady rise in multimorbidity entails serious consequences for our populations, challenges healthcare systems, and calls for specific clinical approaches of proven effectiveness. The MULTIPAP Study comprises three sequential projects (MULTIPAP and MULTIPAP Plus RCTs, and the MULTIPAP Cohort). Results of MULTIPAP RCT are presented.

Aim

To evaluate the effectiveness of a complex, patient-centred intervention in young-old patients with multimorbidity and polypharmacy.

Method

Pragmatic cluster-randomised clinical trial in a primary healthcare setting. GPs were randomly allocated to either conventional care or the MULTIPAP intervention based on the Ariadne Principles with two components: GPs e-training (that is, eMULTIPAP addresses specific, key concepts on multimorbidity, polypharmacy and shared decision-making) and GP–patient-centred interview. Young-old patients aged 65–74 years with multimorbidity and polypharmacy were included. Main outcome: difference in the Medication Appropriateness Index (MAI) after 6-month follow-up between groups. Secondary outcomes: MAI, quality of life, patient perception, health services use, treatment adherence and cost-effectiveness after 12-month follow-up.

Results

117 GPs from 38 Spanish primary health care recruited 593 patients randomly assigned to the intervention/control groups. Difference in MAI scores between groups in the intention-to-treat analysis after 6 months’ follow-up: −2.42 (−4.27 to −0.59), P = 0.009 (adjusted difference in mean MAI score −1.81(−3.35 to −0.27), P = 0.021). Secondary outcomes: not significant, including quality of life (adjusted difference in mean EQ-5D-5L (VAS) 2.94 (−1.39 to 7.28), P = 0.183, EQ-5D-5L (index) −0.006(−0.034 to 0.022), P = 0.689).

Conclusion

The intervention significantly improved medication appropriateness. The observed quality of life improvement was not significant. GPs e-training in multimorbidity has shown to be feasible and well accepted by the professionals. Future studies may test whether this format facilitates implementation.
Chest discomfort at night and risk of acute coronary syndrome: cross-sectional study of telephone conversations
Authors: Wouters Loes , Zwart Dorien , Erkelens Carmen , de Groot Esther , Damoiseaux Roger , Hoes Arno , Rutten Frans
Published: June 2020

Background

During telephone triage it is difficult to assign the adequate urgency to patients with chest discomfort. Considering the time of calling could be helpful.

Aim

To assess the risk of acute coronary syndrome (ACS) in certain time periods and whether sex influences this risk.

Method

Cross-sectional study of 1,655 recordings of telephone conversations of patients who called the out-of-hours services primary care (OHS-PC) for chest discomfort. Call time, patient characteristics, symptoms, medical history and urgency allocation of the triage conversations were collected. The final diagnosis of each call was retrieved at the patient’s general practice. Absolute numbers of patients with and without ACS were plotted and risks per hour were calculated. The risk ratio of ACS at night (0 am to 9 am) was calculated by comparing to the risk at other hours, and was adjusted for gender and age.

Results

The mean age of callers was 58.9 (SD ± 19.5) years, 55.5% were women and in total, 199 (12.0%) had an ACS. The crude risk ratio for an ACS at night was 1.80 (CI = 1.39 to 2.34, P<0.001); 2.33 (1.68 to 3.22, P<0.001) for men, and 1.29 (0.83 to 1.99, P = 0.256) for women. The adjusted risk ratio for ACS of all people at night was 1.82 (1.07 to 3.10, P = 0.039).

Conclusion

Patients calling the OHS-PC for chest discomfort between 0–9 am have almost twice a higher risk of ACS than those calling other hours, a phenomenon more evident in men than in women. At night, dispatching ambulances more ‘straightaway’ could be considered for these patients with chest discomfort.
The Moving Healthcare Professionals Programme
Authors: Brannan Michael , Hughes-Short Matt
Published: June 2020

Background

Healthcare professionals (HCPs) are estimated to see nearly 500 000 patients during their career. Evidence demonstrates that one in four patients would be more active if advised by their GP. However, there is a lack of engagement between HCPs and patients regarding the benefits of physical activity (PA). PA is not discussed with 80% of patients, with 75% of GPs feeling they lack knowledge to advise their patients.

Aim

Moving Healthcare Professionals Programme (MHPP) aims include increasing awareness and skills in PA for prevention and management of ill health; changing clinical practice in the promotion of activity; and evaluating impact to identify ‘what works’.

Method

GPs were recruited as Physical Activity Clinical Champions (PACCs) to deliver peer-to-peer training to HCPs nationally. Additionally, relationships were developed with undergraduate medical schools to embed PA into curriculum. A PA advice pad was developed as a local GP pilot, while the ‘Moving Medicine’ online resource was created.

Results

Over 22 000 HCPs were trained to date, with evaluation demonstrating an increase in knowledge, skills and confidence, and over 18 000 completions of our eLearning modules. PA coverage was expanded across the undergraduate curriculum at multiple medical schools, while feedback on the e-advice pad pilot has informed a further digital pilot. Additionally, there were >3000 monthly users of ‘Moving Medicine’.

Conclusion

This work demonstrated scope for significant improvements in HCP engagement in multiple clinical settings. Working with GPs has proved crucial to this success across various workstreams, with their participation a continued focus moving into Phase 2.
Awareness and use of online appointment booking in general practice: analysis of GP Patient Survey data
Authors: Gomez-Cano Mayam , Atherton Helen , Campbell John , Eccles Abi , Dale Jeremy , Poltawski Leon , Abel Gary
Published: June 2020

Background

General practices are required to provide online booking to patients in line with policy to digitise access. However, uptake of online booking by patients is currently low and there is little evidence about awareness and use by different patient groups.

Aim

To examine variability in awareness and use of online appointment booking in general practice.

Method

Secondary analysis of two questions from the GP Practice Survey data (2018) asking about awareness and use of online booking of appointments. Multivariable logistic regression was used to examine associations with age, gender, ethnicity, deprivation, the presence of a long-term condition, long-term sickness and being deaf.

Results

In total, 43.3% (277 278/647 064) of responders reported being aware of being able to book appointments online, while only 15% (93 671/641 073) reported doing so. There was evidence of variation by all factors considered, with strong deprivation gradients in both awareness and use (for example, most versus least deprived quintile OR for use: 0.63 (95% CI = 0.61 to 0.65). There was a reduction in awareness and use in patients >75 years of age. Patients with long-term conditions were more aware and more likely to use online booking.

Conclusion

While over 40% of patients know that they can book appointment online, the number that actually do so is far lower. With the constant push for online services within the NHS and the roll out of the NHS app, practices should be aware that not all patient groups will book appointments online and that other routes of access need to be maintained to avoid widening health inequalities.
Determinants of primary care workforce variation in England
Authors: Gibson Jon , Spooner Sharon , Sutton Matt
Published: June 2020

Background

The General Practice Forward View (GPFV) outlined how the government plans to attain a strengthened model of general practice. A key component of this proposal is an expansion of the workforce by employing a varied range of practitioners, in other words ‘skill mix’. A significant proportion of this investment focuses on increasing the number of ‘new’ roles such as clinical pharmacists, physiotherapists, physician associates, and paramedics.

Aim

The aim of this study is to examine what practice characteristics are associated with the current employment of these ‘new’ roles.

Method

The study uses practice level workforce data (2015–2019), publicly available from NHS Digital. The authors model FTE of specific workforce groups (for example, advanced nurse) as a function of deprivation, practice rurality, patient demographics (total list size and percentage of patients aged >65 years) and FTEs from other staff groups.

Results

Although analysis is ongoing, initial estimation suggests that the employment of ‘new’ roles has occurred in larger practices (in terms of list size), in practices with a higher proportion of patients living in deprived areas and practices with a larger proportion of patients aged >65 years. FTE for advanced nurses is negatively associated with GP FTE.

Conclusion

A negative correlation between advanced nurse FTE and GP FTE is potentially suggestive of substitution between roles, deliberate or otherwise. For example, practices may employ ‘new’ roles if they are unable to recruit GPs or they may recruit staff to free up GP time. Further work is needed to confirm these findings and to explore the reasons behind practice employment decisions.
Exploring patient preference regarding interpreter use in primary care
Authors: Steele Heather , Lehane David , Walton Elizabeth , Mitchell Caroline
Published: June 2020

Background

Effective communication is considered an essential component of delivering health care. Trained, professional interpreters are the gold standard for overcoming language barriers with those with limited English proficiency (LEP). However, LEP patients often use unqualified interpreters such as family members and friends. Existing literature explores the rationale behind choosing different interpreters, but rarely from the patient perspective.

Aim

To explore the patient perspective on the type of interpreter best suited for primary care consultations.

Method

Participants self-identified as having LEP were recruited from four GP practices in areas of Sheffield with high proportions of black and minority ethnic (BME) residents. The participants were from Urdu-, Arabic-, or Romani-speaking ethnic groups. Semi-structured interpreted interviews were recorded, transcribed, and analysed thematically with independent verification of emergent themes. Interviews continued to data saturation.

Results

All participants expressed a preference for face-to-face interpreters. Urdu and Arabic participants highlighted the importance of using an interpreter with the same dialect; Roma participants were passionate about the need for qualified Roma interpreters. Most participants also identified trust and sex as important factors. However, interpreter preference varied between participants: some valued the continuity of family members, whereas others favoured the professionalism and linguistic accuracy associated with qualified interpreters.

Conclusion

This study identified conflicts between patient preferences and guidance for healthcare professionals; all of the participants disliked telephone interpreting, and many recognised the benefits of untrained interpreters. The study highlights the complexities of interpreter preference in primary care and suggests that the decision should be flexible, and patient centred.
Opioid crisis in primary care? An audit of high-dose opioid prescribing at Bangholm GP Practice
Authors: Greene Charlotte , Pearson Alice
Published: June 2020

Background

Opioids are effective analgesics for acute and palliative pain, but there is no evidence base for long-term pain relief. They also carry considerable risks such as overdose and dependence. Despite this, they are increasingly prescribed for chronic pain. In the UK, opioid prescribing more than doubled between 1998 and 2018.

Aim

An audit at Bangholm GP Practice to understand the scale of high-strength opioid prescribing. The aim of the audit was to find out if indications, length of prescription, discussion, and documentation at initial consultation and review process were consistent with best-practice guidelines.

Method

A search on Scottish Therapeutics Utility for patients prescribed an average daily dose of opioid equivalent ≥50 mg morphine between 1 July 2019 and 1 October 2019, excluding methadone, cancer pain, or palliative prescriptions. The Faculty of Pain Medicine’s best-practice guidelines were used.

Results

Demographics: 60 patients (37 females), average age 62, 28% registered with repeat opioid prescription, 38% comorbid depression. Length of prescription: average 6 years, 57% >5 years, 22% >10 years. Opioid: 52% tramadol, 23% on two opioids. Indications: back pain (42%), osteoarthritis (12%), fibromyalgia (10%). Initial consultation: 7% agreed outcomes, 35% follow-up documented. Review: 56% 4-week, 70% past year.

Conclusion

Opioid prescribing guidelines are not followed. The significant issues are: long-term prescriptions for chronic pain, especially back pain; new patients registering with repeat prescriptions; and no outcomes of treatment agreed, a crucial message is the goal is pain management rather than relief. Changes have been introduced at the practice: a patient information sheet, compulsory 1-month review for new patients on opioids, and in-surgery pain referrals.
Blood tests in general practice: the use of routine data to characterise venous blood testing in North West London, 2016–2018
Authors: Bakhet Marize , Ul-Haq Zia , Kamalati Tahereh , Lucas Amanda , Majeed Azeem , El-Osta Austen
Published: June 2020

Background

Laboratory testing is an integral diagnostic tool, contributing to 70% of diagnoses in the NHS today. Its use has been steadily increasing despite estimates that ≤40% of blood tests ordered are unnecessary. Understanding blood-testing patterns is a fundamental step to tackling overuse.

Aim

To characterise the volume, type, and per patient frequency (PPF) of venous blood testing reported in general practice in North West London, 2016–2018.

Method

Following ethics clearance, aggregate data of blood tests reported in general practice in North West London between 2016 and 2018 were extracted from the Discover database. Non-venous blood test codes and codes not used within the designated time period were excluded. Codes reporting the same analyte were aggregated. Overall volume and PPF were calculated per analyte.

Results

Three hundred and thirty-six individual analytes were reported and grouped into 35 recognised panels or groupings. Blood testing increased by 16.5% over the 3-year period. Full blood count, urea and electrolytes, liver function tests, and lipid profile accounted for 80.4% of all venous blood tests. Requests for HbA1c increased by 52.8% and non-HDL cholesterol by 148.7%, whereas glucose decreased by 13.3% and urea by 15.7%. The PPF remained unchanged over the 3-year period at 1.29 blood tests per person per year. The coagulation assay had the highest PPF at 3.0.

Conclusion

Routine general practice data revealed important trends in blood testing. Trends uncovered can inform innovative and targeted solutions to reduce unnecessary blood testing.
Appropriate secondary prevention of stroke and transient ischaemic attack with antithrombotics: an audit in general practice
Authors: Williams Isabelle , Smith William , Nash Edward , Patel Ajay
Published: June 2020

Background

Stroke is a major cause of death and disability worldwide. Major advances have occurred in secondary prevention of stroke/transient ischaemic attack (TIA) during the past three decades. Primary care is a critical point of contact with patients in the implementation of secondary prevention, with the majority of patients with past stroke/TIA being managed in the community.

Aim

To assess current practice at the New Queen Street and Stanground Surgeries, Peterborough, in reference to the National Institute for Health and Care Excellence guidelines on secondary prevention of stroke/TIA.

Method

An audit at the above practices was undertaken by searching the SystmOne computer system for adult patients with previous stroke/TIA (311), excluding those with haemorrhagic stroke and those on aspirin. The patient records of the remaining group (37) were investigated to find whether they were on appropriate antithrombotic therapy and, if not, why.

Results

Of post-stroke/TIA patients, 234/236 were receiving antithrombotic therapy unless contraindicated. For those not on antithrombotics, risk of bleeding was the reason given in 10/13 of cases, though many of these patients did not have active bleeding (exact number unclear due to poor documentation). In 2/13 cases there was no documented reason given and informed dissent in one of the 13 cases.

Conclusion

It was found that both practices implemented the guidelines to a satisfactory degree. However, to further improve secondary prevention outreach, bleeding risk should be assessed using a tool such as S2TOP-BLEED before withholding antithrombotic therapy, as, on balance, antithrombotic therapy may still be preferable. In addition, accurate and detailed documentation of the indications/contraindications to anticoagulation is paramount for such assessment.
A pilot project on the management of osteoporosis in primary care: results of the audit cycle
Authors: Jothimurugan Sindhuja , Jothimurugan Subramanian , Sanganee Deepali , Wickramaratne Thushani , Lynn Myo
Published: June 2020

Background

Osteoporosis is a major public health problem with the ageing population in the UK. However, there is no known national algorithm for the management of osteoporosis in primary care. Therefore, a treatment pathway was developed in secondary care for patients in the community.

Aim

This audit cycle investigates whether patients at a GP practice with a population of 14 000 have been appropriately identified, coded as osteoporosis, treated, and have followed the recommended pathway.

Method

A search of the practice clinical system was undertaken for three groups of patients coded as: patients currently on the existing osteoporosis register; patients with a code of ‘osteoporosis’ or ‘fragility fracture’ but not prescribed an osteoporosis treatment; and patients currently prescribed an osteoporosis treatment with no coding for ‘osteoporosis’ or ‘fragility fracture’. The words ‘osteoporosis’, ‘fragility fracture’, ‘QOF’, and all individual drug names were used in the search engine.

Results

The completed audit cycle shows an increase in the proportion of patients following the local guidelines pathway, from 75% in 2018 to 81% in 2019, emphasising the importance of having a guideline for GPs to follow in order to optimise treatment and prevent future fragility fractures.

Conclusion

This is a pilot project to assess the ability to identify patients who have osteoporosis and review their treatment pathway. The results are promising as the analysed data indicate that GP practice lists can be used to identify and treat high-risk patients for osteoporosis and assess the adherence to the pathway. Using the pathway, GPs can more efficiently diagnose and manage patients.
Multiple risk behaviour intervention to prevent depression in primary care
Authors: Gómez-Gómez Irene , Moreno-Peral Patricia , López Tomás , Clavería Ana , Oliván Barbara , Marti Ruth , Llobera Joan , Maderuelo-Fernández Jose-Angel , Motrico Emma
Published: June 2020

Background

Primary care is the ideal setting for promotion and prevention intervention. Multiple risk behaviour interventions present several advantages over single-risk lifestyle interventions. Multiple risk behaviour interventions could be easily implemented in primary care to prevent non-communicable disease and depression.

Aim

To test the effectiveness of a multiple risk behaviour intervention to promote Mediterranean diet, physical activity, and/or smoking cessation in people attending Spanish primary health care with incidence of depression and symptoms of depression.

Method

This was a secondary analysis of the EIRA study that aims to test the effectiveness of a multiple risk behaviour intervention to promote healthy lifestyles. Twenty-six primary care centres were randomised to receive multiple risk behaviour intervention or usual care. The multiple risk behaviour intervention included individual sessions, group sessions, communitarian activities, and SMS reception. Participants were followed for 10–14 months. The primary outcomes of this study were incidence of depression and reductions of depressive symptoms.

Results

Three thousand and sixty-seven participants were included. Females accounted for 45.13% and 93.88% were Spanish. Age varied between 45 and 75 years old. The effectiveness of the intervention will be calculated using the Patient Health Questionnaire (PHQ-9) and the Composite International Diagnostic Interview (‎CIDI)‎ depression section. Linear and logistic regression will be used to create predictive models.

Conclusion

Primary care is the most accessible service in the health system for patients. Hence primary care is the ideal setting for health education, promotion, and prevention interventions. This study will provide high-quality evidence about the effectiveness of multiple risk behaviour interventions over depression prevention.
Evaluating the relational continuity of care of four GP practices, one of which uses personalised lists
Authors: Swanepoel Riaan
Published: June 2020

Background

Continuity of care is a fading type of care because GPs are working more flexibly and at reduced working hours. The GP Contract gave a financial incentive to provide prompt GP appointments, but to the detriment of continuity of care. Increased patient demand for appointments has seemingly led to patients favouring ‘any’ appointment with a GP rather than ‘an appointment with the same GP’. Continuity of care in general practice is associated with greater patient satisfaction and is the preferred type of care for patients with chronic disease or psychological problems. In the Northeast of England there is a multi-partner GP practice that operates a true personalised list system. Other GP practices in the area do offer a degree of continuity of care, but this has not been measured.

Aim

To measure and compare the relational continuity of care index of four matched GP practices, one of which operates a personalised list.

Method

A written protocol enabled the authors to extract comparable anonymised data from four GP practices over a year (January to December 2019). Two standardised indexes of continuity of care (UPC and SLICC) were calculated and compared.

Results

Continuity of care was consistently higher with personalised lists. UPC index results show that all GP practices provide surprisingly high continuity of care, albeit not with patients’ assigned GPs. Higher monthly UPC scores versus overall scores indicate patients are receiving continuity of care in relation to their condition.

Conclusion

Continuity of care is still observed in GP practices that do not have personalised lists.