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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Association of social support and medication adherence in Chinese patients with type 2 diabetes mellitus
The prevalence of diabetes is steadily increasing in China. When diabetes is uncontrolled, it generates dire consequences for health and well-being. Numerous studies have shown that health outcomes were associated with social support and medication adherence. Previous study confirmed that social support was associated with medication adherence in patients with heart failure, HIV diseases, and first-episode psychosis. However, the relationship between social support and medication adherence in patients with type 2 diabetes mellitus (T2DM) is remains unclear. This study aims to examine whether social support is associated with medication adherence in patients with T2DM. This study was conducted in the First Affiliated Hospital of the General Hospital of the People’s Liberation Army (PLA). In Beijing, a systematic random sample of 412 patients with T2DM over 18 years was recruited at baseline, and demographic characteristics, clinical data and their assessment of social support were collected from medical records and self-reported questionnaires. 330 of these patients completed a self-report measure of medication adherence at the sixth month after baseline data collection. Regression analysis showed that social support presented a positive effect on medication adherence, additionally, support utilization and the subscale of social support exhibited a significantly strong influence on medication adherence in patients with T2DM. Although medication adherence was influenced by multiple factors, this finding confirmed that social support must be recognized as a core element in interventions aimed at improving in the management of patients with T2DM.
The association among social support, self-efficacy, use of mobile apps, and physical activity: Structural equation models with mediating effects
Background: Physical inactivity is a risk factor for chronic noncommunicable diseases. Insufficient physical activity has become an important public health problem worldwide. As mobile apps have rapidly developed, physical activity apps have the potential to improve the level of physical activity among populations. Objective: This study aimed to evaluate the effect of physical activity apps on levels of physical activity among college students. Methods: A Web-based questionnaire was used to survey college students in Beijing from December 27, 2017, to January 5, 2018. According to a previous survey, 43% of college students using physical activity apps and 36% of those who never used such apps achieved the physical activity recommendations. In this study, the sample size was calculated to be 500. The questionnaire consisted of 5 parts: the use of physical activity apps, sports habits, social support, self-efficacy, and social demographic information. Structural equation modeling was used to test the relationships between the use of physical activity apps, self-efficacy, social support, and level of physical activity. Results: Of the 1245 participants, 384 college students (30.8%) used physical activity apps (in the past month). Of these 384 students, 191 (49.7%) gained new friends via the app. College students who were using physical activity apps had a higher level of physical activity and higher scores for social support and self-efficacy (P<.001) than those who did not use such apps. The use of physical activity apps significantly affected the mediating effect of physical activity level through social support (beta=.126; P<.001) and self-efficacy (beta=.294; P<.001). Gender played an important role in app use, self-efficacy, and physical activity in the mediation model: male users spent more time on physical activity and had higher self-efficacy scores (P<.001). Conclusions: This study focused on college students in Beijing and found that the use of physical activity apps is associated with higher physical activity levels among these students. This effect is mainly through the mediation effect of social support and self-efficacy, rather than the direct effect of physical activity apps. The use of physical activity apps is associated with a higher social support level and higher self-efficacy score. Furthermore, a high social support level and high self-efficacy score are associated with higher physical activity levels.
Metabolomic Biomarkers in Blood Samples Identify Cancers in a Mixed Population of Patients with Nonspecific Symptoms.
PURPOSE: Early diagnosis of cancer is critical for improving patient outcomes, but cancers may be hard to diagnose if patients present with nonspecific signs and symptoms. We have previously shown that nuclear magnetic resonance (NMR) metabolomics analysis can detect cancer in animal models and distinguish between differing metastatic disease burdens. Here, we hypothesized that biomarkers within the blood metabolome could identify cancers within a mixed population of patients referred from primary care with nonspecific symptoms, the so-called "low-risk, but not no-risk" patient group, as well as distinguishing between those with and without metastatic disease. EXPERIMENTAL DESIGN: Patients (n = 304 comprising modeling, n = 192, and test, n = 92) were recruited from 2017 to 2018 from the Oxfordshire Suspected CANcer (SCAN) pathway, a multidisciplinary diagnostic center (MDC) referral pathway for patients with nonspecific signs and symptoms. Blood was collected and analyzed by NMR metabolomics. Orthogonal partial least squares discriminatory analysis (OPLS-DA) models separated patients, based upon diagnoses received from the MDC assessment, within 62 days of initial appointment. RESULTS: Area under the ROC curve for identifying patients with solid tumors in the independent test set was 0.83 [95% confidence interval (CI): 0.72-0.95]. Maximum sensitivity and specificity were 94% (95% CI: 73-99) and 82% (95% CI: 75-87), respectively. We could also identify patients with metastatic disease in the cohort of patients with cancer with sensitivity and specificity of 94% (95% CI: 72-99) and 88% (95% CI: 53-98), respectively. CONCLUSIONS: For a mixed group of patients referred from primary care with nonspecific signs and symptoms, NMR-based metabolomics can assist their diagnosis, and may differentiate both those with malignancies and those with and without metastatic disease.
Clinical prediction rules for childhood UTIs: a cross-sectional study in ambulatory care.
BACKGROUND: Diagnosing childhood urinary tract infections (UTI) is challenging. AIM: Validate clinical prediction rules (UTIcalc, DUTY, Gorelick) for paediatric UTIs in primary care. DESIGN & SETTING: Post-hoc analysis of a cross-sectional study in 39 general practices and 2 emergency departments (Belgium, March 2019 to March 2020). METHOD: Physicians recruited acutely ill children ≤18 years and sampled urine systematically for culture. Per rule, we performed an apparent validation; calculated sensitivities and specificities with 95%CI per threshold in the target group. For the DUTY coefficient-based algorithm, we performed a logistic calibration and calculated the Area Under the Curve with 95%CI. RESULTS: Of 834 children ≤18 years recruited, there were 297 children <5 years. The UTIcalc and Gorelick score had high to moderate sensitivity and low specificity (UTIcalc ≥2%) 75%; and 16% respectively; Gorelick (≥2 variables) 91%; and 8%. In contrast, the DUTY score ≥5 points had low sensitivity (8%), but high specificity (99%). Urine samples would be obtained in 72% vs 38% (UTIcalc), 92% vs 38% (Gorelick) or 1% vs 32% (DUTY) of children, compared to routine care. The number of missed infections per score was 1/4 (UTIcalc), 2/23 (Gorelick) and 24/26 (DUTY). The UTIcalc+ dipstick model had high sensitivity and specificity (100%; and 91%); resulting in no missed cases and 59% (95%CI 49%-68%) of antibiotics prescribed inappropriately. CONCLUSION: In this study, the UTIcalc and Gorelick score were useful for ruling out UTI but resulted in high urine sampling rates. The DUTY score had low sensitivity, meaning that 92% of UTIs would be missed.
Ultraviolet-C Irradiation, Heat, and Storage as Potential Methods of Inactivating SARS-CoV-2 and Bacterial Pathogens on Filtering Facepiece Respirators
The arrival of SARS-CoV-2 to Aotearoa/New Zealand in February 2020 triggered a massive response at multiple levels. Procurement and sustainability of medical supplies to hospitals and clinics during the then upcoming COVID-19 pandemic was one of the top priorities. Continuing access to new personal protective equipment (PPE) was not guaranteed; thus, disinfecting and reusing PPE was considered as a potential alternative. Here, we describe part of a local program intended to test and implement a system to disinfect PPE for potential reuse in New Zealand. We used filtering facepiece respirator (FFR) coupons inoculated with SARS-CoV-2 or clinically relevant multidrug-resistant pathogens (Acinetobacter baumannii Ab5075, methicillin-resistant Staphylococcus aureus USA300 LAC and cystic-fibrosis isolate Pseudomonas aeruginosa LESB58), to evaluate the potential use of ultraviolet-C germicidal irradiation (UV-C) or dry heat treatment to disinfect PPE. An applied UV-C dose of 1000 mJ/cm2 was sufficient to completely inactivate high doses of SARS-CoV-2; however, irregularities in the FFR coupons hindered the efficacy of UV-C to fully inactivate the virus, even at higher UV-C doses (2000 mJ/cm2). Conversely, incubating contaminated FFR coupons at 65 °C for 30 min or 70 °C for 15 min, was sufficient to block SARS-CoV-2 replication, even in the presence of mucin or a soil load (mimicking salivary or respiratory secretions, respectively). Dry heat (90 min at 75 °C to 80 °C) effectively killed 106 planktonic bacteria; however, even extending the incubation time up to two hours at 80 °C did not completely kill bacteria when grown in colony biofilms. Importantly, we also showed that FFR material can harbor replication-competent SARS-CoV-2 for up to 35 days at room temperature in the presence of a soil load. We are currently using these findings to optimize and establish a robust process for decontaminating, reusing, and reducing wastage of PPE in New Zealand.
Using Belgian pharmacy dispensing data to assess antibiotic use for children in ambulatory care.
BACKGROUND: The desired effect of antibiotics is compromised by the rapid escalation of antimicrobial resistance. Children are particularly at high-risk for unnecessary antibiotic prescribing, which is owing to clinicians' diagnostic uncertainty combined with parents' concerns and expectations. Recent Belgian data on ambulatory antibiotic prescribing practices for children are currently lacking. Therefore, we aim to analyse different aspects of antibiotic prescriptions for children in ambulatory care. METHODS: Pharmacy dispensing data on antibiotics for systematic use referring from 2010 to 2019 were retrieved from Farmanet, a database of pharmaceutical dispensations in community pharmacies. Population data were obtained from the Belgian statistical office (Statbel). Descriptive statistics were performed in Microsoft Excel. The Mann-Kendall test for trend analysis and the seasplot function for seasonality testing were conducted in R. RESULTS: The past decade, paediatric antibiotic use and expenditures have relatively decreased in Belgian ambulatory care with 35.5% and 44.3%, respectively. The highest volumes of antibiotics for children are prescribed by GPs working in Walloon region and rural areas, to younger children, and during winter. The most prescribed class of antibiotics for children are the penicillins and the biggest relative reduction in number of packages is seen for the sulfonamides and trimethoprim and quinolone antibacterials. CONCLUSIONS: Paediatric antibiotic use has decreased in Belgian ambulatory care. Further initiatives are needed to promote prudent antibiotic prescribing in ambulatory care.
Erratum to “A syndemic of psychiatric morbidity, substance misuse, violence, and poor physical health among young Scottish men with reduced life expectancy” [SSM - Population Health 15(2021) 100858] (SSM - Population Health (2021) 15, (S2352827321001336), (10.1016/j.ssmph.2021.100858))
The authors regret errors in the coding and description of the analysis in the original manuscript. In summary, a portion of the analysis as described in the published article was incorrect: we reported the estimates as odds ratios when we should have used linear regression with robust standard errors. The direction and statistical significance of most of the estimates remained qualitatively similar, with one exception: the product term for violence and substance misuse, which was of marginal statistical significance in the original manuscript, was not statistically significant in the revised analysis. With no syndemic interaction between violence and the other components, this necessitated slight changes to the conceptual model (Figure 3), discussion, and conclusion. Details are as follows. In the statistical analysis section of the original manuscript, we wrote: “In order to test for syndemic effects between violence, psychiatric morbidity and substance misuse, and physical health risks on poor physical health/long-standing conditions (outcome), we estimated interaction terms using logistic regression” (p.4). This description was incorrect and should have read instead: “In order to test for syndemic effects between standardized factor scores of violence, psychiatric morbidity and substance misuse, and physical health risks on poor physical health/long-standing conditions (outcome), we estimated interaction terms using linear regression with robust standard errors.” In the results section of the original manuscript, we wrote: “Table 3 shows evidence of multiplicative interaction between violence and substance misuse, physical health risks and mental health problems, physical health risks and substance misuse, and mental health problems and substance misuse” (p.6). This description was incorrect and should have read instead: “Table 3 shows evidence of additive interaction between physical health risks and mental health problems, physical health risks and substance misuse, and mental health problems and substance misuse.” In Table 3 of the original manuscript, we presented the results of this analysis as follows: [Table presented] The estimates as presented in Table 3 were incorrect and should have instead been presented as: [Table presented] In Figure 3 of the original manuscript, we presented a hypothetical model as follows: [Figure presented] Given the revised estimates in Table 3, the proposed model was incorrect and should have been presented as follows: [Figure presented] In the discussion section of the original manuscript, we wrote: “In this second pathway, syndemic interactions between multiple morbidities of poor mental health, substance misuse, violence, and a diathesis of biological/behavioural risk lead to this intermediary stage along the pathway consisting of early adult precursors of what will become a range of diseases in mid- and later-life” (p.8). Given the revised estimates in Table 3, this description was incorrect and should have read instead: “In this second pathway, syndemic interactions between multiple morbidities of poor mental health, substance misuse, and a diathesis of biological/behavioural risk lead to this intermediary stage along the pathway consisting of early adult precursors of what will become a range of diseases in mid- and later-life.” Finally, in the conclusion of the abstract, we wrote: “Syndemic effects from synergistic interactions were confirmed between psychiatric morbidity, substance misuse, violence, and biological/behavioural risk for physical health” (p.1). Given the revised estimates in Table 3, this description was incorrect and should have read instead: “Syndemic effects from synergistic interactions were confirmed between psychiatric morbidity, substance misuse, and biological/behavioural risk for physical health.” The authors sincerely apologize for the errors in the original manuscript.
BSAC Vanguard Series: Antimicrobial resistance and the future of diagnostic testing.
In the UK around 80% of all antibiotics are prescribed by GP surgeries and in other community settings. Diagnostic technology has the potential to enable transformative change to antimicrobial stewardship in these settings. Current diagnostics are limited in terms of the information they can provide prescribers and the speed they can provide it. We need to develop diagnostics that are cheap enough for mass application, rapid enough to change prescribing decisions and able to detect bacteria which are causing disease rather than simply resident in the host. To be successful in creating change these diagnostics need to be appropriately funded and embedded in practice in ways which encourage change in prescribing behaviours. Collaboration between academia and industry is key in developing tests which are fit for purpose, well evidenced and appropriately funded in these settings.
Integrating palliative care and heart failure: a protocol for a realist synthesis (PalliatHeartSynthesis)
IntroductionHeart failure affects over 26 million people worldwide with prevalence expected to grow due to an ageing global population. Palliative care can address the holistic needs of patients with heart failure, and integrated palliative care in heart failure management has been indicated to improve outcomes for patients. Despite known benefits for integrated palliative care in heart failure management, implementation is poor across the majority of global health services. Recent systematic reviews have identified the benefits of integrating palliative care into heart failure management and highlighted barriers to implementation. However, there was heterogeneity in terms of countries, healthcare settings, delivery by differing staff across multidisciplinary teams, modes of delivery and different intervention components.Methods and analysisThe aim of this study is to identify how integrated palliative care and heart failure interventions produce desired outcomes, in which contexts, and for which patients. We will undertake a realist synthesis to identify this, using Pawson’s five iterative steps. We will recruit an international stakeholder group comprised of healthcare providers and patients with heart failure to advise and provide feedback throughout the review. Our initial realist programme theory sets out the necessary steps needed to accomplish the final intended outcome(s) from the implementation of integrated palliative care and heart failure. This initial programme theory will be shaped through an iterative process of testing and refinement.Ethics and disseminationEthical approval is not required for this study. With our stakeholder group, we will coproduce a user guide that outlines practical advice to optimise, tailor and implement interventions designed to integrate palliative care and heart failure, taking into consideration local context, alongside user-friendly summaries of the synthesis findings using short animations to convey complex findings. We will draw on the expertise within the stakeholder group to identify key stakeholders for disseminating to relevant audiences, ensuring outputs are tailored for their respective needs.PROSPERO registration numberCRD42021240185.
Factors influencing the family consent rate for organ donation in the UK.
The refusal rate for organ donation in the UK is 42%, among the highest in Europe. We extracted data on every family approach for donation in UK ICUs or Emergency Departments between 1st April 2012 and 30th September 2013, and performed multiple logistic regression to identify modifiable factors associated with consent. Complete data were available for 4703 of 4899 approaches during the study period. Consent for donation after brain death was 68.9%, and for donation after circulatory death 56.5% (p
Correlation between microsatellite discrepancy scores and transplant outcome after haemopoietic SCT for pediatric ALL.
Microsatellite analyses show that self-reported ethnicity often correlates poorly with true genetic ancestry. As unknown ancestral differences could potentially have an impact on transplant outcome, we developed an average allele length discrepancy (AALD) score to assess allele length discrepancy between donor/recipient (D/R) using microsatellites analysed routinely in post-transplant chimeric assessment. This was then compared with outcome in a homogeneously treated cohort of pediatric patients undergoing high-resolution sibling or matched unrelated donor transplantation for acute lymphoblastic leukemia (ALL). AALD scores formed a numeric continuum ranging from 0 to 1.4 (median 0.76) for sibling pairs and 0.8-2.17 (median 1.6) for high-resolution matched unrelated donor (HR-MUD) pairs. There was a trend for worse OS with increasing AALD score, which reached statistical significance above a threshold of 1.7 for OS. Patients whose transplants had an AALD score of ⩾1.8 had a risk of non-relapse mortality 4.9 times greater (P=0.025) and relapse risk three times greater (P=0.058) than those scoring <1.8. This approach will now be explored in a Centre International for Blood and Marrow Transplantation Research (CIBMTR) study of 750 D/R pairs across all disease groups; if confirmed, it has the potential to improve donor selection for patients with multiple prospective donors.
Liver damage during organ donor procurement in donation after circulatory death compared with donation after brain death.
BACKGROUND: During the past decade the number of livers recovered and transplanted from donation after circulatory death (DCD) donors has increased significantly. As reported previously, injuries are more frequent during kidney procurement from DCD than from donation after brain death (DBD) donors. This aim of this study was to compare outcomes between DCD and DBD with respect to liver injuries. METHODS: Data on liver injuries in organs procured between 2000 and 2010 were obtained from the UK Transplant Registry. RESULTS: A total of 7146 livers were recovered from deceased donors during the study, 628 (8·8 per cent) from DCD donors. Injuries occurred in 1001 procedures (14·0 per cent). There were more arterial (1·6 versus 1·0 per cent), portal (0·5 versus 0·3 per cent) and caval (0·3 versus 0·2 per cent) injuries in the DBD group than in the DCD group, although none of these findings was statistically significant. Capsular injuries occurred more frequently in DCD than DBD (15·6 versus 11·4 per cent; P = 0·002). There was no significant difference between DCD and DBD groups in liver discard rates related to damage. CONCLUSION: There were no differences in terms of vascular injuries between DCD and DBD livers, although capsular injuries occurred more frequently in DCD organs. Continuing the trend for increased frequency of DCD liver recovery, and ensuring that there is an adequately skilled surgical team available for procurement, is vital to improving the utilization of DCD livers.