5,544 research outputs found

    The PREVENT Study: Preventing hospital admissions attributable to gout

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    BackgroundGout is the most common form of inflammatory arthritis, affecting 1 in 40 people in the UK. Despite highly effective treatments, hospital admissions for gout flares have doubled in England over the last 20 years. Many of these admissions may have been prevented if optimal gout management had been delivered to patients.Objectives1. Describe the epidemiology of gout management in primary and secondary care in the UK.2. Develop an intervention package for implementation during hospitalisations for gout flares, with the aim of improving care and reducing hospitalisations.3. Implement and evaluate this intervention in people hospitalised for gout.MethodsI used population-level health datasets (CPRD, OpenSAFELY, NHS Digital Hospital Episode Statistics) to evaluate outcomes for people with incident gout diagnoses over a 20-year period. I used multivariable regression and survival modelling to analyse factors associated with outcomes, including: i) initiation of urate-lowering therapies (ULT); ii) attainment of serum urate targets; and iii) hospitalisations for gout flares.With extensive stakeholder input, I developed an evidence-based intervention package to optimise hospital gout care. This incorporated the findings of a systematic literature review and process mapping of the admitted patient journey in a cohort of hospitalised gout patients. My intervention consisted of a care pathway, based upon British (BSR), European (EULAR) and American (ACR) gout management guidelines, which encouraged ULT initiation prior to discharge, followed by a nurse-led, post-discharge review to facilitate handover to primary care. I implemented this intervention in patients hospitalised for gout flares at King’s College Hospital over a 12-month period, and evaluated outcomes including ULT initiation, urate target attainment and re-admission rates.ResultsIn the UK, between 2004 and 2020, I showed that only 29% of patients with gout were initiated on ULT within 12 months of diagnosis, while only 36% attained urate targets. No significant improvements in these outcomes were observed after publication of updated BSR and EULAR gout management guidelines. Comorbidities, including chronic kidney disease, heart failure and obesity, associated with increased odds of ULT initiation but decreased odds of attaining urate targets. For patients who were diagnosed with gout during the COVID-19 pandemic, I showed that ULT initiation improved modestly, relative to before the pandemic, while urate target attainment trends were similar. Underlying these trends was a 31% decrease in incident gout diagnoses in England during the first year of the pandemic.Using linked primary and secondary care data, I showed that the risk of hospitalisations for gout flares is greatest within the first 6 months after diagnosis. ULT initiation is associated with more hospitalisations for flares within the first 6 months of diagnosis, but a reduced risk of hospitalisations beyond 12 months; particularly when urate targets are attained.After process mapping the admitted patient journey and systematically appraising the evidence base, I developed and implemented a multi-faceted intervention at King’s College Hospital, with the aim of improving hospital gout care. Following implementation of this intervention, the proportion of hospitalised gout patients who initiated ULT increased from 49% to 92%; more patients achieved serum urate targets; and there were 38% fewer repeat hospitalisations for gout flares.ConclusionsAt a population level, ULT initiation and urate target attainment remain sub-optimal for people with gout in the UK, despite updated management guidelines. Initiation of ULT is associated with long-term reductions in hospitalisations for flares; however, only a minority of patients hospitalised for gout flares are initiated on ULT. After designing and implementing a strategy to optimise hospital gout care, over 90% of patients were initiated on ULT, urate target attainment improved, and repeat hospitalisations decreased. My findings suggest that improved primary-secondary care integration is essential if we are to reverse the epidemic of gout hospitalisations

    Optimising physiotherapy for people with lateral elbow tendinopathy - Results of a mixed-methods pilot and feasibility randomised controlled trial (OPTimisE)

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    The OPTimisE intervention was developed to address uncertainty regarding the most effective physiotherapy treatment strategy for people with Lateral Elbow Tendinopathy (LET). To assess the feasibility of conducting a fully-powered randomised controlled trial (RCT) evaluating whether the OPTimisE intervention is superior to usual physiotherapy treatment for adults with LET. A mixed-methods multi-centred, parallel pilot and feasibility RCT, conducted in three outpatient physiotherapy departments in the UK. Patients were independently randomised 1:1 in mixed blocks, stratified by site, to the OPTimisE intervention or usual care. Outcomes were assessed using pre-defined feasibility progression criteria. 50 patients were randomised (22 Female, 28 Male), mean age 48 years (range 27-75). Consent rate was 71% (50/70), fidelity to intervention 89% (16/18), attendance rate in the OPTimisE group 82% (55/67) vs 85% (56/66) in usual care, outcome measure completion 81% (39/48) at six-month follow-up. There were no related adverse events. Patients and physiotherapists reported that the OPTimisE intervention was acceptable but suggested improvements to the trial design. 49 patients were recruited from physiotherapy referrals vs one from primary care records. Outcome measure return rates were higher when completed online (74%) compared to postal questionnaire (50%). Exploratory analysis showed improvements in both groups over time. It is methodologically feasible to conduct a fully powered RCT comparing the clinical and cost-effectiveness of the OPTimisE intervention versus usual physiotherapy treatment. Considering the similar improvements observed in both groups, careful consideration is needed regarding the priority research question to be addressed in future research. [Abstract copyright: Copyright Š 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.

    Combined Nutrition and Exercise Interventions in Community Groups

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    Diet and physical activity are two key modifiable lifestyle factors that influence health across the lifespan (prevention and management of chronic diseases and reduction of the risk of premature death through several biological mechanisms). Community-based interventions contribute to public health, as they have the potential to reach high population-level impact, through the focus on groups that share a common culture or identity in their natural living environment. While the health benefits of a balanced diet and regular physical activity are commonly studied separately, interventions that combine these two lifestyle factors have the potential to induce greater benefits in community groups rather than strategies focusing only on one or the other. Thus, this Special Issue entitled “Combined Nutrition and Exercise Interventions in Community Groups” is comprised of manuscripts that highlight this combined approach (balanced diet and regular physical activity) in community settings. The contributors to this Special Issue are well-recognized professionals in complementary fields such as education, public health, nutrition, and exercise. This Special Issue highlights the latest research regarding combined nutrition and exercise interventions among different community groups and includes research articles developed through five continents (Africa, Asia, America, Europe and Oceania), as well as reviews and systematic reviews

    Acute adaptation of central and peripheral motor unit features to exercise‐induced fatigue differs with concentric and eccentric loading

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    New Findings: What is the central question of this study? Conflicting evidence exists on motor unit (MU) firing rate in response to exercise‐induced fatigue, possibly due to the contraction modality used: Do MU properties adapt similarly following concentric and eccentric loading? What is the main finding and its importance? MU firing rate increased following eccentric loading only despite a decline in absolute force. Force steadiness deteriorated following both loading methods. Central and peripheral MU features are altered in a contraction type‐dependant manner, which is an important consideration for training interventions. Abstract: Force output of muscle is partly mediated by the adjustment of motor unit (MU) firing rate (FR). Disparities in MU features in response to fatigue may be influenced by contraction type, as concentric (CON) and eccentric (ECC) contractions demand variable amounts of neural input, which alters the response to fatigue. This study aimed to determine the effects of fatigue following CON and ECC loading on MU features of the vastus lateralis (VL). High‐density surface (HD‐sEMG) and intramuscular (iEMG) electromyography were used to record MU potentials (MUPs) from bilateral VLs of 12 young volunteers (six females) during sustained isometric contractions at 25% and 40% of the maximum voluntary contraction (MVC), before and after completing CON and ECC weighted stepping exercise. Multi‐level mixed effects linear regression models were performed with significance assumed as P 0.1) but neuromuscular junction transmission instability increased in both legs (P < 0.04), and markers of fibre membrane excitability increased following CON only (P = 0.018). These data demonstrate that central and peripheral MU features are altered following exercise‐induced fatigue and differ according to exercise modality. This is important when considering interventional strategies targeting MU function

    Scientific opinion on the tolerable upper intake level for vitamin B6

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    Following a request from the European Commission, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was asked to deliver a scientific opinion on the tolerable upper intake level (UL) for vitamin B6. Systematic reviews of the literature were conducted by a contractor. The relationship between excess vitamin B6 intakes and the development of peripheral neuropathy is well established and is the critical effect on which the UL is based. A lowest-observed-effect-level (LOAEL) could not be established based on human data. A reference point (RP) of 50 mg/day is identified by the Panel from a case–control study, supported by data from case reports and vigilance data. An uncertainty factor (UF) of 4 is applied to the RP to account for the inverse relationship between dose and time to onset of symptoms and the limited data available. The latter covers uncertainties as to the level of intake that would represent a LOAEL. This leads to a UL of 12.5 mg/day. From a subchronic study in Beagle dogs, a LOAEL of 50 mg/kg body weight (bw) per day can be identified. Using an UF of 300, and a default bw of 70 kg, a UL of 11.7 mg/day can be calculated. From the midpoint of the range of these two ULs and rounding down, a UL of 12 mg/day is established by the Panel for vitamin B6 for adults (including pregnant and lactating women). ULs for infants and children are derived from the UL for&nbsp;adults using allometric scaling: 2.2–2.5 mg/day (4–11 months), 3.2–4.5 mg/day (1–6 years), 6.1–10.7 mg/day (7–17 years). Based on available intake data, EU populations are unlikely to exceed ULs, except for regular users of food supplements containing high doses of vitamin B6
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