A two-year participatory intervention project with owners to reduce lameness and limb abnormalities in working horses in Jaipur, India

Participatory methods are increasingly used in international human development, but scientific evaluation of their efficacy versus a control group is rare. Working horses support families in impoverished communities. Lameness and limb abnormalities are highly prevalent in these animals and a cause for welfare concern. We aimed to stimulate and evaluate improvements in lameness and limb abnormalities in horses whose owners took part in a 2-year participatory intervention project to reduce lameness (PI) versus a control group (C) in Jaipur, India.In total, 439 owners of 862 horses participated in the study. PI group owners from 21 communities were encouraged to meet regularly to discuss management and work practices influencing lameness and poor welfare and to track their own progress in improving these. Lameness examinations (41 parameters) were conducted at the start of the study (Baseline), and after 1 year and 2 years. Results were compared with control horses from a further 21 communities outside the intervention. Of the 149 horses assessed on all three occasions, PI horses showed significantly (P<0.05) greater improvement than C horses in 20 parameters, most notably overall lameness score, measures of sole pain and range of movement on limb flexion. Control horses showed slight but significantly greater improvements in four parameters, including frog quality in fore and hindlimbs.This participatory intervention succeeded in improving lameness and some limb abnormalities in working horses, by encouraging changes in management and work practices which were feasible within owners’ socioeconomic and environmental constraints. Demonstration of the potentially sustainable improvements achieved here should encourage further development of participatory intervention approaches to benefit humans and animals in other contexts

Dynamic contrast-enhanced CT compared with positron emission tomography CT to characterise solitary pulmonary nodules: the SPUtNIk diagnostic accuracy study and economic modelling

BACKGROUND: Current pathways recommend positron emission tomography-computerised tomography for the characterisation of solitary pulmonary nodules. Dynamic contrast-enhanced computerised tomography may be a more cost-effective approach. OBJECTIVES: To determine the diagnostic performances of dynamic contrast-enhanced computerised tomography and positron emission tomography-computerised tomography in the NHS for solitary pulmonary nodules. Systematic reviews and a health economic evaluation contributed to the decision-analytic modelling to assess the likely costs and health outcomes resulting from incorporation of dynamic contrast-enhanced computerised tomography into management strategies. DESIGN: Multicentre comparative accuracy trial. SETTING: Secondary or tertiary outpatient settings at 16 hospitals in the UK. PARTICIPANTS: Participants with solitary pulmonary nodules of ≥ 8 mm and of ≤ 30 mm in size with no malignancy in the previous 2 years were included. INTERVENTIONS: Baseline positron emission tomography-computerised tomography and dynamic contrast-enhanced computer tomography with 2 years' follow-up. MAIN OUTCOME MEASURES: Primary outcome measures were sensitivity, specificity and diagnostic accuracy for positron emission tomography-computerised tomography and dynamic contrast-enhanced computerised tomography. Incremental cost-effectiveness ratios compared management strategies that used dynamic contrast-enhanced computerised tomography with management strategies that did not use dynamic contrast-enhanced computerised tomography. RESULTS: A total of 380 patients were recruited (median age 69 years). Of 312 patients with matched dynamic contrast-enhanced computer tomography and positron emission tomography-computerised tomography examinations, 191 (61%) were cancer patients. The sensitivity, specificity and diagnostic accuracy for positron emission tomography-computerised tomography and dynamic contrast-enhanced computer tomography were 72.8% (95% confidence interval 66.1% to 78.6%), 81.8% (95% confidence interval 74.0% to 87.7%), 76.3% (95% confidence interval 71.3% to 80.7%) and 95.3% (95% confidence interval 91.3% to 97.5%), 29.8% (95% confidence interval 22.3% to 38.4%) and 69.9% (95% confidence interval 64.6% to 74.7%), respectively. Exploratory modelling showed that maximum standardised uptake values had the best diagnostic accuracy, with an area under the curve of 0.87, which increased to 0.90 if combined with dynamic contrast-enhanced computerised tomography peak enhancement. The economic analysis showed that, over 24 months, dynamic contrast-enhanced computerised tomography was less costly (£3305, 95% confidence interval £2952 to £3746) than positron emission tomography-computerised tomography (£4013, 95% confidence interval £3673 to £4498) or a strategy combining the two tests (£4058, 95% confidence interval £3702 to £4547). Positron emission tomography-computerised tomography led to more patients with malignant nodules being correctly managed, 0.44 on average (95% confidence interval 0.39 to 0.49), compared with 0.40 (95% confidence interval 0.35 to 0.45); using both tests further increased this (0.47, 95% confidence interval 0.42 to 0.51). LIMITATIONS: The high prevalence of malignancy in nodules observed in this trial, compared with that observed in nodules identified within screening programmes, limits the generalisation of the current results to nodules identified by screening. CONCLUSIONS: Findings from this research indicate that positron emission tomography-computerised tomography is more accurate than dynamic contrast-enhanced computerised tomography for the characterisation of solitary pulmonary nodules. A combination of maximum standardised uptake value and peak enhancement had the highest accuracy with a small increase in costs. Findings from this research also indicate that a combined positron emission tomography-dynamic contrast-enhanced computerised tomography approach with a slightly higher willingness to pay to avoid missing small cancers or to avoid a 'watch and wait' policy may be an approach to consider. FUTURE WORK: Integration of the dynamic contrast-enhanced component into the positron emission tomography-computerised tomography examination and the feasibility of dynamic contrast-enhanced computerised tomography at lung screening for the characterisation of solitary pulmonary nodules should be explored, together with a lower radiation dose protocol

Symptoms that predict chest X-ray results suspicious for lung cancer in UK primary care: results from a prospective study

Background/introduction:?Predictive values of lung cancer (LC) symptoms that inform UK LC referral guidelines have been calculated from GP records and databases, with the potential for recording bias by GPs. The Identifying Symptom Predictors of Chest and Respiratory Disease (IPCARD) self-completion questionnaire was designed, for use in prospective studies, to obtain accurate positive predictive values (PPVs) of patient-elicited potential LC symptoms. The IPCARD Feasibility Study provides the first prospectively collected, patient-elicited comprehensive symptom data to identify PPVs of potential LC symptoms in UK primary care.Research question:?Which patient-elicited symptoms predict chest X-rays (CXR) suspicious for LC in a GP-referred CXR population (LC incidence 1%)?Methods:?GP-referred CXR attendees (1414) at three UK sites completed IPCARD before CXR; LC diagnosis was obtained 6 months post-CXR. Multiple logistic regression was used to calculate PPVs of symptoms for abnormal CXR, adjusting for age and sex; and stratifying by smoking status and COPD.Results:?Common chest symptoms – cough for longer than 3 weeks, generic chest aches/pains, and breathlessness – did not predict suspicious CXR. Weight loss and less common variants of chest pain (pain in side of chest/ribs, severe pain, and pain that ‘feels like indigestion – not associated with eating’ in patients with non-progressive/less severe pain) predicted CXR suspicious for LC in this high risk, referred population.Discussion/conclusion:?Common chest systems, identified as referral criteria by NICE, and included in UK ‘Be Clear about Cancer’ public awareness campaigns, although potentially predicting LC in a lower risk pre-referral population, did not predict CXR suspicious for LC in this referred population with higher rates of non-malignant chest and respiratory disease. The possibility that weight loss, and variants of chest pain, might also predict LC in pre-referral primary care populations with chronic respiratory disease will be investigated in ongoing studies using IPCARD

Eliciting symptoms interpreted as normal by patients with early-stage lung cancer: could GP elicitation of normalised symptoms reduce delay in diagnosis? Cross-sectional interview study

Objectives: To investigate why symptoms indicative of early-stage lung cancer (LC) were not presented to general practitioners (GPs) and how early symptoms might be better elicited within primary care.Design, setting and participants: A qualitative cross-sectional interview study about symptoms and help-seeking in 20 patients from three south England counties, awaiting resection of LC (suspected or histologically confirmed). Analysis drew on principles of discourse analysis and constant comparison to identify processes involved in interpretation and communication about symptoms, and explain nonpresentation.Results: Most participants experienced health changes possibly indicative of LC which had not been presented during GP consultations. Symptoms that were episodic, or potentially caused by ageing or lifestyle, were frequently not presented to GPs. In interviews, open questions about health changes/symptoms in general did not elicit these symptoms; they only emerged in response to closed questions detailing specific changes in health. Questions using disease-related labels, for example, pain or breathlessness, were less likely to elicit symptoms than questions that used non-disease terminology, such as aches, discomfort or ‘getting out of breath’. Most participants described themselves as feeling well and were reluctant to associate potentially explained, nonspecific or episodic symptoms with LC, even after diagnosis.Conclusions: Patients with early LC are unlikely to present symptoms possibly indicative of LC that they associate with normal processes, when attending primary care before diagnosis. Faced with patients at high LC risk, GPs will need to actively elicit potential LC symptoms not presented by the patient. Closed questions using non-disease terminology might better elicit normalised symptoms

Surveillance for the detection of early lung cancer in patients with bronchial dysplasia

BACKGROUND: The natural history of bronchial preinvasive lesions and the risk of developing lung cancer in patients with these lesions are not clear. Previous studies have treated severe dysplasia and carcinoma in situ (CIS) on the assumption that most will progress to invasive carcinoma. AIMS: To define the natural history of preinvasive lesions and assess lung cancer risk in patients with these lesions. HYPOTHESIS: Most preinvasive lesions will not progress to invasive carcinoma but patients with these lesions will be at high risk. METHODS: A cohort of patients with preinvasive lesions underwent fluorescence bronchoscopy every 4-12 months and computed tomography of the chest annually. The main end point was the development of invasive carcinoma. RESULTS: 22 patients with 53 lesions were followed up for 12-85 months. 11 cancers were diagnosed in 9 patients. Of the 36 high-grade lesions (severe dysplasia and CIS), 6 progressed to invasive cancers. 5 separate cancers developed at remote sites in patients with high-grade lesions. All cancers were N0M0 and curative treatment was given to 8 of the 9 patients. The cumulative risk of developing lung cancer in a patient with a high-grade lesion was 33% and 54% at 1 and 2 years, respectively. Of the 17 low-grade lesions, none progressed to invasive carcinoma. CONCLUSIONS: Although the risk of malignant progression of individual preinvasive lesions is relatively small, patients with high-grade lesions are at high risk of lung cancer. Surveillance facilitated early detection and treatment with curative intent in most patients

Significant differences in lameness and limb-related abnormalities between Baseline and Final examinations of 149 working horses belonging to 131 owners from Jaipur, India.

<p>(Participatory intervention group n = 83 horses belonging to 73 people; Control group n = 66 horses belonging to 58 people). The group with the largest relative improvement between Baseline and Final has the text depicting the magnitude of change in bold.</p><p>¹ See <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0124342#pone.0124342.t001" target="_blank">Table 1</a> for scoring methods</p><p>² For continuous or ordinal data = mean of horses (for whole horse measures) or limbs (for limb-specific measures) affected. For binary measures or those aggregated into two groups for analysis = percentage of horses/ limbs affected</p><p>³ Relative improvement: the group which showed the most positive clinical change and/or the least negative clinical change (except for 'Shod' and 'Active response when approached' where no clinical value was applied)</p><p>⁴ Calculated as Year 1—Year 3, i.e. a positive value = clinical improvement; a negative value = deterioration (except for 'Shod' and 'Active response when approached' where no clinical value was applied)</p><p>⁵ 1st-order MQL estimation (otherwise, less-biased 2nd-order PQL estimation was employed in all binary and multinomial response models)</p><p>Significant differences in lameness and limb-related abnormalities between Baseline and Final examinations of 149 working horses belonging to 131 owners from Jaipur, India.</p

Components of individual exit interviews with horse owners in participatory intervention (PI) and control (C) groups at the end of the 2-year project.

<p>¹ Semi-structured interview questions were addressed directly to each horse owner and referred to the 2-year project period only. In some cases the owner was absent and the interview was carried out with a relative.</p><p>² Each card stated a single equine resource or management need taken from the monitoring chart used in group meetings, as shown in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0126160#pone.0126160.t002" target="_blank">Table 2</a>. Some cards referred to management or work practices which were only relevant to some horses, for example cart maintenance, feeding during pregnancy. These were omitted from the card-sorting exercise for individual owners if not relevant.</p><p>Components of individual exit interviews with horse owners in participatory intervention (PI) and control (C) groups at the end of the 2-year project.</p