Optimizing patient risk stratification for colonoscopy screening and surveillance of colorectal cancer: The role for linked data

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BUDGET PERSPECTIVES 2011. RESEARCH SERIES NUMBER 18 October 2010

The Budget Perspectives Conference, co‐hosted annually by the Economic and Social Research Institute (ESRI) and the Foundation for Fiscal Studies provides a forum for discussing key public policy issues of both immediate concern (in upcoming budgets) and longer term concern. In the context of the current fiscal and economic crisis, research insights aimed at making more efficient use of scarce resources are needed now more than ever. Furthermore, research on the allocation of benefits and tax burdens is critical not only for intrinsic reasons but also to ensure that policies are publicly acceptable. It is not enough for policy to promote efficiency and fairness – it must be seen to do so. The research papers presented at this year’s annual Budget Perspectives conference continue in this tradition, providing an opportunity for policymakers, social partners and researchers to engage on some of the major issues that we face today

Progression of Carotid Artery Intima-Media Thickness During 12 Years in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study

OBJECTIVE This study investigated the long-term effects of intensive diabetic treatment on the progression of atherosclerosis, measured as common carotid artery intima-media thickness (IMT). RESEARCH DESIGN AND METHODS A total of 1,116 participants (52% men) in the Epidemiology of Diabetes Interventions and Complications (EDIC) trial, a long-term follow-up of the Diabetes Control and Complications Trial (DCCT), had carotid IMT measurements at EDIC years 1, 6, and 12. Mean age was 46 years, with diabetes duration of 24.5 years at EDIC year 12. Differences in IMT progression between DCCT intensive and conventional treatment groups were examined, controlling for clinical characteristics, IMT reader, and imaging device. RESULTS Common carotid IMT progression from EDIC years 1 to 6 was 0.019 mm less in intensive than in conventional (P < 0.0001), and from years 1 to 12 was 0.014 mm less (P = 0.048); but change from years 6 to 12 was similar (intensive − conventional = 0.005 mm, P = 0.379). Mean A1C levels during DCCT and DCCT/EDIC were strongly associated with progression of IMT, explaining most of the differences in IMT progression between DCCT treatment groups. Albuminuria, older age, male sex, smoking, and higher systolic blood pressure were significant predictors of IMT progression. CONCLUSIONS Intensive treatment slowed IMT progression for 6 years after the end of DCCT but did not affect IMT progression thereafter (6–12 years). A beneficial effect of prior intensive treatment was still evident 13 years after DCCT ended. These differences were attenuated but not negated after adjusting for blood pressure. These results support the early initiation and continued maintenance of intensive diabetes management in type 1 diabetes to retard atherosclerosis

The U&I study: study protocol for a feasibility randomised controlled trial of a pre-cognitive behavioural therapy digital ‘informed choice’ intervention to improve attitudes towards uptake and implementation of CBT for psychosis

Background: At least 40% of people with psychosis have persistent distressing symptoms despite optimal medication treatment. Cognitive Behaviour Therapy for psychosis (CBTp) is the only NICE recommended individual therapy for psychosis, with effects on symptoms, distress and quality of life. Yet fewer than 20% of service-users receive it and 94% of trusts struggle to provide it. Of those offered it, 22-43% refuse or do not attend. We have developed a new pre-CBTp informed choice intervention to address knowledge and attitudes that influence uptake and implementation and now want to test it in a feasibility trial. Methods: The design is a 2-arm, feasibility RCT, with 1:1 randomisation, stratified by participant group and site. Participants are 40 psychosis patients and 40 clinicians, who are ambivalent towards uptake or implementation of CBTp. Sites are community and inpatient services in Sussex and London. The intervention is a pre-CBT digital psychoeducation intervention designed to address identified knowledge and attitudinal barriers to uptake and implementation of CBTp, incorporating behaviour change mechanisms, and supported by animated introductory, patient and clinician stories. The comparator is the NHS choices website for CBT. The primary aim is to assess clinical feasibility (recruitment, randomization, acceptability, use, delivery, outcome measurement, retention). A secondary aim is a preliminary evaluation of efficacy. Outcomes will be assessed at baseline, post-intervention, and one-month follow up (blind to treatment arm). The primary efficacy outcome is likelihood of offering/taking up CBTp. Secondary outcomes include knowledge and attitudes towards CBTp; illness perceptions; empowerment; psychological wellbeing (patients only); CBTp implementation (clinicians only). Use of the intervention and CBT behaviours during the follow-up period will be recorded, and captured in a feedback questionnaire. Use, acceptability and experience of outcome assessment will be explored in qualitative interviews with participants (n = 6 per group). The efficacy evaluation will report descriptive data, key model parameters and 95% Highest Probability Density intervals in a Bayesian growth model. Discussion: This is the first feasibility trial of a digital ‘informed choice’ decision aid for the implementation of CBTp. If the trial proves feasible and demonstrates preliminary evidence of efficacy, a large multi-site trial will be warranted

Structural modification of the Pseudomonas aeruginosa alkylquinoline cell–cell communication signal, HHQ, leads to benzofuranoquinolines with anti-virulence behaviour in ESKAPE pathogens

Microbial populations have evolved intricate networks of negotiation and communication through which they can coexist in natural and host ecosystems. The nature of these systems can be complex and they are, for the most part, poorly understood at the polymicrobial level. The Pseudomonas Quinolone Signal (PQS) and its precursor 4- hydroxy- 2-heptylquinoline (HHQ) are signal molecules produced by the important nosocomial pathogen Pseudomonas aeruginosa. They are known to modulate the behaviour of co-colonizing bacterial and fungal pathogens such as Bacillus atropheaus, Candida albicans and Aspergillus fumigatus. While the structural basis for alkyl-quinolone signalling within P. aeruginosa has been studied extensively, less is known about how structural derivatives of these molecules can influ-ence multicellular behaviour and population- level decision-making in other co-colonizing organisms. In this study, we investigated a suite of small molecules derived initially from the HHQ framework, for anti-virulence activity against ESKAPE pathogens, at the species and strain levels. Somewhat surprisingly, with appropriate substitution, loss of the alkyl chain (present in HHQ and PQS) did not result in a loss of activity, presenting a more easily accessible synthetic framework for investigation. Virulence profiling uncovered significant levels of inter-strain variation among the responses of clinical and environmental isolates to small-molecule challenge. While several lead compounds were identified in this study, further work is needed to appreciate the extent of strain- level tolerance to small-molecule anti-infectives among pathogenic organisms.National Forum for the Enhancement of Teaching and Learning in Higher Education SFI/12/IP/1315, US Cystic Fibrosis Foundation SFI/12/RC/2275, National Health and Medical Research Council (NHMRC) of Australia SFI/12/RC/2275_P2, UCC Strategic Research Fund and Science Foundation Ireland (SFI) SSPC-3 12/RC/2275_2, Synthesis and Solid State Pharmaceutical Centre (SSPC) HRB-ILP-POR-2019-004, MRCG-2018-16, Universidade do Algarve TL19UCC1481/02, OGARA1710, APP1183640 2020-5,info:eu-repo/semantics/publishedVersio

Mapping of diabetes susceptibility LOCI in a domestic cat breed with an unusually high incidence of diabetes mellitus

© 2020 by the authors. Licensee MDPI, Basel, Switzerland. Genetic variants that are associated with susceptibility to type 2 diabetes (T2D) are important for identification of individuals at risk and can provide insights into the molecular basis of disease. Analysis of T2D in domestic animals provides both the opportunity to improve veterinary management and breeding programs as well as to identify novel T2D risk genes. Australian-bred Burmese (ABB) cats have a 4-fold increased incidence of type 2 diabetes (T2D) compared to Burmese cats bred in the United States. This is likely attributable to a genetic founder effect. We investigated this by performing a genome-wide association scan on ABB cats. Four SNPs were associated with the ABB T2D phenotype with p values \u3c 0.005. All exons and splice junctions of candidate genes near significant single-nucleotide polymorphisms (SNPs) were sequenced, including the genes DGKG, IFG2BP2, SLC8A1, E2F6, ETV5, TRA2B and LIPH. Six candidate polymorphisms were followed up in a larger cohort of ABB cats with or without T2D and also in Burmese cats bred in America, which exhibit low T2D incidence. The original SNPs were confirmed in this cohort as associated with the T2D phenotype, although no novel coding SNPs in any of the seven candidate genes showed association with T2D. The identification of genetic markers associated with T2D susceptibility in ABB cats will enable preventative health strategies and guide breeding programs to reduce the prevalence of T2D in these cats

Mapping of diabetes susceptibility LOCI in a domestic cat breed with an unusually high incidence of diabetes mellitus

© 2020 by the authors. Licensee MDPI, Basel, Switzerland. Genetic variants that are associated with susceptibility to type 2 diabetes (T2D) are important for identification of individuals at risk and can provide insights into the molecular basis of disease. Analysis of T2D in domestic animals provides both the opportunity to improve veterinary management and breeding programs as well as to identify novel T2D risk genes. Australian-bred Burmese (ABB) cats have a 4-fold increased incidence of type 2 diabetes (T2D) compared to Burmese cats bred in the United States. This is likely attributable to a genetic founder effect. We investigated this by performing a genome-wide association scan on ABB cats. Four SNPs were associated with the ABB T2D phenotype with p values \u3c 0.005. All exons and splice junctions of candidate genes near significant single-nucleotide polymorphisms (SNPs) were sequenced, including the genes DGKG, IFG2BP2, SLC8A1, E2F6, ETV5, TRA2B and LIPH. Six candidate polymorphisms were followed up in a larger cohort of ABB cats with or without T2D and also in Burmese cats bred in America, which exhibit low T2D incidence. The original SNPs were confirmed in this cohort as associated with the T2D phenotype, although no novel coding SNPs in any of the seven candidate genes showed association with T2D. The identification of genetic markers associated with T2D susceptibility in ABB cats will enable preventative health strategies and guide breeding programs to reduce the prevalence of T2D in these cats

Computed Tomography Angiography for Detection of Pulmonary Embolism in Western Australia Shows Increasing Use with Decreasing Diagnostic Yield

(1) Background: Pulmonary embolism (PE) can be fatal. Computed tomography pulmonary angiography (CTPA) can accurately diagnose PE, but it should be used only when reasonable pre-test probability exists. Overtesting with CTPA exposes patients to excess ionizing radiation and contrast media, while PE overdiagnosis leads to the treatment of small emboli unlikely to cause harm. This study assessed trends in CTPA use and diagnostic yield. We also assessed trends in PE hospitalizations and mortality to indicate PE severity. (2) Methods: Analysis of Western Australian linked administrative data for 2003–2015 including hospitalizations, emergency department (ED) attendances, and CTPA performed at hospitals. Age-sex standardized trends were calculated for CTPA use, PE hospitalizations, and mortality (as a proxy for severity). Logistic regression assessed diagnostic yield of CTPA following unplanned ED presentations. (3) Results: CTPA use increased from 3.3 per 10,000 person-years in 2003 (95% CI 3.0–3.6) to 17.1 per 10,000 person-years (16.5–17.7) in 2015. Diagnostic yield of CTPA increased from 12.7% in 2003 to 17.4% in 2005, declining to 12.2% in 2015 (p = 0.049). PE hospitalizations increased from 3.8 per 10,000 (3.5–4.1) in 2003 to 5.2 per 10,000 (4.8–5.5) in 2015. Mortality remained constant at 0.50 per 10,000 (0.39–0.62) in 2003 and 0.42 per 10,000 (0.32–0.51) in 2015. (4) Conclusions: CTPA increased from 2003 to 2015, while diagnostic yield decreased, potentially indicating overtesting. PE mortality remained constant despite increasing hospitalizations, likely indicating a higher proportion of less severe cases. As treatment can be harmful, this could represent overdiagnosis

Live virtual placements: an alternative to traditional ‘in person’ placements

Background and aim: The role of the paramedic is diversifying, and universities need to respond by developing curriculums that support paramedic graduates to meet future workforce needs. Placements are key to our students developing the necessary competencies to become qualified paramedics and the pressure is on universities to offer a wide range of placements to reflect professional diversification. In addition, Health and Care Professions Council’s new standards of proficiency acknowledge that paramedics of the future are likely to consult patients in the virtual world [1]. As universities strive to meet this demand, they are often faced with placement capacity issues. Rising student numbers, staff retention issues and competition for placements from other healthcare students can make it extremely challenging to secure placements, especially in desirable areas such as primary care. Activity: The author, with the support from colleagues, was successful in obtaining funding from Health Education England to pilot a series of live virtual placement experiences, the first of which was successfully delivered on 20th April. On this date, 30 learners from our paramedic degree apprenticeship programme, in a classroom on our Lancaster campus, virtually attended a live clinic in a primary care setting in the south of England. The clinic was rigged with various cameras and microphones, with real patients consenting to being filmed. The experience comprised of 5 patients, with the lead clinician providing a brief to the learners before each patient arrived for their consultation. Afterwards, the clinician would complete their clinical documentation before engaging in a two-way conversation with our learners and academic staff via Microsoft teams. Following the clinic, our apprentices had the opportunity to consolidate their learning via case study driven seminars which linked to the mornings experience. Findings: Overall, student feedback was supportive, with the majority stating they found the experience enjoyable and engaging. The video stream of the placement was recorded for reuse in the programme’s curriculum, and we hope that future live virtual placements will see other professions, such as physiotherapy and nursing, take part. Eventually, we want to develop the model for other disciplines and placement settings Conclusion: The academic team are looking forward to the second of three experiences, in May, with the view to contributing to the growing evidence base in this area, to reflect the value that we believe ‘Live Virtual Placement’ experiences have in the development of our future workforce. Ethics statement: Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable. References: 1. Health and Care Professions Council [Internet]. 2023 [cited 2023 Apr 29]. Available from: https://www.hcpc-uk.org/globalassets/standards/standards-of-proficiency/reviewing/paramedics---new-standards.pd

Paying for Care Costs in Later Life Using the Value in People’s Homes

With the number of U.K. citizens aged 75+ doubling to 10 million by 2040, and with 1.3 million people already receiving social care services in England alone, social care funding is a key public policy challenge. The government has launched a set of reforms designed to get social care funding onto a sustainable footing by establishing a new level for what individuals and the state will pay. The reforms are designed to encourage individuals to explore how best to use their available wealth and assets to meet care costs through a mixed system of local authority and private sector care-funding options. One option is to use the value in the home to bridge the cost between out-of-pocket costs and care home fees. In this article, we consider two new financial arrangements designed to meet the needs of people in different financial circumstances based on releasing equity from the home. These are an equity-backed insurance product and an “equity bank” that lets a person draw down an income from their hom