Improving detection of familial hypercholesterolaemia in primary care using electronic audit and nurse-led clinics

RATIONALE, AIMS AND OBJECTIVES: In the UK fewer than 15% of familial hypercholesterolemia (FH) cases are diagnosed, representing a major gap in coronary heart disease prevention. We wished to support primary care doctors within the Medway Clinical Commissioning Group (CCG) to implement NICE guidance (CG71) and consider the possibility of FH in adults who have raised total cholesterol concentrations, thereby improving the detection of people with FH. METHODS: Utilizing clinical decision support software (Audit+) we developed an FH Audit Tool and implemented a systematic audit of electronic medical records within GP practices, first identifying all patients diagnosed with FH or possible FH and next electronically flagging patients with a recorded total cholesterol of >7.5 mmol L(-1) or LDL-C > 4.9 mmol L(-1) (in adults), for further assessment. After a 2-year period, a nurse-led clinic was introduced to screen more intensely for new FH index cases. We evaluated if these interventions increased the prevalence of FH closer to the expected prevalence from epidemiological studies. RESULTS: The baseline prevalence of FH within Medway CCG was 0.13% (1 in 750 persons). After 2 years, the recorded prevalence of diagnosed FH increased by 0.09% to 0.22% (1 in 450 persons). The nurse advisor programme ran for 9 months (October 2013-July 2014) and during this time, the recorded prevalence of patients diagnosed with FH increased to 0.28% (1 in 357 persons) and the prevalence of patients 'at risk and unscreened' reduced from 0.58% to 0.14%. CONCLUSIONS: Our study shows that two simple interventions increased the detection of FH. This systematic yet simple electronic case-finding programme with nurse-led review allowed the identification of new index cases, more than doubling the recorded prevalence of detected disease to 1 in 357 (0.28%). This study shows that primary care has an important role in identifying patients with this condition

The Work of the Course: validity and reliability in assessing English Literature

© 2017 National Association for the Teaching of English This article reflects on the values and practices of a revolutionary UK A level (senior secondary) course that achieved a high degree of validity and reliability in assessing the study of English literature. John Hodgson and Bill Greenwell were involved in its teaching and assessment from an early stage, and Greenwell's comments on an early draft of the article have been incorporated. The practice of literary response enshrined in the course was based on a striking application of “personal response” to literature, gave students opportunities to show capability in studying and writing a range of literary styles and genres, and engaged teachers regionally and nationally in a developed professional community of practice. It remains a touchstone of quality as well as of innovation in English curriculum and assessment

FAN1 modifies Huntington's disease progression by stabilising the expanded HTT CAG repeat

Huntington's disease (HD) is an inherited neurodegenerative disease caused by an expanded CAG repeat in the HTT gene. CAG repeat length explains around half of the variation in age-at-onset, but genetic variation elsewhere in the genome accounts for a significant proportion of the remainder. Genome-wide association studies have identified a bidirectional signal on chromosome 15, likely underlain by FAN1 (FANCD2 and FANCI Associated Nuclease 1), a nuclease involved in DNA interstrand cross link repair. Here we show that increased FAN1 expression is significantly associated with delayed age-at-onset and slower progression of HD suggesting FAN1 is protective in the context of an expanded HTT CAG repeat. FAN1 overexpression in human cells reduces CAG repeat expansion in exogenously expressed mutant HTT exon 1, and in patient-derived stem cells and differentiated medium spiny neurons, FAN1 knockdown increases CAG repeat expansion. The stabilising effect is FAN1 concentration and CAG repeat length dependent. We show that FAN1 binds to the expanded HTT CAG repeat DNA and its nuclease activity is not required for protection against CAG repeat expansion. These data shed new mechanistic insights into how the genetic modifiers of HD act to alter disease progression, and show that FAN1 affects somatic expansion of the CAG repeat through a nuclease-independent mechanism. This provides new avenues for therapeutic interventions in HD and potentially other triplet repeat disorders

Influence of coding variability in APP-Aß metabolism genes in sporadic Alzheimer's disease

The cerebral deposition of Aß42, a neurotoxic proteolitic derivate of amyloid precursor protein (APP), is a central event in Alzheimer’s disease (AD)(Amyloid hypothesis). Given the key role of APP-Aß metabolism in AD pathogenesis, we selected 29 genes involved in APP processing, Aß degradation and clearance. We then used exome and genome sequencing to investigate the single independent (single-variant association test) and cumulative (gene-based association test) effect of coding variants in these genes as potential susceptibility factors for AD, in a cohort composed of 435 sporadic and mainly late-onset AD cases and 801 elderly controls from North America and the UK. Our study shows that common coding variability in these genes does not play a major role for the disease development. In the single-variant association analysis, the main hits, which were nominally significant, were found to be very rare coding variants (MAF 0.3%-0.8%) that map to genes involved in APP processing (MEP1B), trafficking and recycling (SORL1), Aß extracellular degradation (ACE) and clearance (LRP1). Moreover, four genes (ECE1, LYZ, TTR and MME) have been found as nominally associated to AD using c-alpha and SKAT tests. We suggest that Aβ degradation and clearance, rather than Aβ production, may play a crucial role in the etiology of sporadic AD

Maps, Memories and Manchester: The Cartographic Imagination of the Hidden Networks of the Hydraulic City

The largely unseen channelling, culverting and controlling of water into, through and out of cities is the focus of our cartographic interpretation. This paper draws on empirical material depicting hydraulic infrastructure underlying the growth of Manchester in mapped form. Focusing, in particular, on the 19th century burst of large-scale hydraulic engineering, which supplied vastly increased amounts of clean drinking water, controlled unruly rivers to eliminate flooding, and safely removed sewage, this paper explores the contribution of mapping to the making of a more sanitary city, and towards bold civic minded urban intervention. These extensive infrastructures planned and engineered during Victorian and Edwardian Manchester are now taken-for-granted but remain essential for urban life. The maps, plans and diagrams of hydraulic Manchester fixed particular forms of elite knowledge (around planning foresight, topographical precision, civil engineering and sanitary science) but also facilitated and freed flows of water throughout the city. The survival of these maps and plans in libraries, technical books and obscure reports allows the changing cultural work of water to be explored and evokes a range of socially specific memories of a hidden city. Our aetiology of hydraulic cartographics is conducted using ideas from science and technology studies, semiology, and critical cartography with the goal of revealing how they work as virtual witnesses to an 1 unseen city, dramatizing engineering prowess and envisioning complex and messy materiality into a logical, holistic and fluid network underpinning the urban machine. 1

Influence of coding variability in APP-Aß metabolism genes in sporadic Alzheimer's disease

The cerebral deposition of Aß42, a neurotoxic proteolitic derivate of amyloid precursor protein (APP), is a central event in Alzheimer’s disease (AD)(Amyloid hypothesis). Given the key role of APP-Aß metabolism in AD pathogenesis, we selected 29 genes involved in APP processing, Aß degradation and clearance. We then used exome and genome sequencing to investigate the single independent (single-variant association test) and cumulative (gene-based association test) effect of coding variants in these genes as potential susceptibility factors for AD, in a cohort composed of 435 sporadic and mainly late-onset AD cases and 801 elderly controls from North America and the UK. Our study shows that common coding variability in these genes does not play a major role for the disease development. In the single-variant association analysis, the main hits, which were nominally significant, were found to be very rare coding variants (MAF 0.3%-0.8%) that map to genes involved in APP processing (MEP1B), trafficking and recycling (SORL1), Aß extracellular degradation (ACE) and clearance (LRP1). Moreover, four genes (ECE1, LYZ, TTR and MME) have been found as nominally associated to AD using c-alpha and SKAT tests. We suggest that Aβ degradation and clearance, rather than Aβ production, may play a crucial role in the etiology of sporadic AD

FAN1 modifies Huntington's disease progression by stabilising the expanded HTT CAG repeat

Huntington’s disease (HD) is an inherited neurodegenerative disease caused by an expanded CAG repeat in the HTT gene. CAG repeat length explains around half of the variation in age-at-onset, but genetic variation elsewhere in the genome accounts for a significant proportion of the remainder. Genome-wide association studies have identified a bidirectional signal on chromosome 15, likely underlain by FAN1 (FANCD2 and FANCI Associated Nuclease 1), a nuclease involved in DNA interstrand cross link repair. Here we show that increased FAN1 expression is significantly associated with delayed age-at-onset and slower progression of HD suggesting FAN1 is protective in the context of an expanded HTT CAG repeat. FAN1 overexpression in human cells reduces CAG repeat expansion in exogenously expressed mutant HTT exon 1, and in patient-derived stem cells and differentiated medium spiny neurons, FAN1 knockdown increases CAG repeat expansion. The stabilising effect is FAN1 concentration and CAG repeat length dependent. We show that FAN1 binds to the expanded HTT CAG repeat DNA and its nuclease activity is not required for protection against CAG repeat expansion. These data shed new mechanistic insights into how the genetic modifiers of HD act to alter disease progression, and show that FAN1 affects somatic expansion of the CAG repeat through a nuclease-independent mechanism. This provides new avenues for therapeutic interventions in HD and potentially other triplet repeat disorders

Back to basics in the marketing of place: the impact of litter upon place attitudes

YesAttempts to apply marketing theory and principles to place have become a legitimate area of academic and 'real world' practice. However, place marketing does not typically incorporate all elements of the traditional 7 Ps, focusing far too often on just one of these - promotion. Besides this rather myopic approach, place marketing suffers from an overly strategic view of the world that ignores the meaning and lived experience of places to individuals, especially residents. The purpose of this article is twofold - first, we investigate the impact of litter on place attitudes. Litter is a common, but negative, element of place, which is intimately connected to the lived experience of a place but typically far removed from the positive promotional activity favoured by place marketing efforts and the study thereof. In this sense, the article reframes place marketing from a strategic to a micro-marketing endeavour. We found that exposing respondents to litter significantly lowers their place attitudes. Our second contribution is to demonstrate the relevance of classic marketing research approaches, such as attitudinal measures, to investigate litter and its impact on place evaluations, through quasi-experimental design (with 662 respondents). Through this, we extend the range of theory and method applied in place marketing - away from controllable promotional endeavours investigated through case-studies to a more holistic and robust interpretation of place marketing, which has a measurable impact upon the places where people live and visit

Playing on common ground: Spaces of sport, education and corporate connectivity, contestation and creativity

In this article we examine connectivities within the ‘messy’ organizational commons of sport, education and corporate partnerships. As scholars forewarn, there are currently key stakeholders within the commons that that have set agendas, occupied ideological and physical terrain, and legitimized a presence and authority. The intertwining of organizations here is an evident function of an increased symbiosis between sport, education and governmental and non-governmental stakeholders to carve out significant sector spaces, and exert authority and power over the creation, implementation and ownership ‘collaborative’ and intersectional work. Drawing on spatial theorists, Henri Lefebvre and Yi Fu Tuan, and examples from FIFA and the IOC, we present a conceptual framework of global stakeholder relations. Focusing of processes of thought, production and action, we offer an intersectional critique of the nuances of Sport–Corporate–Education nexus and consider possibilities and potential for sport education spaces to be reconfigured ane