Persistent inequalities in Hospice at Home provision.

OBJECTIVE: To describe the nature and scope of a new Hospice at Home (H@H) service and to identify its equality of provision. METHODS: Case note review of patients supported by a H@H service for 1 year from September 2012 to August 2013 (n=321). Descriptive analysis to report frequencies and proportions of quantitative data extracted from service logs, referral forms and care records; thematic analysis of qualitative data from care record free text. RESULTS: Demand outstripped supply. Twice as many night care episodes were requested (n=1237) as were provided (n=613). Inequalities in access to the service related to underlying diagnosis and socioeconomic status. 75% of patients using the service had cancer (221/293 with documented diagnosis). Of those who died at home in the areas surrounding the hospice, 53% (163/311) of people with cancer and 11% (49/431) of those without cancer received H@H support. People who received H@H care were often more affluent than the population average for the area within which they lived. Roles of the service identified included: care planning/implementation, specialist end-of-life care assessment and advice, 'holding' complex patients until hospice beds become available and clinical nursing care. CONCLUSION: There is significant unmet need and potentially large latent demand for the H@H service. People without cancer or of lower socioeconomic status are less likely to access the service. Action is needed to ensure greater and more equitable service provision in this and similar services nationally and internationally

Cardiovascular disease biomarkers are associated with declining renal function in type 2 diabetes

Aims/hypothesis: We investigated whether biochemical cardiovascular risk factors and/or markers of subclinical cardiovascular disease were associated with the development of reduced renal function in people with type 2 diabetes. Methods: A cohort of 1066 Scottish men and women aged 60–74 years with type 2 diabetes from the Edinburgh Type 2 Diabetes Study were followed up for a median of 6.7 years. New-onset reduced renal function was defined as two eGFRs <60 ml−1 min−1 (1.73 m)−2 at least 3 months apart with a > 25% decline from baseline eGFR. Ankle brachial pressure index (ABI), N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin T (hsTnT) were measured at baseline. Pulse wave velocity (PWV) and carotid intima media thickness were measured 1 year into follow-up. Data were analysed using Cox proportional hazards models. Results: A total of 119 participants developed reduced renal function during follow-up. ABI, PWV, NT-proBNP and hsTnT were all associated with onset of decline in renal function following adjustment for age and sex. These associations were attenuated after adjustment for additional diabetes renal disease risk factors (systolic BP, baseline eGFR, albumin:creatinine ratio and smoking pack-years), with the exception of hsTnT which remained independently associated (HR 1.51 [95% CI 1.22, 1.87]). Inclusion of hsTnT in a predictive model improved the continuous net reclassification index by 0.165 (0.008, 0.286). Conclusions/interpretation: Our findings demonstrate an association between hsTnT, a marker of subclinical cardiac ischaemia, and subsequent renal function decline. Further research is required to establish the predictive value of hsTnT and response to intervention

Diphthamide modification of eEF2 requires a J-domain protein and is essential for normal development

The intracellular target of diphtheria toxin is a modified histidine residue, diphthamide, in the translation elongation factor, eEF2. This enigmatic modification occurs in all eukaryotes, and is produced in yeast by the action of five gene products, DPH1 to DPH5. Sequence homologues of these genes are present in all sequenced eukaryotic genomes and in higher eukaryotes there is functional evidence for DPH1, 2, 3, and 5 acting in diphthamide biosynthesis. We have identified a mouse mutant in the remaining gene, Dph4. Cells derived from homozygous mutant embryos lack the diphthamide modification of EF2 and are resistant to killing by diphtheria toxin. Reporter-tagged DPH4 protein localizes to the cytoskeleton, in contrast to the localization of DPH1, and consistent with evidence that DPH4 is not part of a proposed complex containing DPH1, 2 and 3. Mice homozygous for the mutation are retarded in growth and development and almost always die before birth. Those that survive long enough have preaxial polydactyly, a duplication of digit 1 of the hind foot. This same defect is seen in embryos homozygous for mutation of DPH1, suggesting that lack of diphthamide on eEF2 could result in translational failure of specific proteins, rather than a generalized translation downregulation

A multi-component stair climbing promotional campaign targeting calorific expenditure for worksites; a quasi-experimental study testing effects on behaviour, attitude and intention

BACKGROUND: Accumulation of lifestyle physical activity is a current aim of health promotion, with increased stair climbing one public health target. While the workplace provides an opportunity for regular stair climbing, evidence for effectiveness of point-of-choice interventions is equivocal. This paper reports a new approach to worksite interventions, aimed at changing attitudes and, hence, behaviour. METHODS: Pre-testing of calorific expenditure messages used structured interviews with members of the public (n = 300). Effects of multi-component campaigns on stair climbing were tested with quasi-experimental, interrupted time-series designs. In one worksite, a main campaign poster outlining the amount of calorific expenditure obtainable from stair climbing and a conventional point-of-choice prompt were used (Poster alone site). In a second worksite, additional messages in the stairwell about calorific expenditure reinforced the main campaign (Poster + Stairwell messages site). The outcome variables were automated observations of stair and lift ascent (28,854) and descent (29,352) at baseline and for three weeks after the intervention was installed. Post-intervention questionnaires for employees at the worksites assessed responses to the campaign (n = 253). Analyses employed Analysis of Variance with follow-up Bonferroni t-tests (message pre-testing), logistic regression of stair ascent and descent (campaign testing), and Bonferroni t-tests and multiple regression (follow-up questionnaire). RESULTS: Pre-testing of messages based on calorific expenditure suggested they could motivate stair climbing if believed. The new campaign increased stair climbing, with greater effects at the Poster + Stairwell messages site (OR = 1.52, 95% CI = 1.40-1.66) than Posters alone (OR = 1.24, 95% CI = 1.15-1.34). Follow-up revealed higher agreement with two statements about calorific outcomes of stair climbing in the site where they were installed in the stairwell, suggesting more positive attitudes resulted from the intervention. Future intentions for stair use were predicted by motivation by the campaign and beliefs that stair climbing would help weight control. CONCLUSIONS: Multi-component campaigns that target attitudes and intentions may substantially increase stair climbing at work

Divergent drivers of carbon dioxide and methane dynamics in an agricultural coastal floodplain: post-flood hydrological and biological drivers

Many coastal floodplains have been artificially drained for agriculture, altering hydrological connectivity and the delivery of groundwater-derived solutes including carbon dioxide (CO2) and methane (CH4) to surface waters. Here, we investigated the drivers of CO2 and CH4 within the artificial drains.of a coastal floodplain under sugarcane plantation and quantify the contribution of groundwater discharge to CO2 and CH4 dynamics over a flood event (290 mm of rainfall). High temporal resolution, in situ observations of dissolved CO2 and CH4, carbon stable isotopes of CH4 (delta C-13-CH4), and the natural groundwater tracer radon (Rn-222) allowed us to quantify. CO2, CH4 and groundwater dynamics during the rapid recession of a flood over a five day period. Extreme super-saturation of free CO2 ([CO2*]) up to 2,951 mu M (25,480% of atmospheric equilibrium) was driven by large groundwater input into the drains (maximum 87 cm day-(1)), caused by a steep hydraulic head in the adjacent water table. Groundwater input sustained between 95 and 124% of the surface [CO2*] flux during the flood recession by delivering high carbonate alkalinity groundwater (DIC = 10,533 mu M, similar to pH = 7.05) to acidic surface water (pH <4), consequently transforming all groundwater-derived DIC to [CO2*]. In contrast, groundwater was not a major direct driver of CH4 contributing only 14% of total CH4 fluxes. A progressive increase in CH4 concentrations of up to similar to 2400 nM day-(1) occurred as a combination of increased substrate availability delivered by post-flood drainage water and longer residence times, which allowed for a biogenic CH4 signal to develop. The progressive enrichment in delta C-13-CH4 values (- 70%. to-48%.) and increase in CH4 concentrations (46-2460 nM) support coupled production-oxidation, with concentrations and delta C-13 values remaining higher (2,798 nM and-47%.) than pre-flood conditions (534 nM and-55 parts per thousand) three weeks after the flood. Our findings demonstrate how separate processes can drive the aquatic CO2 and CH4 response to a flood event in a drained coastal floodplain, and the key role groundwater had in post-flood [CO2*] evasion to the atmosphere, but not CH4. (C) 2016 Elsevier B.V. All rights reserved

Starting injectable treatments in Adults with Type 2 diabetes

Intended as a resource for clinicians working in general practice and community settings, this guide includes an overview of the underlying principles for starting injectable therapies, along with some practical tips on diabetes education, adjustment of doses, how these therapies work and some case studies. In turn it is hoped that this guidance could help develop clinical skill, confidence and competency that the nurse could benchmark alongside such documents as An integrated career and competency framework for diabetes nursing 5th Edition (TREND-UK, 2019a)

Comparison of single and combination diuretics on glucose tolerance (PATHWAY-3):protocol for a randomised double-blind trial in patients with essential hypertension

INTRODUCTION: Thiazide diuretics are associated with increased risk of diabetes mellitus. This risk may arise from K(+)-depletion. We hypothesised that a K(+)-sparing diuretic will improve glucose tolerance, and that combination of low-dose thiazide with K(+)-sparing diuretic will improve both blood pressure reduction and glucose tolerance, compared to a high-dose thiazide.METHODS AND ANALYSIS: This is a parallel-group, randomised, double-blind, multicentre trial, comparing hydrochlorothiazide 25-50 mg, amiloride 10-20 mg and combination of both diuretics at half these doses. A single-blind placebo run-in of 1 month is followed by 24 weeks of blinded active treatment. There is forced dose-doubling after 3 months. The Primary end point is the blood glucose 2 h after oral ingestion of a 75 g glucose drink (OGTT), following overnight fasting. The primary outcome is the difference between 2 h glucose at weeks 0, 12 and 24. Secondary outcomes include the changes in home systolic blood pressure (BP) and glycated haemoglobin and prediction of response by baseline plasma renin. Eligibility criteria are: age 18-79, systolic BP on permitted background treatment ≥140 mm Hg and home BP ≥130 mm Hg and one component of the metabolic syndrome additional to hypertension. Principal exclusions are diabetes, estimated-glomerular filtration rate &lt;45 mL/min, abnormal plasma K(+), clinic SBP &gt;200 mm Hg or DBP &gt;120 mm Hg (box 2). The sample size calculation indicates that 486 patients will give 80% power at α=0.01 to detect a difference in means of 1 mmol/L (SD=2.2) between 2 h glucose on hydrochlorothiazide and comparators.ETHICS AND DISSEMINATION: PATHWAY-3 was approved by Cambridge South Ethics Committee, number 09/H035/19. The trial results will be published in a peer-reviewed scientific journal.TRIAL REGISTRATION NUMBERS: Eudract number 2009-010068-41 and clinical trials registration number: NCT02351973.</p

Prevention And Treatment of Hypertension With Algorithm-based therapy (PATHWAY) number 2: protocol for a randomised crossover trial to determine optimal treatment for drug-resistant hypertension.

This is the final published version. It first appeared at http://bmjopen.bmj.com/content/5/8/e008951.full.INTRODUCTION: Resistant hypertension is inadequately controlled blood pressure (BP) despite treatment with at least three BP-lowering drugs. A popular hypothesis is that resistant hypertension is due to excessive Na(+)-retention, and that 'further diuretic therapy' will be superior to alternative add-on drugs. METHODS AND ANALYSIS: Placebo-controlled, random crossover study of fourth-line treatment when added to standard (A+C+D) triple drug therapy: ACE inhibitor or Angiotensin receptor blocker (A) +Calcium channel blocker (C)+Diuretic (D). Patients (aged 18-79 years) with clinical systolic BP ≥ 140 mm Hg (135 mm Hg in diabetics) and Home BP Monitoring (HBPM) systolic BP average ≥ 130 mm Hg on treatment for at least 3 months with maximum tolerated doses of A+C+D are randomised to four consecutive randomly allocated 12-week treatment cycles with an α-blocker, β-blocker, spironolactone and placebo. The hierarchical coprimary end point is the difference in HBPM average systolic BP between (in order) spironolactone and placebo, spironolactone and the average of the other two active drugs, spironolactone and each of the other two drugs. A key secondary outcome is to determine whether plasma renin predicts the BP response to the different drugs. A sample size of 346 (allowing 15% dropouts) will confer 90% power to detect a 3 mm Hg HBPM average systolic BP difference between any two drugs. The study can also detect a 6 mm Hg difference in HBPM average systolic BP between each patient's best and second-best drug predicted by tertile of plasma renin. ETHICS AND DISSEMINATION: The study was initiated in May 2009 and results are expected in 2015. These will provide RCT evidence to support future guideline recommendations for optimal drug treatment of resistant hypertension. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov NCT02369081, EUDract number: 2008-007149-30.The study is funded by a special project grant from the British Heart Foundation (number SP/08/002). Further funding is provided by the National Institute for Health Research (NIHR) Comprehensive Local Research Networks. BW is supported by the NIHR UCL/UCL Hospitals Biomedical Research Centre