Contact tracing for chronic hepatitis B in primary care? : A ‘snapshot’ audit in Grampian, Northeast Scotland

Peer reviewedPostprin

Community acquired acute kidney injury: findings from a large population cohort

Background: The extent of patient contact with medical services prior to development of community acquired-acute kidney injury (CA-AKI)is unknown. Aim: We examined the relationship between incident CA-AKI alerts, previous contact with hospital or primary care and clinical outcomes. Design: A prospective national cohort study of all electronic AKIalerts representing adult CA-AKI. Methods: Data were collected for all cases of adult (≥18 years of age) CA-AKI in Wales between 1 November 2013 and 31 January 2017. Results: There were a total of 50 560 incident CA-AKI alerts. In 46.8% there was a measurement of renal function in the 30 days prior to the AKI alert. In this group, in 63.8% this was in a hospital setting, of which 37.6% were as an inpatient and 37.5% in Accident and Emergency. Progression of AKI to a higher AKI stage (13.1 vs. 9.8%, P  50% from the creatinine value generating the alert), the proportion of patients admitted to Intensive Care (5.5 vs. 4.9%, P = 0.001) and 90-day mortality (27.2 vs. 18.5%, P < 0.001) was significantly higher for patients with a recent test. 90-day mortality was highest for patients with a recent test taken in an inpatient setting prior to CA-AKI (30.9%). Conclusion: Almost half of all patients presenting with CA-AKI are already known to medical services, the majority of which have had recent measurement of renal function in a hospital setting, suggesting that AKI for at least some of these may potentially be predictable and/or avoidable

The origin and evolution of the Siletz terrane in Oregon, Washington and Vancouver Island

The Siletz terrane, a predominantly mafic accreted oceanic terrane, is located in the Cascadia Forearc region of Oregon, Washington and Vancouver Island. The terrane represents a late Palaeocene – Eocene large igneous province that consists of pillow lavas, massive flows and intrusive sheets. Previously it has been proposed that the Siletz terrane represents either an accreted oceanic plateau, hotspot island chain, back -arc basin, island arc, or a sequence of slab window volcanics. A province-wide geochemical reassessment of the terrane, including new high precision Sr-Pb-Nd-Hf isotope, has been used to evaluate the validity of the proposed tectonomagmatic models for the Siletz terrane along with the subsequent evolution of the magmas. Fractional crystallisation of the primary magmas of the terrane appears to have occurred at relatively low pressures. The estimated initial mantle potential temperatures of the Siletz terrane range from 1400 - 1500 °C while the amount of partial melting undergone generally varies between ~ 25 – 33 %. The rocks of the terrane are geochemically similar, both in trace element (generally flat to Light Rare Earth Element (REE) enriched REE patterns) and radiogenic isotope composition to several well-characterised oceanic plateaus. The data produced in this study are consistent with a mantle source for the Siletz terrane that appears to have been heterogeneous and slightly enriched. The enriched signature has characteristics of both EM2 and HIMU components and this, combined with a calculated mantle potential temperature significant above that of ambient mantle, indicates derivation of the Siletz magmatism from a source influenced by a mantle plume, possibly the Yellowstone Hotspot. Overall, the terranes’ geochemistry suggests interaction between the Farallon – Kula/ Resurrection ridge and a hotter enriched mantle source region. It is therefore concluded that the Siletz terrane represents an accreted oceanic plateau and so is the youngest oceanic plateau thus far characterised

How good are we at managing acute kidney injury in hospital?

Introduction. Acute kidney injury (AKI) is a common clinical problem associated with adverse outcomes. This study identifies the incidence of AKI in two UK district general hospitals’ without on-site renal services and assesses AKI management and level of nephrologist input. Methods. The AKIN classification was used to identify 1020 AKI patients over 6 months. Data were collated on patient demographics, AKI management and referral to nephrology and intensive care services. Short/long-term renal outcomes were investigated. Patients were followed up for 14 months post-discharge. Results. Incidence of hospital-based AKI was 6.4%. Mean patient age was 73 years. There was 28.1% acute in-hospital mortality with a further 21.6% 14-month mortality. Only 8.3% of patients were referred to nephrology services for in-hospital review, and only 8.1% had outpatient nephrology follow-up. Compliance with the AKI National Confidential Enquiry into Patient Outcomes and Deaths (NCEPOD) recommendations was poor with 32.8% of patients having renal imaging and 15% of patients having acid–base status assessed. NCEPOD compliance improved with nephrology input. Patients referred to nephrology were likely to be younger with pre-existing CKD and severe AKI. 10.5% of AKI episodes were unrecognized. Forty percent of those with unrecognized AKI, (compared with 15% of recognized AKI) developed de novo or progression of pre-existing CKD. Conclusion. AKI in DGHs is mostly managed without nephrology input. There are significant shortcomings in AKI recognition and management in this setting. This is associated with poor mortality and long-term CKD. This study supports a need to improve the teaching and training of front-line medical staff in identifying AKI. Additionally, implementation of AKI e-alert systems may encourage early recognition and provide a prompt for renal referral

Setting research priorities in Global Health : appraising the value of evidence generation activities to support decision-making in health care

The allocation of scarce resources among competing health care priorities is a key objective in all jurisdictions, whether in low- and middle-income countries (LMICs) or high-income countries. This involves allocating resources to ensure access to health care programmes, which can deliver improvements in health, but also to managing innovation in the development of new technologies, and investing in evidence generation activities to improve health for future generations. The allocation of health care resources among competing priorities requires an assessment of the expected health effects and costs of investing resources in the different activities and the opportunity costs of these expenditures, as well as an assessment of the uncertainty in health effects and costs. Uncertainty can lead to unintended adverse health consequences, e.g., when expected benefits of an activity are not realised when implemented in practice, or resources committed by an activity are transferred away from other health improving activities. The consequences of uncertainty can be reduced by investing in evidence generation activities that improve the information available to support future resource allocation decisions. An analytic framework is developed to assess the value of evidence generation activities to support international research funders, who have the responsibility for allocating funds among competing research priorities in Global Health. Within the framework, the costs and health benefits of evidence generation activities are assessed using the same principles as those employed when evaluating the cost-effectiveness of investments in service provision. Metrics of value, founded on an understanding of the health opportunity costs imposed by research expenditure, are used to quantify the scale of the potential global net health impact across all beneficiary populations (in net disability-adjusted life years averted), or the equivalent health care system resources required to deliver this net health impact, and research costs and their potential health opportunity costs. The framework can be applied to answer key questions such as: whether investment in research activities is worthwhile; which research activities should be prioritised; what type of research activity is necessary and what is the most appropriate design of the research; what are the opportunity costs associated with evidence generation; what is the optimal timing of research; and whether evidence generation activities should be prioritised over investments in service provision or new technology development. An illustrative example is used to demonstrate the application of the framework for informing research priorities in Global Health

Time-efficient physical activity interventions to reduce blood pressure in older adults: a randomized controlled trial

BackgroundHypertension is a risk factor for both cardiovascular and cerebrovascular disease, with an increasing incidence with advancing patient age. Exercise interventions have the potential to reduce blood pressure in older adults, however, rates of exercise uptake and adherence are low, with ‘lack of time’ a commonly cited reason. As such, there remains the need for time-efficient physical activity interventions to reduce blood pressure in older adults.ObjectiveTo compare the effect of three, novel time-efficient physical activity interventions on resting blood pressure in older adults.MethodsForty-eight, healthy, community-dwelling older adults (mean age: 71 years) were recruited to a 6-week randomised control trial. Resting blood pressure was measured before and after one of three supervised, time-efficient interventions: high-intensity interval training (HIIT) on a cycle ergometer; isometric handgrip training (IHG); unilateral, upper limb remote ischaemic preconditioning (RIPC) or non-intervention control.ResultsBoth HIIT and IHG led to a statistically significant reduction in resting systolic blood pressure (SBP) of 9 mmHg, with no significant change in the RIPC or control groups. There was no change in diastolic blood pressure or pulse pressure in any group.ConclusionsSupervised HIIT or IHG using the protocols described in this study can lead to statistically significant and clinically relevant reductions in resting SBP in healthy older adults in just 6 weeks

A double-blind randomized controlled trial of the effects of eicosapentaenoic acid supplementation on muscle inflammation and physical function in patients undergoing colorectal cancer resection

BackgroundResection of colorectal cancer (CRC) initiates inflammation, mediated at least partly by NFĸB (nuclear factor kappa-light-chain-enhancer of activated B-cells), leading to muscle catabolism and reduced physical performance. Eicosapentaenoic acid (EPA) has been shown to modulate NFĸB, but evidence for its benefit around the time of surgery is limited.ObjectiveTo assess the effect of EPA supplementation on muscle inflammation and physical function around the time of major surgery.DesignIn a double-blind randomized control trial, 61 patients (age: 68.3 ± 0.95 y; 42 male) scheduled for CRC resection, received 3 g per day of EPA (n = 32) or placebo (n = 29) for 5-days before and 21-days after operation. Lean muscle mass (LMM) (via dual energy X-ray absorptiometry (DXA)), anaerobic threshold (AT) (via cardiopulmonary exercise testing (CPET)) and hand-grip strength (HG) were assessed before and 4-weeks after surgery, with muscle biopsies (m. vastus lateralis) obtained for the assessment of NF-ĸB protein expression.ResultsThere were no differences in muscle NFĸB between EPA and placebo groups (mean difference (MD) −0.002; 95% confidence interval (CI) −0.19 to 0.19); p = 0.98). There was no difference in LMM (MD 704.77 g; 95% CI -1045.6 g–2455.13 g; p = 0.42) or AT (MD 1.11 mls/kg/min; 95% CI -0.52 mls/kg/min to 2.74 mls/kg/min; p = 0.18) between the groups. Similarly, there was no difference between the groups in HG at follow up (MD 0.1; 95% CI -1.88 to 2.08; p = 0.81). Results were similar when missing data was imputed.ConclusionEPA supplementation confers no benefit in terms of inflammatory status, as judged by NFĸB, or preservation of LMM, aerobic capacity or physical function following major colorectal surgery