Investigating the prognostic performance of non-invasive tests in alcohol related liver disease

Alcohol-related Liver Disease (ArLD) often presents late, when opportunities to improve prognosis are limited. In the last 18 months, the SARS-CoV-2 pandemic has exacerbated already climbing mortality rates from ArLD, with a 20% increase in ArLD-related deaths between 2019 and 2020, on the background of a 43% increase between 2001 and 2019. Non-invasive-tests for liver fibrosis are increasingly advocated for use in ArLD but are not yet established in routine practice. In this thesis I aimed to investigate current alcohol referral practice from primary-care to specialist hepatology services, and the performance of commonly used non- invasive tests to detect fibrosis severity and predict mortality in ArLD. A systematic review and meta-analysis on four non-invasive tests in ArLD revealed a paucity of studies on alcohol compared to other liver aetiologies, but found good performance (AUROC >0.7) of all four tests (FIB4/FibroTest/ELF/FibroScan) in detecting F2/F3/F4 fibrosis-stages. A 3-year retrospective evaluation of alcohol- referrals to secondary-care found two-thirds of referrals were ‘unnecessary’, in that they had no evidence of advanced fibrosis or cirrhosis. Only 16% had a non-invasive fibrosis test performed prior to referral, and I applied modelling of simple fibrosis scores (FIB4 and APRI) to demonstrate that the proportion of unnecessary referrals could be reduced by 50% if simple non-invasive fibrosis tests were used in primary- care before referral. I report the design and set-up of a pathway involving use of non-invasive tests in primary-care (specifically, the Enhanced Liver Fibrosis (ELF) test in people with alcohol-use-disorder (AUD), based in Camden and Islington practices). A prospective 1-year study in 99 inpatients diagnosed with AUD found a third of 3 patients had elevated ELF scores indicative of advanced fibrosis that had not been detected previously, despite multiple previous hospital attendances. ELF was not associated with recent alcohol intake or AST/ALT values, differentiating it from FibroScan. A second systematic review on prognostic-performance of non-invasive fibrosis tests found FIB4/ELF/FibroScan/FibroTest performed well (AUROCs all >0.7) in predicting mortality, and ELF/FibroTest performed equally well or better than liver histology. Finally, in a cohort of 162 serum samples from patients with Alcoholic Hepatitis (AH) from the ‘STOPAH’ cohort (a published Randomised Controlled Trial of steroids and pentoxifylline conducted in over 1,000 patients with AH), I provide the first evidence that the Enhanced Liver Fibrosis (ELF) test can be used to predict outcomes in alcoholic hepatitis (AH), and discovered a new prognostic biomarker combining ELF and ABIC, which outperformed traditional prognostic biomarkers in predicting 90-day mortality in AH

Public Collaboration Lab

This paper describes the exhibition that introduces the Public Collaboration Lab (PCL), a one-year research project that explores the potential for, and value of, strategic collaboration between design education and local government to better engage council staff and the citizens they serve, in the development and application of design-led approaches to social challenges and to inform policy. It displays a selection of practice-based PCL collaborative design engagement tools that provide a site for argument, debate and exchange between participants in the process of creative engagement. Taking these tools as a starting point, the mini-workshop explores the various definitions of such tools (thing, boundary object, cultural probe, etc.), discussing their role in participatory design research

A ‘promising tool’? A critical review of the social and ethico-political effects of wastewater analysis in the context of illicit drug epidemiology and drug policy

Wastewater analysis has been taken up with enthusiasm in the illicit drugs field. Through a critical social science lens, we consider claims to what these ‘promising’ methods might afford in the context of drug epidemiology and policy, recognising that all methods have social effects in their specific contexts of use. We outline several ethico-political issues, highlighting how methods can have different effects as they move from one discipline (environmental science or analytic chemistry) into another (illicit drugs). Translated into the drugs field, wastewater analysis problematically shifts the focus of drug policy from harm reduction to drug use prevalence and entrenches stigma. Without comprehensive information about the social and contextual aspects of drug harms, effective drug policy is not possible

Yoga for Traumatic Stress: A Three Paper Dissertation

Thesis advisor: Paul KlineThis three paper dissertation considers whether yoga--a popular mind-body practice combining physical postures and movement, mindfulness, and breath exercises--may be a useful component of treatment for adult trauma survivors. The first paper involves a systematic review and meta-analyses of the current evidence base for yoga in the treatment of anxiety, depression, and PTSD among trauma survivors. The second and third papers are grounded in a single, mixed-methods multi-wave data source aimed at examining yoga's contribution to recovery for adult women who have complex trauma histories (i.e., sustained and/or multiple traumatic experiences such as recurring physical or sexual abuse). The second paper is a quantitative study employing hierarchical linear and logistic regression to examine associations between yoga practice and reductions in traumatic symptomology over time. The third paper is a hermeneutic phenomenological study exploring how women with complex trauma histories experience practicing yoga and its potential role in their coping and healing processes over time. Taken together, these three papers offer insights into the complex healing needs of adult survivors suffering from the effects of traumatization, and the promising role of yoga within their recovery processes.Thesis (PhD) — Boston College, 2014.Submitted to: Boston College. Graduate School of Social Work.Discipline: Social Work

A Conceptual Model of the Psychological Health System for U.S. Active Duty Service Members: An Approach to Inform Leadership and Policy Decision Making

The influence of individual-level factors such as pretraumatic risk and protective factors and the availability of unit-level and enterprise-level factors on psychological health outcomes have been previously considered individually, but have not been considered in tandem across the U.S. Military psychological health system. We use the existing literature on military psychological health to build a conceptual system dynamics model of the U.S.Military psychological health system “service-cycle” from accession and deployment to future psychological health screening and treatment. The model highlights a few key observations, challenges, and opportunities for improvement for the system that relate to several topics including the importance of modeling operational demand combined with the population’s psychological health as opposed to only physical health; the role of resilience and post-traumatic growth on the mitigation of stress; the positive and negative effects of pretraumatic risk factors, unit support, and unit leadership on the service-cycle; and the opportunity to improve the system more rapidly by including more feedback mechanisms regarding the usefulness of pre- and post-traumatic innovations to medical leaders, funding authorities, and policy makers.Department of Defens

Using the Person-Based Approach to Develop a Digital Intervention Targeting Diet and Physical Activity in Pregnancy: Development Study

Background: In pregnancy, eating well, keeping active, and avoiding excessive weight gain are associated with better maternal and fetal health outcomes. Dietary and physical activity (PA) interventions can be effective in changing behaviors and managing weight gain. The comparatively lower cost and greater accessibility of digital interventions make them an attractive alternative to in-person interventions. Baby Buddy is a free pregnancy and parenting app from the charity Best Beginnings. Designed to support parents, improve health outcomes, and reduce inequalities, the app is actively used within the UK National Health Service. It offers an ideal platform for delivering and evaluating a new prenatal dietary and PA intervention./ Objective: The aim of this study was to create a theory-based intervention within Baby Buddy to empower, encourage, and support expectant parents to develop healthier dietary and PA habits for pregnancy and parenthood. Methods: The intervention’s development process was guided by the Behavior Change Wheel, with the person-based approach used to create and test its design. Three stages of qualitative research with pregnant and recently pregnant parents guided the intervention design. Study 1 (n=30), comprising 4 web-based focus groups and 12 telephone interviews, gauged response to the rudimentary concept and generated ideas for its development. Results were analyzed thematically. At this stage, the guiding principles for the intervention development were established, and regular team meetings ensured that the intervention design remained aligned with Best Beginnings’ objectives, evidence-based approach, and feasibility criteria. Study 2 (n=29), comprising web-based individual and couple interviews, explored design ideas using wireframes and scripts and generated iterative feedback on the intervention content, branding, and tone. A table of changes analysis tracked design amendments. Study 3 (n=19) tested an app prototype using think-aloud interviews with current Baby Buddy users. A patient and public involvement and engagement activity (n=18) and other expert contributors (n=14) provided ad hoc input into the research process and design development./ Results: Study 1 confirmed the appeal and relevance of the intervention concept and its novel approach of including partners. The identified themes underpinned the development of the intervention design. Iterative feedback from study 2, in conjunction with patient and public involvement and engagement and expert contributor input, helped refine the intervention design and ensure its relevance and appeal to a diverse target user group. Study 3 highlighted functionality, content, and design issues with the app prototype and identified ways of improving the user experience./ Conclusions: This study illustrates the value of combining a theoretical method for intervention development with the person-based approach to create a theory-based intervention that is also user-friendly, appealing, and engaging for its target audience. Further research is needed to evaluate the effectiveness of the intervention in improving diet, PA, and weight management in pregnancy