Association of multimorbidity and changes in health-related quality of life following myocardial infarction: a UK multicentre longitudinal patient-reported outcomes study.

BACKGROUND: Multimorbidity is prevalent for people with myocardial infarction (MI), yet previous studies investigated single-health conditions in isolation. We identified patterns of multimorbidity in MI survivors and their associations with changes in HRQoL. METHODS: In this national longitudinal cohort study, we analysed data from 9566 admissions with MI from 77 National Health Service hospitals in England between 2011 and 2015. HRQoL was measured using EuroQol 5 dimension (EQ5D) instrument and visual analogue scale (EQVAS) at hospitalisation, 6, and 12 months following MI. Latent class analysis (LCA) of pre-existing long-term health conditions at baseline was used to identify clusters of multimorbidity and associations with changes in HRQoL quantified using mixed effects regression analysis. RESULTS: Of 9566 admissions with MI (mean age of 64.1 years [SD 11.9], 7154 [75%] men), over half (5119 [53.5%] had multimorbidities. LCA identified 3 multimorbidity clusters which were severe multimorbidity (591; 6.5%) with low HRQoL at baseline (EQVAS 59.39 and EQ5D 0.62) which did not improve significantly at 6 months (EQVAS 59.92, EQ5D 0.60); moderate multimorbidity (4301; 47.6%) with medium HRQoL at baseline (EQVAS 63.08, EQ5D 0.71) and who improved at 6 months (EQVAS 71.38, EQ5D 0.76); and mild multimorbidity (4147, 45.9%) at baseline (EQVAS 64.57, EQ5D 0.75) and improved at 6 months (EQVAS 76.39, EQ5D 0.82). Patients in the severe and moderate groups were more likely to be older, women, and presented with NSTEMI. Compared with the mild group, increased multimorbidity was associated with lower EQ-VAS scores (adjusted coefficient: -5.12 [95% CI -7.04 to -3.19] and -0.98 [-1.93 to -0.04] for severe and moderate multimorbidity, respectively. The severe class was more likely than the mild class to report problems in mobility, OR 9.62 (95% confidence interval: 6.44 to 14.36), self-care 7.87 (4.78 to 12.97), activities 2.41 (1.79 to 3.26), pain 2.04 (1.50 to 2.77), and anxiety/depression 1.97 (1.42 to 2.74). CONCLUSIONS: Among MI survivors, multimorbidity clustered into three distinct patterns and was inversely associated with HRQoL. The identified multimorbidity patterns and HRQoL domains that are mostly affected may help to identify patients at risk of poor HRQoL for which clinical interventions could be beneficial to improve the HRQoL of MI survivors. TRIAL REGISTRATION: ClinicalTrials.gov NCT01808027 and NCT01819103.

A prospective observational study to investigate utility of the Delirium Observational Screening Scale (DOSS) to detect delirium in care home residents.

Background: care home residents are particularly at risk of delirium due to high prevalence of dementia. The Delirium Observation Screening Scale (DOSS) identifies behavioural changes associated delirium onset that nursing staff are uniquely placed to recognise. We tested the psychometric properties of the DOSS in UK care homes compared with the Confusion Assessment Method (CAM). Design: prospective observational cohort study performed between 1 March 2015 and 30 June 2016. Setting: nine UK residential and nursing care homes. Subjects: residents over 65 years except those approaching end of life or unable to complete delirium assessments. Methods: the 25-item DOSS was completed daily by care home staff and compared with the temporally closest CAM performed twice per week by trained researchers. Sensitivity, specificity, positive and negative predictive values, diagnostic odds and likelihood ratios were calculated. Results: 216 residents participated; mean age 84.9 (SD 7.9); 50% had cognitive impairment (median AMTS 7 (IQR 3-9)). Half of all expected DOSS assessments occurred (30,201); of these, 11,659 (39%) were complete. 78 positive CAM measurements were made during 71 delirium episodes in 45 residents over 70 weeks. Sensitivity and specificity for delirium detection were optimised at a DOSS cut point of ≥5 (sensitivity 0.61 (95% CI: 0.39-0.80) and specificity (0.71 95% CI: 0.70-0.73)). Positive and negative predictive values were 1.6 and 99.5%, respectively. Conclusions: the low sensitivity of the DOSS limits clinical utility for detection of delirium as part of routine care for care home residents, although a negative DOSS affords confidence that delirium is not present.

Preoperative sentinel lymph node identification, biopsy and localisation using contrast enhanced ultrasound (CEUS) in patients with breast cancer: a systematic review and meta-analysis.

AIM: To evaluate whether contrast-enhanced ultrasound (CEUS)-guided core biopsy of the sentinel lymph node (SLN) could identify metastatic nodes preoperatively and reduce the number of surgical SLN biopsies in patients with breast cancer and normal axillary B-mode ultrasound; and to establish whether CEUS SLN identification and localisation is a viable alternative to standard lymphatic mapping using isotope and blue dye. MATERIALS AND METHODS: A search of several electronic databases was performed and identified studies were assessed using QUADAS-2 for methodological quality. Pooled estimates of sensitivity and specificity for identification of nodal metastases were calculated. RESULTS: Eleven prospective studies and one retrospective study with 1,520 participants were included. The SLN identification and localisation rate for CEUS-guided skin marking was 70-100%, CEUS guided-wire localisation was 89-97%, and CEUS-guided iodine-125 (125I) seed localisation was 60%. Across the four studies that evaluated preoperative CEUS-guided SLN biopsy, pooled sensitivity for identification of nodal metastases was 54% (95% confidence interval [CI]: 47-61) and pooled specificity 100% (95% CI: 99-100). CONCLUSION: CEUS is a promising technique for preoperative staging of the axilla. CEUS-guided core biopsy has the potential to identify nodal metastases in over half (54%) of patients with normal axillary B-mode ultrasound. CEUS-guided identification and localisation of the SLN may offer a viable alternative to standard lymphatic mapping using isotope and blue dye; however, further prospective studies with larger samples are warranted.

A comparison of the presentation of molar incisor hypomineralisation in two communities with different fluoride exposure.

AIM: To compare the clinical presentation of two cohorts of children diagnosed with molar incisor hypomineralisation (MIH) and living in areas of low and high background fluoridation. METHODS: The study population comprised 12-year-old children participating in the 2008-2009 National Dental Epidemiological Programme in five regions in Northern England. Participating dentists were trained and calibrated in the use of the modified Developmental Defects of Enamel Index. Children were examined at school under direct vision with the aid of a dental mirror. First permanent molars and incisors were recorded for the presence and type of enamel defects greater than 2 mm. A diagnosis of MIH was ascribed to any child with a demarcated defect in any first permanent molar. Risk ratios for the occurrence of demarcated, diffuse and hypoplastic defects were generated for MIH children in the fluoridated and non-fluoridated area. RESULTS: 3,233 children were examined. The prevalence of MIH in the fluoridated community was 11 % and in the non-fluoridated community was 17.5 %. Incisors in children with MIH were at greater risk of having demarcated defects (risk ratio 4.0, 3.6-4.5) and diffuse defects (risk ratio 2.2, 2.0-2.5). Molars in children with MIH were at greater risk of diffuse defects (risk ratio 4.4, 3.8-5.0). The teeth of children with MIH living in the fluoridated area were at greater risk of demarcated defects for both incisors (risk ratio 1.6, 1.3-2.0) and molars (risk ratio 1.3, 1.2-1.5) relative to the teeth of MIH children living in the non-fluoridated area. CONCLUSIONS: Children with MIH were at increased risk of both diffuse and demarcated defects in their incisors. Children with MIH living in the fluoridated area were at increased risk of diffuse and demarcated defects relative to MIH children living in the non-fluoridated area.

The prevalence of incisor hypomineralisation and its relationship with the prevalence of molar incisor hypomineralisation.

AIM: To establish the prevalence of incisor hypomineralisation (IH) in a cohort of 12-year-old children in Northern England and to relate the prevalence to gender, socioeconomic status, and the prevalence of molar incisor hypomineralisation (MIH). METHOD: The study population comprised 12-year-old children participating in the 2008-2009 National Dental Epidemiological Programme in five regions in Northern England. Participating dentists were trained and calibrated in the use of the modified Developmental Defects of Enamel Index. Children were examined at school under direct vision with the aid of a dental mirror. First permanent molars and incisors were recorded for the presence and type of enamel defects greater than 2 mm. A diagnosis of MIH was ascribed to any child with a demarcated defect in any first permanent molar. A diagnosis of IH was ascribed to any child with a demarcated defect in an incisor but with molar sparing. RESULTS: 3,233 children were examined. The prevalence of IH was 11.0 % (95 % CI 11.0-12.2 %). There was a strong positive correlation between the prevalence of MIH and IH in different regions which reached significance (r = 0.9, p = 0.037) according to Spearman's rho test of correlation. There was a similar pattern of prevalence in the different socioeconomic quintiles although this correlation did not reach significance. The most common teeth affected in IH were the maxillary central incisors, followed by the maxillary lateral incisors and followed by the mandibular incisors. There was no difference in the prevalence of IH by gender. CONCLUSIONS: The prevalence of IH was 11.0 %. The variation of prevalence between regions and socioeconomic groups and the distribution of lesions in the teeth were very similar to observations seen in MIH children from the same cohort.

The development and validation of a psychological questionnaire for patients undergoing orthognathic treatment.

OBJECTIVES: To develop a questionnaire to assess the psychosocial aspects which orthognathic patients considered important regarding their dento-facial deformity. SETTING AND SAMPLE POPULATION: A multicentre, prospective, questionnaire development and validation study based in the UK. MATERIAL AND METHODS: Questionnaire development involved item (question) selection through literature review, consultation and feedback from a questionnaire development group and semi-structured interviews. A 'final' questionnaire was tested on a cross-sectional sample of 110 pre-operative and 74 post-operative orthognathic patients and a longitudinal sample of 23 orthognathic patients. Validity was tested using Rasch analysis. RESULTS: Reliability for the Hospital Anxiety and Depression Scale (HADS) section was unsatisfactory (ICC = 0.232-0.829, Cronbach alpha = 0.625-0.670), but for the well- being (ICC = 0.857, Cronbach alpha = 0.827-0.895) and expectations (ICC = 0.861, Cronbach alpha = 0.804-0.882) sections were satisfactory. The well-being section was the only section found to be valid for the pre-and post-operative samples. Responsiveness was satisfactory for the well-being scale (p = 0.001). CONCLUSIONS: A new condition-specific orthognathic questionnaire has been developed which has been shown to be reliable, valid and responsive for the well-being scale. The HADS, as tested by Rasch analysis, was found not to be valid for this orthognathic population.

The effect of premature extraction of primary teeth on the subsequent need for orthodontic treatment.

AIM: To investigate if premature extraction of primary teeth was associated with orthodontic need in the permanent dentition. STUDY DESIGN: This was a case-control study based on retrospective dental records. METHODS: As part of NHS (UK) Dental Epidemiology Programme a sample of 366, 12-year-old children from Bradford and Airedale were examined. The survey collected data on patient demographics, dental health status including orthodontic need. Data linkage was undertaken for those children participating in the NHS Dental Epidemiology Programme who had previously accessed the local Salaried Dental Service (SDS). For these children, retrospective dental information was collected about premature extraction of primary teeth. RESULTS: From the 366 children who were surveyed, 116 children had received treatment at the local SDS in the past. Significantly more children from ethnic minorities, low socioeconomic backgrounds and high caries rate (p < 0.001) were seen in the SDS. For the 107 children who attended SDS, an increased total number of primary teeth extractions was positively associated with orthodontic need (odds ratio:1.18, CI -1.01 to 1.37). STATISTICS: Multilevel modelling was undertaken to identify variables associated with orthodontic need. CONCLUSIONS: In the study group, orthodontic need was significantly associated with the number of primary teeth extracted.

A study of factors that influence the number of visits following traumatic dental injuries.

OBJECTIVE: To investigate in children the factors that influence the number of visits per tooth following traumatic dental injuries (TDI) to the permanent dentition. METHOD: A retrospective convenient sample of 100 children who had been treated for TDI at Leeds Dental Institute was identified. A multilevel negative binomial regression model was developed to identify factors influencing the number of visits per tooth. Data including age, gender, postcode, number of visits, treatment provided, number of teeth injured, type of periodontal and hard tissue diagnoses, healing modality, root maturity, pulp and tooth survival, and any history of previous or subsequent trauma to same tooth were analysed using SPSS 18.0 and MLWIN. RESULTS: 186 teeth were affected by trauma in 100 patients. Median total number of visits per tooth was six visits with a range of 1-22 visits. The factors that were found to influence number of visits included: distance travelled, hard tissue diagnosis, periodontal injury diagnosis and pulp survival (P < 0.05). A mile increase in distance travelled from home to clinic led to a 1.2% reduction in the number of visits per month (-0.012; SE 0.005), a diagnosis of a severe hard tissue injury was associated with 44% increase (0.362; SE 0.105) compared to no hard tissue injury, a diagnosis of a complicated periodontal injury compared to no periodontal injury was associated with a 30% increase (0.260; SE 0.124), a diagnosis of a uncomplicated periodontal injury compared to no periodontal injury was associated with a 31% increase (0.271; SE 0.124) and a diagnosis and treatment for a non-vital tooth in comparison to a vital tooth led to a 26% increase (0.230; SE 0.080) in the number of visits. There was a significant variation in the number of treatment visits at patient level (0.260; SE 0.048). CONCLUSION: Complicated hard tissue injuries, complicated and uncomplicated periodontal injuries, diagnosis and treatment for pulp necrosis and the distance between clinic and patient's home all significantly influenced the number of visits needed to treat TDI.

Vascular access strategy for delivering long-term antimicrobials to patients with infective endocarditis: device type, risk of infection and mortality.

BACKGROUND: This paper reports the use of different vascular access devices and the incidence of intravascular catheter-related infection (CRI) in patients receiving intravenous antibiotics for infective endocarditis (IE). AIM: To examine whether rates of infection vary with type of vascular access device, and assess the impact of CRI on mortality in IE. METHODS: A prospective observational service evaluation of all inpatients who received intravenous antibiotics for IE was performed. In total, 114 inpatients were evaluated. All cases of CRI [including exit-site infection, intravascular catheter-related bloodstream infection (CRBSI) and mortality] were recorded. Tunnelled and non-tunnelled central venous catheters (CVCs), and peripherally inserted cannulae were used for antibiotic delivery. FINDINGS: There were 15 episodes of CRI, 11 of which were CRBSI (all associated with CVC use). The remainder comprised uncomplicated exit-site infections. Use of tunnelled CVCs [hazard ratio (HR) 16.95, 95% confidence interval (CI) 2.13-134.93; P = 0.007] and non-tunnelled CVCs (HR 24.54, 95% CI 2.83-212.55; P = 0.004) was associated with a significantly increased risk of CRI. Risk of mortality increased significantly with Staphylococcus aureus as the cause of IE (P < 0.001) and CRBSI (P = 0.034). CONCLUSION: Risk of CRI in patients with IE is linked to the type of vascular access device used. Rates of CRBSI were greatest with CVCs, while peripheral venous cannulae were not associated with CRBSI or serious sequelae. Many patients (40%) tolerated complete treatment courses delivered via peripheral cannulae. These findings confirm the importance of device selection in reducing the risk of CRI; a potentially modifiable variable that impacts on outcome and mortality in IE.

The effectiveness and cost of single and multi-factorial cardiovascular risk factor modification to guideline targets in type 2 diabetes.

AIMS: Cardiovascular disease is the main cause of morbidity and mortality in type 2 diabetes (T2DM), at huge cost to the NHS. We investigated the potential effect on population cardiovascular risk and associated costs of single and multi-factorial intervention, to target levels, in individuals with T2DM. METHODS: Baseline population means and proportions for cardiovascular risk factors were calculated for 159 patients with T2DM from 3 general practices. Predicted 10year cardiovascular risk, and associated costs were calculated using the LIP2687 risk calculator, based on Framingham and UKPDS equations. Systolic blood pressure, HbA(1C), total cholesterol and HDL-cholesterol were altered to NICE and SIGN target levels and the model run again. The difference in outcomes was observed. RESULTS: 45%, 76% and 38% of patients met NICE targets for cholesterol, systolic blood pressure and HbA1c, respectively. As expected, comparing the two guidelines, fewer patients met the 'stricter' targets (P=0.0001). Treatment-to-target produced no significant difference in cardiovascular risk or costs, although greater reductions in outcomes were seen with multi-factorial intervention. CONCLUSION: This small study suggests that intervention in only those patients with the highest cardiovascular risk brings little reduction in population cardiovascular risk and associated health costs. Multi-factorial intervention in all patients with T2DM, regardless of baseline values, is likely to bring greater reductions. This raises the question as to whether the current emphasis on treatment to target should be modified to encourage multi-factorial intervention in all patients with T2DM, even those with baseline values below target levels.

Effect of CD4+ lymphocyte count, viral load, and duration of taking anti-retroviral treatment on presence of oral lesions in a sample of South African children with HIV+/AIDS.

AIMS: This was to determine the presence and types of oral mucosal lesions in a sample of HIV(+)/AIDS South African children taking antiretroviral therapy and to investigate the relationship between CD4(+) lymphocyte counts, viral load, duration of taking antiretroviral therapy (DART), and age on presence of oral lesions. METHODS: The samples consisted of 56 South African children aged 0-4 years (mean age =7.09 years) with HIV(+)/AID, infected at birth. Subjects were divided into two groups according to the presence of oral lesions with test group (patients with oral lesions) and control group (patients with no oral lesions). Children were also divided into two groups, those <6 years and those >6 years old to study the effect of age on presence of lesions. RESULTS: Oral Candidiasis was the most common lesion reported in 19/56 children, followed by Recurrent Herpetic Infection in 9 children. Other lesions such as Kaposi's sarcoma, Multifocal Epithelial Hyperplasia, Oral Hairy Leukoplakia, Linear Gingival Erythema, and oral ulceration were also present. A statistical significant difference in CD4(+) lymphocyte count (p value 0.005), and viral load (p value 0.002) was found between the oral lesion and no oral lesion groups, those with oral lesions having a significantly higher viral load and lower CD4+ count. No statisticaly significant difference between the two groups in terms of the DART effect (p value 0.811) was found. Furthermore, there was no effect of age groups on the presence of lesions in children with HIV(+)/AIDS. CONCLUSION: This study contributes to the relatively scant literature on the prevalence of oral lesions in children with HIV infection in South Africa and also the relationship of these lesions to the viral load and CD4(+) lymphocyte counts.

Occurrence of diabetogenic changes in pregnancy among black women in an urban setting.

OBJECTIVE: To find out if pregnancy in black Zimbabwean women is a diabetogenic state using basal blood levels of cortisol, insulin, C-peptide and glucose. METHODS: 111 women (28 non-pregnant, 29 first trimester, 26 second trimester and 28 third trimester) aged between 18 and 35 years were recruited for the study. Fasting plasma cortisol, insulin, C-peptide and glucose were determined by standard methods. The glucose/insulin ratio was used as an index of insulin sensitivity and the C-peptide/glucose ratio as well as the homeostasis assessment model (HOMA) as an index of insulin resistance. RESULTS: The means of fasting plasma cortisol levels were significantly elevated, p < 0.0001 among the four groups (non-pregnant, first, second and third trimester women). Fasting plasma insulin levels peaked during the third trimester and significant differences were noted among all women, p < 0.05. Similar data was obtained for C-peptide levels (a better indicator of beta-cell insulin secretory activity) among the groups, p < 0.01. The means of fasting plasma glucose levels were significantly decreased with advancing gestation, p < 0.0001. Significantly lower glucose/insulin ratios, a measure of insulin sensitivity and elevated C-peptide/glucose ratios, an index of insulin resistance, were demonstrated among the women, (p < 0.05 and < 0.01 respectively). CONCLUSION: The basal data presented in this paper clearly demonstrates that the diabetogenic effects of pregnancy are also expressed by Zimbabwean black women, especially in late gestation.

Metabolic syndrome disorders in urban black Zimbabweans with type 2 Diabetes mellitus.

OBJECTIVE: The main aim of the study was to determine the prevalence of metabolic syndrome disorders and their interrelations in black Zimbabwean type 2 diabetic patients. STUDY DESIGN: Prospective cross sectional study. SETTING: Outpatient diabetic clinics at Harare and Parirenyatwa tertiary hospitals. MAIN OUTCOME MEASURES: We recruited 109 adult diabetic subjects attending a tertiary hospital Diabetic Clinic. Anthropometric and metabolic parameters were measured by standard methods. Eighty percent of the patients were hypertensive, 32% dyslipidaemic, 32% obese, 50% hyperinsulinaemic, 61% had poor glycaemic control and 43% of the participants had the metabolic syndrome. The means of BMI and triglycerides were significantly different in hyperinsulinaemic versus non-hyperinsulinaemic patients (p < 0.001 and 0.041 respectively), and diastolic blood pressure was significantly raised in the obese group (p = 0.043). The following significant associations were observed, hyperinsulinaemia with the metabolic syndrome (odds ratio = 3.9, p < 0.001) as well with obesity (odds ratio = 4.8, p < 0.001), however, only a weak association was observed between hypertension and hyperinsulinaemia (odds ratio = 2.5, p = 0.064). Patients exhibiting three metabolic disorders (dyslipidaemia, hypertension and obesity) were five times more likely to be hyperinsulinaemic (p = 0.025) and hypertensive patients were almost three times more likely to be hyperinsulinaemic. CONCLUSION: In comparison to their counterparts from certain ethnic groups, this urban diabetic population is also burdened with a variety of metabolic disorders which are risk factors for coronary artery disease. In this population, hyperinsulinaemia has a relatively weak association with hypertension and the relationship between obesity versus diastolic blood pressure as well as hypertriglyceridaemia versus serum insulin levels requires further investigation.

Asymptomatic bacteriuria among outpatients with diabetes mellitus in an urban black population.

OBJECTIVE: To determine the prevalence of asymptomatic bacteriuria (ASB) in individuals afflicted by Diabetes mellitus; the antibiotic susceptibility of the microbial isolates and the association of host factors with ASB. DESIGN: This was a prospective cross sectional study. SETTING: Attendants of outpatient polyclinics at three main tertiary hospitals; namely, Harare, Chitungwiza and Parirenyatwa Hospitals. SUBJECTS: 176 participants. MAIN OUTCOME MEASURES: Patients attending the polyclinics between 6.30 am and 9.30 am from Monday to Friday were randomly selected. Demographic data was obtained at enrollment using a standardized questionnaire. Fasting venous blood was withdrawn from the participants for glucose analysis. Clean-catch midstream urine samples from all men and women were cultured and the causal organisms were isolated and identified by standard microbiological methods. Antibiotic susceptibility testing was performed using a disc diffusion method. Potential host factors included age, type of diabetes, duration of diabetes, glucosuria and leukocyturia. RESULTS: The prevalence of ASB was 32% in the diabetics and 11% in nondiabetic participants. The commonest bacterial organism isolated in participants afflicted by Diabetes mellitus was Escherichia coli (26%) followed by Staphylococcus aureus (21%), Streptococcus group B (14%), Streptococcus group D and non-lactose fermenting coliforms (7% respectively). Other isolates were Micrococcus and Pseudomonas (5% respectively), Klebsiella and Proteus (2% respectively). Gentamicin, nitrofurantoin, ampicillin and nicene were the most effective antimicrobials in the majority of isolates. Certain isolates exhibited some bacterial resistance to conventional antibiotics. Of the host factors, an association was found between bacteriuria and glucosuria (p < 0.001) and between leukocyturia and bacteriuria (p = 0.005). CONCLUSION: The prevalence of ASB is increased in diabetes and the rather high blood glucose levels exhibited by these individuals may further complicate this condition. As some bacterial species exhibited resistance to some common antimicrobials, these results raise questions regarding future clinical reliability of some conventional antimicrobials when considering therapy for asymptomatic bacteriuria.