Estimating the impact of changes in weight and BMI on EQ-5D-3L: a longitudinal analysis of a behavioural group-based weight loss intervention.

PURPOSE: To estimate the association between changes in BMI and changes in Health-Related Quality of Life (EQ-5D-3L). METHODS: The WRAP trial was a multicentre, randomised controlled trial with parallel design and recruited 1267 adults (BMI ≥ 28 kg/m2). Participants were allocated to Brief Intervention, a Commercial weight management Programme (WW, formerly Weight Watchers) for 12 weeks, or the same Programme for 52 weeks. Participants were assessed at 0, 3, 12, 24, and 60 months. We analysed the relationship between BMI and EQ-5D-3L, adjusting for age and comorbidities, using a fixed effects model. Test for attrition, model specification and missing data were conducted. Secondary analyses investigated a non-symmetric gradient for weight loss vs. regain. RESULTS: A unit increase in BMI was associated with a - 0.011 (95% CI - 0.01546, - 0.00877) change in EQ-5D-3L. A unit change in BMI between periods of observation was associated with - 0.016 017 (95% CI - 0.0077009, - 0.025086) change in EQ-5D-3L. The negative association was reduced during weight loss, as opposed to weight gain, but the difference was not statistically significant. CONCLUSIONS: We have identified a strong and statistically significant negative relationship between BMI changes and HRQoL. These estimates could be used in economic evaluations of weight loss interventions to inform policymaking. CLINICAL TRIAL REGISTRATION: This trial was registered with Current Controlled Trials, number ISRCTN82857232.

Using health economic modelling to inform the design and development of an intervention: estimating the justifiable cost of weight loss maintenance in the UK.

BACKGROUND: There is a need to develop cost-effective weight loss maintenance interventions to prolong the positive impact of weight loss on health outcomes. Conducting pre-trial health economic modelling is recommended to inform the design and development of behavioural interventions. We aimed to use health economic modelling to estimate the maximum cost per-person (justifiable cost) of a cost-effective behavioural weight loss maintenance intervention, given an estimated intervention effect for individuals with: i) a Body Mass Index (BMI) of 28 kg/m2 or above without diabetes and ii) a diagnosis of type 2 diabetes prescribed a single non-insulin diabetes medication. METHODS: The School for Public Health Research Diabetes prevention model was used to estimate the lifetime Quality-adjusted life year (QALY) gains, healthcare costs, and maximum justifiable cost associated with a weight loss maintenance intervention. Based on a meta-analysis, the estimated effect of a weight loss maintenance intervention following a 9 kg weight loss, was a regain of 1.33 kg and 4.38 kg in years one and two respectively compared to greater regain of 2.84 kg and 5.6 kg in the control group. Sensitivity analysis was conducted around the rate of regain, duration of effect and initial weight loss. RESULTS: The justifiable cost for a weight loss maintenance intervention at an ICER of £20,000 per QALY was £104.64 for an individual with a BMI of 28 or over and £88.14 for an individual with type 2 diabetes. Within sensitivity analysis, this varied from £36.42 to £203.77 for the former, and between £29.98 and £173.05 for the latter. CONCLUSIONS: Researchers developing a weight loss maintenance intervention should consider these maximum justifiable cost estimates and the potential impact of the duration of effect and initial weight loss when designing intervention content and deciding target populations. Future research should consider using the methods demonstrated in this study to use health economic modelling to inform the design and budgetary decisions in the development of a behavioural interventions.

Phylogenetic signals and predictability in plant-soil feedbacks.

There is strong evidence for a phylogenetic signal in the degree to which species share co-evolved biotic partners and in the outcomes of biotic interactions. This implies there should be a phylogenetic signal in the outcome of feedbacks between plants and the soil microbiota they cultivate. However, attempts to identify a phylogenetic signal in plant-soil feedbacks have produced mixed results. Here we clarify how phylogenetic signals could arise in plant-soil feedbacks and use a recent compilation of data from feedback experiments to identify: whether there is a phylogenetic signal in the outcome of plant-soil feedbacks; and whether any signal arises through directional or divergent changes in feedback outcomes with evolutionary time. We find strong evidence for a divergent phylogenetic signal in feedback outcomes. Distantly related plant species show more divergent responses to each other's soil microbiota compared with closely related plant species. The pattern of divergence implies occasional co-evolutionary shifts in how plants interact with soil microbiota, with strongly contrasting feedback responses among some plant lineages. Our results highlight that it is difficult to predict feedback outcomes from phylogeny alone, other than to say that more closely related species tend to have more similar responses.

Delayed cord clamping with stabilisation at all preterm births - feasibility and efficacy of a low cost technique.

OBJECTIVES: Meta-analysis data suggests that Delayed cord clamping (DCC) in preterm infants is associated with a 32% reduction in mortality. Reported rates of this intervention are low, particularly for caesarean deliveries. Perceived difficulties providing respiratory support and thermal care during DCC may be barriers to implementation of this intervention. Commercially available equipment to facilitate this can be expensive. This study aimed to evaluate the feasibility and efficacy of a simple, low cost technique to deliver respiratory support and thermal care during DCC at all preterm deliveries (including caesarean), with the hypothesis that this could increase rates of preterm infants receiving DCC. STUDY DESIGN: Data was collected retrospectively from 46 infants born at <32 weeks gestation in 2015. The technique was introduced in early 2017, as part of a perinatal Quality Improvement project. Data was collected prospectively from 63 infants born at <32 weeks gestation in 2017-2018. RESULTS: Rates of DCC in infants born <32 weeks gestation have increased from 12.5% in 2015 to 89.4% in 2017-2018. In 2017-2018, thermal care and respiratory support was provided to all infants who received DCC. CONCLUSION: Multidisciplinary perinatal team working allowed development of a simple, low cost technique to deliver DCC at all preterm deliveries. We have demonstrated feasibility and efficacy of this technique, and a significant and sustained improvement in rates of DCC in our preterm population. We hope that by sharing this approach, other centres will be able to implement a similar strategy, closing the gap between evidence base and translation into clinical practice, and allowing provision of DCC for preterm infants as a standard part of high quality perinatal care.

Variation in the management of SSRI-exposed babies across England.

BACKGROUND: Depression in pregnancy is commonly treated using selective serotonin reuptake inhibitors (SSRIs). A possible withdrawal syndrome following in utero exposure has been reported, but there is currently no UK guidance on the management of these neonates. METHODS: All 160 neonatal units in England were asked for information regarding their management of SSRI-exposed babies. RESULTS: Responses were obtained from 112/160 (70%) units. Only four units had a specific protocol for managing SSRI-exposed neonates. Twenty-one units (19%) conduct routine observations on exposed neonates, while 37 units (33%) would consider treating babies with signs of withdrawal or toxicity. CONCLUSIONS: Very few neonatal units in England have specific guidelines for the management of babies exposed to SSRIs in utero, with practice varying greatly between units. Further research is needed on the outcomes of SSRI-exposed babies to support development of standardised evidence-based guidelines to ensure all mothers and babies receive similar high-quality care.

Resuscitation of the Newborn: Simulating for Confidence.

INTRODUCTION: Non-pediatric trainees working in pediatrics in the UK are expected to attend newborn deliveries and provide initial newborn life support if needed. In Swindon, new junior doctors receive a 90-minute teaching session at the start of their pediatrics rotation, but the content has not previously been standardized, and it may be several weeks before a doctor attends a newborn delivery. Thus, the confidence and competence in newborn resuscitation of doctors attending deliveries can vastly vary. METHODS: A standardized teaching package was developed as part of the pediatrics induction program. This includes an interactive lecture on the physiology of the newborn, skills stations, and mini-simulations to consolidate skills. This is accompanied by a program of regular neonatal mini-simulations as part of the departmental morning teaching program. These sessions allow junior doctors to practice their skills in a safe, simulated environment and reinforce the newborn life support pathway. RESULTS: Qualitative and quantitative feedback was sought following delivery of the induction training session. Junior doctors were asked to rate their confidence before and after the induction session using Likert scales from 1 (least confident) to 5 (most confident). Median confidence in attending term deliveries increased from 2 (range 1 - 4) to 4 (2 - 5), P=0.008. There was evidence that confidence was maintained at one month following induction. CONCLUSIONS: A simulation program has been successful at improving confidence among junior doctors in attending newborn deliveries. This has the potential to improve patient care and trainees' experiences of their pediatrics placement.