Nuffield Health

With more patients now consulting with non-GPs there is a strong rationale for enabling non-medically qualified (NMQ) clinicians to request CXR in accordance with National Institute for Health and Care Excellence guidance.However, wider uptake requires reducing bureaucratic barriers and provision of access to proportionate and relevant IR(ME)R training.

To explore associations of clinic and 24-hour ambulatory blood pressure (BP) monitoring (ABPM) with cardiovascular death (CVD), parameters were modeled for age and sex in this large cohort in primary care. In the Spanish ABPM Registry, 59.124 patients had complete data on mortality, age, sex, and all ABPM. Office, mean, 24-hour, daytime, and nighttime systolic BP (SBP), diastolic BP, and pulse pressure (PP) were related to CVD according to age and sex and were modelled with restricted cubic splines to get trajectories. During a median of 9.7 years, 2361 patients had CVD (1229 males, 1132 females). Nonlinear relationships for office, 24-hour mean, daytime, and nighttime SBP, diastolic BP, and PP (P<0.0001 for all) for both sexes were observed. Until 75 years, SBP was higher in males than females, but differences were minimized after ≈60 to 70 years (P for interaction <0.0001). High SBP and PP are associated with CVD without heterogeneity between sexes and across aging. The increase of SBP and PP was higher at a higher age for females than males (P for interaction <0.0001). CVD was age-dependent, and ABPM, in particular nighttime BP did more closely associated with risk than office BP in younger than in older individuals. Twenty-four-hour mean, nighttime BP, and PP were closely associated with risk being higher in elderly females than males after 75 years, corresponding to a rise in BP in older females. Guidelines should continue to mandate the evaluation of 24-hour ABPM data for risk prediction.

The treatment of pain in the prehospital setting is suboptimal. The scope of paramedic practice is broadening, with more medicines becoming available to these professionals, including ketamine for pain management. A systematic literature review was carried out to examine the safety and efficacy of ketamine for adult trauma in a prehospital setting and its suitability for paramedics working outside an enhanced care scope of practice. Ketamine is effective in hypovolaemic patients and a preferred option for critically ill and hypotensive patients; it is particularly effective in alleviating trauma-based pain when used with opiates such as morphine or fentanyl. Side effects are rare and easily managed. Ketamine is a safe and effective addition to prehospital analgesia for adult trauma patients and safe for paramedics working outside an enhanced care scope of practice to administer. Advancing paramedics' understanding of the co-administration of ketamine and morphine versus ketamine alone would support decision-making in trauma-based patient.

Reinforcement sensitivity theory outlines three systems which guide our decision-making and risk-taking. The behavioral activation system (BAS) increases sensitivity to rewarding stimuli (i.e., approach motivation), while the flight-fright-freeze system (FFFS) increases sensitivity to threatening stimuli (i.e., avoidance motivation) and revised behavioral inhibition system (r-BIS) mediates competition between BAS and FFFS. Alcohol is established to diminish neural indices associated with FFFS and r-BIS; however, whether intoxication also influences neural correlates of BAS is unclear. The current experiment (N = 71) used electroencephalography (EEG) to assess frontal-cortical asymmetry associated with BAS versus r-BIS during the balloon analogue risk task (BART). Participants consumed alcoholic versus non-alcoholic (placebo) drinks. Intoxicated participants exhibited greater risk-taking compared to placebos. Yet, placebos exhibited greater relative left frontal-cortical asymmetry during the first half of BART trials (i.e., associated with approach motivation) followed by a shift toward relative right frontal-cortical asymmetry in the second half of trials (i.e., associated with inhibition). Relative left frontal-cortical asymmetry observed among placebos predicted poorer BART performance. Intoxicated participants did not exhibit these shifts in frontal asymmetry, likely indicating impaired or delayed engagement of inhibitory control. Despite greater risk-taking, intoxicated participants responded more conservatively during the second set of BART trials. However, unlike placebos, these shifts in performance were unrelated to frontal asymmetry, suggesting alternative mechanisms underlying their behavioral adjustments. Findings provide novel insights into neural correlates of approach motivation following actual versus perceived consumption of alcohol, supporting links between frontal-cortical asymmetry and risk-taking, in addition to suggesting unique pathways which promote impulsiveness.

The brain continuously integrates rapidly changing visual input across eye movements to maintain stable perception, yet the precise mechanisms underpinning dynamic working memory and how these break down in brain diseases remain unclear. We developed a novel eye-tracking paradigm and computational models to investigate how spatial and colour information are updated across saccades in the human brain. Our findings reveal that saccades selectively impair spatial but not colour memory. Computational modelling identified that spatial representations are maintained in a dual eye-centred frame of reference which is actively updated by a noisy memory of saccades but is vulnerable to interference. Using this model, we found that specific mechanistic failures in initial encoding and memory decay, rather than the saccadic updating process itself, account for spatial working memory deficits in Alzheimer’s and Parkinson’s disease. These results provide a mechanistic understanding of how dynamic spatial memory operates in health and its disruption in neurodegenerative disorders.

BACKGROUND:The pullback pressure gradient (PPG) is a novel physiological metric that quantifies coronary artery disease patterns as focal or diffuse on a scale from 0 to 1. This study assessed the relationship between PPG and residual angina at 1 year.METHODS:PPG Global is a prospective, investigator-initiated, single-arm, multicenter study that enrolled patients with at least 1 lesion with a fractional flow reserve ≤0.80 intended to be treated with percutaneous coronary intervention. After the PPG calculation, physicians could revise treatment assignment to medical therapy or coronary artery bypass graft surgery instead of percutaneous coronary intervention. Focal and diffuse disease were defined based on the median PPG value of 0.62. Patient-reported outcomes were assessed using the Seattle Angina Questionnaire at baseline and 1-year follow-up.RESULTS:The study included 947 patients with PPG and the Seattle Angina Questionnaire at 1 year. The mean age was 67.6±10.2 years, 24% were female, and 29% had diabetes. At 1 year, patients with focal coronary artery disease reported less angina than those with diffuse disease (Seattle Angina Questionnaire angina frequency score, 95.3±9.9 versus 92.5±15.0; P=0.006). PPG was independently associated with improvement in angina (P=0.017).CONCLUSIONS:In patients with flow-limiting coronary artery disease, a focal disease pattern defined by high PPG was associated with greater symptomatic relief at 1 year compared with diffuse disease (low PPG). By capturing the underlying pathophysiologic distribution of epicardial disease and its relation to post-treatment symptom relief, PPG may support a more tailored revascularization decision-making and percutaneous coronary intervention strategy.

ABSTRACTIntroductionThe effectiveness of low‐fats diet for managing bile acid diarrhoea (BAD) is unclear, yet many individuals may restrict fat intake. This study aims to explore factors associated with reducing fat intake.MethodsCross‐sectional survey using convenience sampling recruited adults from the United Kingdom with a self‐reported diagnosis of BAD via online platforms (April to May 2021). Demographics, clinical characteristics, and low‐fat diet follower status data were collected. Potential predictors of intention to reduce fat intake were assessed using a modified validated questionnaire framed on the Theory of Planned Behaviour. Multinomial logistic regression was performed.ResultsOf 434 respondents, current, past and non‐followers of low‐fat diets were 49%, 34% and 17%, whilst 79%, 83% and 78% reported chronic diarrhoea, respectively. Intention to reduce fat intake was associated with higher odds for six out of 20 predictor variables: current versus past‐followers, for its necessity for health (odds ratio [OR] = 1.4, 95% confidence interval [CI] 1.2 to 1.7), improving diarrhoea (OR = 1.5, 95% CI 1.3 to 1.7), abdominal pain (OR = 1.4, 95% CI: 1.3 to 1.7), bloating (OR = 1.4, 95% CI 1.2 to 1.6), flatulence (OR = 1.4, 95% CI 1.4 to 1.7), controlling gut symptoms (OR = 1.3, 95% CI 1.2 to 1.5); current versus non‐followers, for its necessary for health (OR = 1.3, 95% CI 1.1 to 1.5).ConclusionAddressing the association between fat intake and an individual's attitude about its necessity for health and beliefs about controlling diarrhoeal symptoms may improve BAD management. For developing new therapies for symptom and body weight management, dietary behaviour components additional to fat intake warrant investigation.

Statistical theory forms a foundation for how epidemiologists learn about populations in public health and medical studies and is fundamental for the understanding of more advanced epidemiological methods (e.g., in causal inference and machine learning). Textbooks provide in-depth coverage of probability and statistical theory, but with such comprehensive coverage that it can be easy to miss the forest for the trees. Here, we provide a summary of fundamental concepts from large-sample statistical theory to allow for more focused understanding tailored to epidemiologists and health science researchers. This primer aims to promote appropriate understanding and application of statistical methods in epidemiologic research. We clarify several often-confused statistical topics and provide a motivation for the application of large-sample inferential methods to data from population health and medical studies. Assumptions underlying commonly used statistical methods that must be considered for valid inference are also discussed. These ideas are contextualized with an example from the Women's Interagency HIV Study.