Changes in diet and physical activity following a community-wide pilot intervention to tackle childhood obesity in a deprived inner-London ward.

BACKGROUND: Local authorities in England have an important role in shaping healthy local environments contributing to childhood obesity. This study examined changes in diet and physical activity in primary school children following a three-year, complex, community-based intervention in Golborne ward, the second most deprived ward in London. METHODS: The Go-Golborne intervention aimed to shape the local environment across multiple settings with the engagement of a large number of local government and community stakeholders in a joint approach. Activities focused on six co-created themes to make changes to local environments and reduce sugary snacks and beverage consumption, increase fruit and vegetable intake, promote healthy snacks, increase active play and travel, and reduce screen time. We analysed changes in self-reported diet and physical activity, collected annually between 2016 and 2019, from 1,650 children aged 6-11 years through six local schools, who all received the intervention. We used multilevel, linear and logistic random-slope regression models adjusted for time on study, baseline age, gender, ethnicity, deprivation quintile, school, and baseline weight status. RESULTS: After three years of follow-up, there were reductions in sugar-sweetened beverage consumption (adjusted beta -0·43 occasions/day, 95% CI -0·55 to -0·32), fruit and vegetable consumption (adjusted beta -0.22 portions, 95% CI -0.44 to 0.001) and car travel to and from school (adjusted OR 0·19, 95% CI 0·06 to 0·66), while screen time increased (high versus moderate/low: OR 2·30, 95% CI 1·36 to 3·90). For other behavioural outcomes, there was no statistically significant evidence of changes. CONCLUSION: Local authorities have substantial powers to make positive changes to the obesogenic environment but programmes remain under-evaluated. Results from the ambitious Go-Golborne intervention demonstrated mixed results in health behaviours following programme implementation. These results underline the importance of a coordinated and comprehensive policy response to support changes in wider environmental and social conditions as well as appropriate and holistic evaluations of initiatives to inform local actions on obesogenic environments.

Characterizing restrictions on commercial advertising and sponsorship of harmful commodities in local government policies: a nationwide study in England.

BACKGROUND: Commercial advertising and sponsorship drive the consumption of harmful commodities. Local authorities (LAs) have considerable powers to reduce such exposures. This study aimed to characterize local commercial policies across all English LAs. METHODS: We conducted a census of all English LAs (n = 333) to identify local commercial policies concerning advertising and sponsorship of tobacco, alcohol, less healthy foods and gambling, through online searches and Freedom of Information requests. We explored policy presence, commodity frequency and type, and associations with LA characteristics (region, urban/rural and deprivation). RESULTS: Only a third (106) of LAs in England had a relevant policy (32%). These included restrictions on tobacco (91%), gambling (79%), alcohol (74%) and/or less healthy foods (24%). Policy prevalence was lowest in the East of England (22%), North East (25%) and North West (27%), higher in urban areas (36%) than rural areas (28%) and lower in the least (27%) compared with the most (38%) deprived areas. Definitions in policies varied, particularly for alcohol and less healthy foods. CONCLUSIONS: English LAs currently underutilize their levers to reduce the negative impacts of harmful commodity industry marketing, particularly concerning less healthy foods. Standardized guidance, including clarity on definitions and application, could inform local policy development.

Empowering community health professionals for effective air pollution information communication.

BACKGROUND: Air pollution remains a significant public health risk, particularly in urban areas. Effective communication strategies remain integral to overall protection by encouraging the adoption of personal air pollution exposure reduction behaviours. This study aims to explore how community health professionals can be empowered to communicate air pollution information and advice to the wider community, to encourage the uptake of desired behaviours in the population. METHODS: The study adopted a qualitative methodology, where four homogenous Focus Group Discussions (FGDs) were held with a range of community health professionals, including Health Care Professionals, Community Health and Wellbeing Workers (CHWWs) and Social Prescribing Link Workers (SPLW). A classical content analysis was conducted with the Structural Empowerment Theory (SET) and Psychological Empowerment Theory (PET) as guiding concepts. RESULTS: Five key themes were identified: from a structural empowerment perspective: [1] resources and support, [2] knowledge. From a psychological empowerment perspective: [3] confidence as advisor, [4] responsibility as advisor, and [5] residents' receptiveness to advice. It was concluded that advice should be risk stratified, clear, easy to follow and provide alternatives. CONCLUSION: This study identified ways for community health professionals to be empowered by local councils or other organisations in providing advice on air pollution, through the provision of essential structural support and opportunities to enhance their knowledge and confidence in the subject. Implementing recommendations from this study would not only empower community health professionals to advise on air pollution to the wider community but also increase adherence to health advice.

Learning from the universal, proactive outreach of the Brazilian Community Health Worker model: impact of a Community Health and Wellbeing Worker initiative on vaccination, cancer screening and NHS health check uptake in a deprived community in the UK.

BACKGROUND: Delays in preventative service uptake are increasing in the UK. Universal, comprehensive monthly outreach by Community Health and Wellbeing Workers (CHW), who are integrated at the GP practice and local authority, offer a promising alternative to general public health campaigns as it personalises health promotion and prevention of disease holistically at the household level. We sought to test the ability of this model, which is based on the Brazilian Family Health Strategy, to increase prevention uptake in the UK. METHODS: Analysis of primary care patient records for 662 households that were allocated to five CHWWs from July 2021. Primary outcome was the Composite Referral Completion Indicator (CRCI), a measure of how many health promotion activities were received by members of a household relative to the ones that they were eligible for during the period July 2021-April 2022. The CRCI was compared between the intervention group (those who had received at least one visit) and the control group (allocated households that were yet to receive a visit). A secondary outcome was the number of GP visits in the intervention and control groups during the study period and compared to a year prior. RESULTS: Intervention and control groups were largely comparable in terms of household occupancy and service eligibilities. A total of 2251 patients in 662 corresponding households were allocated to 5 CHWs and 160 households had received at least one visit during the intervention period. The remaining households were included in the control group. Overall service uptake was 40% higher in the intervention group compared to control group (CRCI: 0.21 ± 0.15 and 0.15 ± 0.19 respectively). Likelihood of immunisation uptake specifically was 47% higher and cancer screening and NHS Health Checks was 82% higher. The average number of GP consultations per household decreased by 7.4% in the intervention group over the first 10 months of the pilot compared to the 10 months preceding its start, compared with a 0.6% decrease in the control group. CONCLUSIONS: Despite the short study period these are promising findings in this deprived, traditionally hard to reach community and demonstrates potential for the Brazilian community health worker model to be impactful in the UK. Further analysis is needed to examine if this approach can reduce health inequalities and increase cost effectiveness of health promotion approaches.

Factors associated with accessing long-term adult social care in people aged 75 and over: a retrospective cohort study.

BACKGROUND: An ageing population and limited resources have put strain on state provision of adult social care (ASC) in England. With social care needs predicted to double over the next 20 years, there is a need for new approaches to inform service planning and development, including through predictive models of demand. OBJECTIVE: Describe risk factors for long-term ASC in two inner London boroughs and develop a risk prediction model for long-term ASC. METHODS: Pseudonymised person-level data from an integrated care dataset were analysed. We used multivariable logistic regression to model associations of demographic factors, and baseline aspects of health status and health service use, with accessing long-term ASC over 12 months. RESULTS: The cohort comprised 13,394 residents, aged ≥75 years with no prior history of ASC at baseline. Of these, 1.7% became ASC clients over 12 months. Residents were more likely to access ASC if they were older or living in areas with high socioeconomic deprivation. Those with preexisting mental health or neurological conditions, or more intense prior health service use during the baseline period, were also more likely to access ASC. A prognostic model derived from risk factors had limited predictive power. CONCLUSIONS: Our findings reinforce evidence on known risk factors for residents aged 75 or over, yet even with linked routinely collected health and social care data, it was not possible to make accurate predictions of long-term ASC use for individuals. We propose that a paradigm shift towards more relational, personalised approaches, is needed.

Interaction of the signaling state analog and the apoprotein form of the orange carotenoid protein with the fluorescence recovery protein.

Photoprotection in cyanobacteria relies on the interplay between the orange carotenoid protein (OCP) and the fluorescence recovery protein (FRP) in a process termed non-photochemical quenching, NPQ. Illumination with blue-green light converts OCP from the basic orange state (OCPO) into the red-shifted, active state (OCPR) that quenches phycobilisome (PBs) fluorescence to avoid excessive energy flow to the photosynthetic reaction centers. Upon binding of FRP, OCPR is converted to OCPO and dissociates from PBs; however, the mode and site of OCPR/FRP interactions remain elusive. Recently, we have introduced the purple OCPW288A mutant as a competent model for the signaling state OCPR (Sluchanko et al., Biochim Biophys Acta 1858:1-11, 2017). Here, we have utilized fluorescence labeling of OCP at its native cysteine residues to generate fluorescent OCP proteins for fluorescence correlation spectroscopy (FCS). Our results show that OCPW288A has a 1.6(±0.4)-fold larger hydrodynamic radius than OCPO, supporting the hypothesis of domain separation upon OCP photoactivation. Whereas the addition of FRP did not change the diffusion behavior of OCPO, a substantial compaction of the OCPW288A mutant and of the OCP apoprotein was observed. These results show that sufficiently stable complexes between FRP and OCPW288A or the OCP apoprotein are formed to be detected by FCS. 1:1 complex formation with a micromolar apparent dissociation constant between OCP apoprotein and FRP was confirmed by size-exclusion chromatography. Beyond the established OCP/FRP interaction underlying NPQ cessation, the OCP apoprotein/FRP interaction suggests a more general role of FRP as a scaffold protein for OCP maturation.

Erratum to: Interaction of the signaling state analog and the apoprotein form of the orange carotenoid protein with the fluorescence recovery protein.

In Fig. 1a in the original article, the amino acid side chains were incorrectly labeled in the structure representation of the orange carotenoid protein (OCP). The corrected figure is printed in this erratum.

Disruption of Ankyrin B and Caveolin-1 Interaction Sites Alters Na+,K+-ATPase Membrane Diffusion.

The Na+,K+-ATPase is a plasma membrane ion transporter of high physiological importance for ion homeostasis and cellular excitability in electrically active tissues. Mutations in the genes coding for Na+,K+-ATPase α-subunit isoforms lead to severe human pathologies including Familial Hemiplegic Migraine type 2, Alternating Hemiplegia of Childhood, Rapid-onset Dystonia Parkinsonism, or epilepsy. Many of the reported mutations lead to change- or loss-of-function effects, whereas others do not alter the functional properties, but lead to, e.g., reduced protein stability, reduced protein expression, or defective plasma membrane targeting. Na+,K+-ATPase frequently assembles with other membrane transporters or cellular matrix proteins in specialized plasma membrane microdomains, but the effects of these interactions on targeting or protein mobility are elusive so far. Mutation of established interaction motifs of the Na+,K+-ATPase with ankyrin B and caveolin-1 are expected to result in changes in plasma membrane targeting, changes of the localization pattern, and of the diffusion behavior of the enzyme. We studied the consequences of mutations in these binding sites by monitoring diffusion of eGFP-labeled Na+,K+-ATPase constructs in the plasma membrane of HEK293T cells by fluorescence correlation spectroscopy as well as fluorescence recovery after photobleaching or photoswitching, and observed significant differences compared to the wild-type enzyme, with synergistic effects for combinations of interaction site mutations. These measurements expand the possibilities to study the consequences of Na+,K+-ATPase mutations and provide information about the interaction of Na+,K+-ATPase α-isoforms with cellular matrix proteins, the cytoskeleton, or other membrane protein complexes.

eGFP-pHsens as a highly sensitive fluorophore for cellular pH determination by fluorescence lifetime imaging microscopy (FLIM).

The determination of pH in the cell cytoplasm or in intracellular organelles is of high relevance in cell biology. Also in plant cells, organelle-specific pH monitoring with high spatial precision is an important issue, since e.g. ΔpH across thylakoid membranes is the driving force for ATP synthesis critically regulating photoprotective mechanisms like non-photochemical quenching (NPQ) of chlorophyll (Chl) fluorescence or the xanthophyll cycle. In animal cells, pH determination can serve to monitor proton permeation across membranes and, therefore, to assay the efficiency of drugs against proton-selective transporters or ion channels. In this work, we demonstrate the applicability of the pH-sensitive GFP derivative (eGFP-pHsens, originally termed deGFP4 by Hanson et al. [1]) for pH measurements using fluorescence lifetime imaging microscopy (FLIM) with excellent precision. eGFP-pHsens was either expressed in the cytoplasm or targeted to the mitochondria of Chinese hamster ovary (CHO-K1) cells and applied here for monitoring activity of the M2 proton channel from influenza A virus. It is shown that the M2 protein confers high proton permeability of the plasma membrane upon expression in CHO-K1 cells resulting in rapid and strong changes of the intracellular pH upon pH changes of the extracellular medium. These pH changes are abolished in the presence of amantadine, a specific blocker of the M2 proton channel. These results were obtained using a novel multi-parameter FLIM setup that permits the simultaneous imaging of the fluorescence amplitude ratios and lifetimes of eGFP-pHsens enabling the quick and accurate pH determination with spatial resolution of 500 nm in two color channels with time resolution of below 100 ps. With FLIM, we also demonstrate the simultaneous determination of pH in the cytoplasm and mitochondria showing that the pH in the mitochondrial matrix is slightly higher (around 7.8) than that in the cytoplasm (about 7.0). The results obtained for CHO-K1 cells without M2 channels in comparison to M2-expressing cells show that the pH dynamics is determined by the specific H⁺ permeability of the membrane, the buffering of protons in the internal cell lumen and/or an outwardly directed proton pump activity that stabilizes the interior pH at a higher level than the external acidic pH. This article is part of a special issue entitled: photosynthesis research for sustainability: keys to produce clean energy.

Typology of how 'harmful commodity industries' interact with local governments in England: a critical interpretive synthesis.

INTRODUCTION: Industries that produce and market potentially harmful commodities or services (eg, tobacco, alcohol, gambling, less healthy foods and beverages) are a major influence on the drivers of behavioural risk factors for non-communicable diseases. The nature and impact of interactions between public bodies and 'harmful commodity industries' (HCIs) has been widely recognised and discussed at national and international levels, but to date little is known about such interactions at local or regional government levels. This study aimed to identify and characterise actual and potential interactions and proposes a typology of interactions between HCIs and English local authorities (LAs). METHODS: Five electronic databases covering international literature (PubMed, EBSCO, OVID, Scopus and Web of Science) were searched up to June 2021. We also performed online searches for publicly available, web-based grey literature and documented examples of interactions in an English LA context. We conducted a critical interpretive synthesis of the published and grey literature to integrate and conceptualise the data in the context of English LAs. RESULTS: We included 47 published papers to provide the frame for the typology, which was refined and contextualised for English LAs through the available grey literature. Three categories were developed, describing the medium through which interactions occur: (1) direct involvement with LAs, (2) involvement through intermediaries and (3) involvement through the local knowledge space. Within these, we grouped interactions into 10 themes defining their nature and identified illustrative examples. CONCLUSION: Our typology identifies complex inter-relationships and characterises interactions between HCIs and LAs, with illustrative examples from English LAs. Drawn from well-established theories and frameworks in combination with contextual information on English LAs, this typology explores the LA perspective and could help local decision-makers to maximise population health while minimising negative impacts of HCIs. PROSPERO REGISTRATION NUMBER: CRD42021257311.

Ethnic differences in long-term improvement of angina following revascularization or medical management: a comparison between south Asians and white Europeans.

BACKGROUND: It is not known whether there are disparities in morbidity outcomes between south Asians and whites with established coronary disease. METHODS: Six-year prospective cohort study to determine whether improvement of angina symptoms differs between 196 south Asians and 1508 whites following revascularization or medical management. RESULTS: 43.9% of south Asians reported improvement in angina at 6 years compared with 60.3% of whites (age-adjusted OR 0.56, 95% CI 0.41-0.76, adjusted for diabetes, hypertension, smoking, number of diseased vessels, left ventricular function and social class OR 0.59, 95% CI 0.41-0.85). Similar proportions of whites and south Asians underwent percutaneous coronary intervention (PCI) (19.6% versus 19.9%) and coronary artery bypass surgery (CABG) (32.8% versus 30.1%). South Asians were less likely to report improved angina after PCI (OR 0.19, 95% CI 0.06-0.56) or CABG (OR 0.36, 95% CI 0.17-0.74). There was less evidence of ethnic differences in angina improvement when treatment was medical (OR 0.87, 95% CI 0.48-1.57). CONCLUSION: South Asians were less likely to experience long-term improvements in angina than whites after receipt of revascularization. Further research is needed to identify why these ethnic groups differ in symptomatic prognosis following revascularization for coronary disease and how these differences may be mitigated.

Appropriateness criteria for coronary angiography in angina: reliability and validity.

BACKGROUND: Evaluated criteria for tailoring the decision to perform coronary angiography in specific clinical scenarios are lacking. OBJECTIVE: To determine the reliability and prognostic validity of patient-specific appropriateness criteria for coronary angiography among patients with suspected angina pectoris. DESIGN: Prospective observational study. Two independent panels of clinicians scored 2400 patient-specific indications for coronary angiography as inappropriate, uncertain, or appropriate. Using a simple computer algorithm, patients were matched to 1 of these indications. SETTING: 6 urban ambulatory care clinics in the United Kingdom. PATIENTS: 9356 consecutive patients with recent-onset chest pain in whom stable angina was suspected. MEASUREMENTS: Appropriateness ratings and clinical outcomes (coronary death and acute coronary syndrome events) over a median of 3 years of follow-up. RESULTS: 660 coronary deaths or acute coronary syndrome events occurred. Agreement between the 2 panels (reliability) on appropriateness category was moderate (weighted kappa = 0.58; P < 0.001). Use of subsequent angiography was strongly related to appropriateness category (P for linear trend <0.001) according to scores from either panel. Among patients judged as appropriate candidates for angiography, underuse was common (57% according to panel A and 71.3% according to panel B), and not undergoing coronary angiography was associated with higher coronary event rates than was undergoing the procedure. The hazard ratio after adjustment for age, sex, exercise electrocardiography result, and secondary prevention medication was similar according to panel A (2.78 [95% CI, 1.77 to 4.37]) and panel B (2.47 [CI, 1.72 to 3.55]). LIMITATION: The study was too small to assess the relationship of angiography with coronary death and did not assess the reasons why patients did not receive angiography. CONCLUSION: Appropriateness scores offer prognostically valid criteria for judging which specific patients might benefit from coronary angiography. Patient-specific appropriateness scores help pinpoint areas where judgments diverge and are a promising tool for making guidelines more effective.

Presentation of stable angina pectoris among women and South Asian people.

BACKGROUND: There is speculation that women and South Asian people are more likely than men and white people to report atypical angina and that they are less likely to undergo invasive management of angina. We sought to determine whether atypical symptoms of angina pectoris in women and South Asians impacted clinically important outcomes and clinical management. METHODS: We prospectively identified 2189 South Asian people and 5605 white people with recent-onset chest pain at 6 chest-pain clinics in the United Kingdom. We documented hospital admissions for acute coronary syndromes, coronary deaths as well as coronary angiography and revascularization procedures. RESULTS: Atypical chest pain was reported by more women than men (56.5% vs 54.5%, p < 0.054) and by more South Asian patients than white patients (59.9% vs 52.5%, p < 0.001). Typical symptoms were associated with coronary death or acute coronary syndromes among women (hazard ratio [HR] 2.30, 95% CI 1.70-3.11, p < 0.001) but not among men (HR 1.23, 95% CI 0.96-1.57, p = 0.10). Typical symptoms were associated with coronary outcomes in both South Asian and white patients. Among those with typical symptoms, women (HR 0.76, 95% CI 0.63-0.92, p = 0.004) and South Asian patients (HR 0.52, 95% CI 0.41-0.67, p < 0.001) were less likely than men and white patients to receive angiography. INTERPRETATION: Compared to those with atypical chest pain, women and South Asian patients with typical pain had worse clinical outcomes. However, sex and ethnic background did not explain differences in the use of invasive procedures.

Effect of patient-specific ratings vs conventional guidelines on investigation decisions in angina: Appropriateness of Referral and Investigation in Angina (ARIA) Trial.

BACKGROUND: Conventional guidelines have limited effect on changing physicians' test ordering. We sought to determine the effect of patient-specific ratings vs conventional guidelines on appropriate investigation of angina. METHODS: Randomized controlled trial of 145 physicians receiving patient-specific ratings (online prompt stating whether the specific vignette was considered appropriate or inappropriate for investigation, with access to detailed information on how the ratings were derived) and 147 physicians receiving conventional guidelines from the American Heart Association and the European Society of Cardiology. Physicians made recommendations on 12 Web-based patient vignettes before and on 12 vignettes after these interventions. The outcome was the proportion of appropriate investigative decisions as defined by 2 independent expert panels. RESULTS: Decisions for exercise electrocardiography were more appropriate with patient-specific ratings (819/1491 [55%]) compared with conventional guidelines (648/1488 [44%]) (odds ratio [OR], 1.57; 95% confidence interval [CI], 1.36-1.82). The effect was stronger for angiography (1274/1595 [80%] with patient-specific ratings compared with 1009/1576 [64%] with conventional guidelines [OR, 2.24; 95% CI, 1.90-2.62]). Within-arm comparisons confirmed that conventional guidelines had no effect but that patient-specific ratings significantly changed physicians' decisions toward appropriate recommendations for exercise electrocardiography (55% vs 42%; OR, 2.62; 95% CI, 2.14-3.22) and for angiography (80% vs 65%; OR, 2.10; 95% CI, 1.79-2.47). These effects were robust to physician specialty (cardiologists and general practitioners) and to vignette characteristics, including older age, female sex, and nonwhite race/ethnicity. CONCLUSION: Patient-specific ratings, unlike conventional guidelines, changed physician testing behavior and have the potential to reduce practice variations and to increase the appropriate use of investigation.

ATP1A2 Mutations in Migraine: Seeing through the Facets of an Ion Pump onto the Neurobiology of Disease.

Mutations in four genes have been identified in familial hemiplegic migraine (FHM), from which CACNA1A (FHM type 1) and SCN1A (FHM type 3) code for neuronal voltage-gated calcium or sodium channels, respectively, while ATP1A2 (FHM type 2) encodes the α2 isoform of the Na(+),K(+)-ATPase's catalytic subunit, thus classifying FHM primarily as an ion channel/ion transporter pathology. FHM type 4 is attributed to mutations in the PRRT2 gene, which encodes a proline-rich transmembrane protein of as yet unknown function. The Na(+),K(+)-ATPase maintains the physiological gradients for Na(+) and K(+) ions and is, therefore, critical for the activity of ion channels and transporters involved neuronal excitability, neurotransmitter uptake or Ca(2+) signaling. Strikingly diverse functional abnormalities have been identified for disease-linked ATP1A2 mutations which frequently lead to changes in the enzyme's voltage-dependent properties, kinetics, or apparent cation affinities, but some mutations are truly deleterious for enzyme function and thus cause full haploinsufficiency. Here, we summarize structural and functional data about the Na(+),K(+)-ATPase available to date and an overview is provided about the particular properties of the α2 isoform that explain its physiological relevance in electrically excitable tissues. In addition, current concepts about the neurobiology of migraine, the correlations between primary brain dysfunction and mechanisms of headache pain generation are described, together with insights gained recently from modeling approaches in computational neuroscience. Then, a survey is given about ATP1A2 mutations implicated in migraine cases as documented in the literature with focus on mutations that were described to completely destroy enzyme function, or lead to misfolded or mistargeted protein in particular model cell lines. We also discuss whether or not there are correlations between these most severe mutational effects and clinical phenotypes. Finally, perspectives for future research on the implications of Na(+),K(+)-ATPase mutations in human pathologies are presented.

Do physiological scoring and a novel point of care metabolic screen predict 48-h outcome in admissions from the emergency department resuscitation area?

OBJECTIVE: We aimed to compare the performance of a widely used physiological score [Modified Early Warning Score (MEWS)] and a novel metabolic score (derived from a blood gas) in predicting outcome in emergency department patients. DESIGN, SETTING AND PARTICIPANTS: We carried out a prospective observational study using a convenience sample of 200 patients presenting to the resuscitation area of an inner-city teaching hospital over 4 months. MAIN OUTCOME MEASURES: We looked primarily at whether either score predicted new organ failure at 48 h. Our secondary outcome measures were escalation of care and mortality at 48 h. RESULTS: In univariate analysis, MEWS and the metabolic score predicted 48-h organ failure [odds ratio (OR) 1.19, 95% confidence interval (CI) 1.04-1.35, P=0.009, and OR 1.34, 95% CI 1.015-1.56, P<0.001, respectively]. Both MEWS and the metabolic score predicted 48-h death (OR 1.32, 95% CI 1.02-1.71, P=0.03, and OR 1.56, 95% CI 1.18-2.06, P=0.002, respectively) in univariate analysis. Neither predicted 48-h escalation of care. The metabolic score remained statistically significant at predicting organ failure or death after controlling for MEWS parameters (OR 1.35, 95% CI 1.13-1.62, P=0.001, and OR 1.74, 95% CI 1.13-2.69, P=0.01, respectively). In contrast, MEWS was no longer associated with these outcomes; however, our study has small participant numbers. CONCLUSION: This pilot data suggest that a blood gas-derived metabolic score on emergency department arrival may be superior to MEWS at predicting organ failure and death at 48 h.

Atypical chest pain in diabetic patients with suspected stable angina: impact on diagnosis and coronary outcomes.

AIMS: Silent myocardial ischaemia occurs commonly in diabetes. Whether altered perception of ischaemia also predisposes to atypical presentations with under-diagnosis of coronary disease is not known. To determine whether (i) patients with diabetes diagnosed with angina are more likely to report atypical symptoms compared with patients without diabetes, and (ii) atypical symptoms in patients with diabetes cause angina to go unrecognized, increasing the risk of coronary events. METHODS AND RESULTS: Prospective, multicentre cohort study of 8662 ambulatory patients with suspected angina, of whom 906 had diabetes. We recorded detailed chest pain descriptors and fatal and non-fatal coronary events over a median of 3.08 years of follow-up. Proportionately more patients with than without diabetes received a diagnosis of angina (42.7 vs. 25.1%). Among patients with diabetes diagnosed with angina, a greater proportion had atypical chest pain compared with patients without diabetes (21.0 vs. 11.3%), but the hazard of fatal and non-fatal coronary events was similar. However, among patients diagnosed with non-cardiac chest pain, those with diabetes-most of whom had atypical symptoms-remained at greater risk of coronary events [2.29 (95% CI 1.54, 3.41)] and all-cause mortality [1.67 (95% confidence interval, CI 1.04, 2.69)] compared with non-diabetic patients. CONCLUSION: Patients with diabetes and atypical symptoms are nearly twice as likely to be diagnosed with angina compared with non-diabetic patients. Those diagnosed with non-cardiac pain are at increased risk of coronary events. Our study emphasizes the need for more intensive investigation of diabetic patients with chest pain, particularly those presenting with atypical symptoms.