Prasanthi Sivakumaran

Age at menarche and adult body mass index: a Mendelian randomization study.

BackgroundPubertal timing has psychological and physical sequelae. While observational studies have demonstrated an association between age at menarche and adult body mass index (BMI), confounding makes it difficult to infer causality.MethodsThe Mendelian randomization (MR) technique is not limited by traditional confounding and was used to investigate the presence of a causal effect of age at menarche on adult BMI. MR uses genetic variants as instruments under the assumption that they act on BMI only through age at menarche (no pleiotropy). Using a two-sample MR approach, heterogeneity between the MR estimates from individual instruments was used as a proxy for pleiotropy, with sensitivity analyses performed if detected. Genetic instruments and estimates of their association with age at menarche were obtained from a genome-wide association meta-analysis on 182,416 women. The genetic effects on adult BMI were estimated using data on 80,465 women from the UK Biobank. The presence of a causal effect of age at menarche on adult BMI was further investigated using data on 70,692 women from the GIANT Consortium.ResultsThere was evidence of pleiotropy among instruments. Using the UK Biobank data, after removing instruments associated with childhood BMI that were likely exerting pleiotropy, fixed-effect meta-analysis across instruments demonstrated that a 1 year increase in age at menarche reduces adult BMI by 0.38 kg/m2 (95% CI 0.25–0.51 kg/m2). However, evidence of pleiotropy remained. MR-Egger regression did not suggest directional bias, and similar estimates to the fixed-effect meta-analysis were obtained in sensitivity analyses when using a random-effect model, multivariable MR, MR-Egger regression, a weighted median estimator and a weighted mode-based estimator. The direction and significance of the causal effect were replicated using GIANT Consortium data.ConclusionMR provides evidence to support the hypothesis that earlier age at menarche causes higher adult BMI. Complex hormonal and psychological factors may be responsible.

Intra-arterial Treatment for Basilar Artery Occlusion

Intra-arterial Treatment for Basilar Artery Occlusion To the Editor We thank van Houwelingen et al1 for their retrospective study exploring the efficacy and safety of intraarterial (IA) treatment in basilar artery occlusion (BAO). They reported adequate recanalization and favorable outcomes in the cohort receiving IA therapy after BAO. We commend the authors’ stringent diagnostic workup to confirm the presence of BAO. However, we note that the mean age of the patient cohort was younger than 60 years, and given that this age demographic harbors fewer comorbidities compared with the older than 65 age group where stroke incidence is higher, this confers a favorable outcome regardless of the intervention. Furthermore, although some prestroke comorbidities have been accounted for, atrial fibrillation has not been considered. In patients with atrial fibrillation receiving systemic antithrombotic therapy, IA thrombolysis is contraindicated owing to the increased risk for an adverse intracranial hemorrhage,2 thus leaving stenting as the only suitable option. Therefore, the very nature of judgement-based treatment allocation leaves the door open for potential selection bias that may significantly affect outcome measures. Although effort has been taken to categorize patency according to vessel subtype, inclusion of multiple criteria within the same category overlooks the varying pathophysiology underlying reduced patency. For example, no patency of vertebral arteries was defined as either complete occlusion, posterior inferior cerebellar artery termination, aplasia or vessel hypoplasia, or high-grade stenosis of more than 70%. Stenotic vessels are commonly caused by platelet plugs associated with atherosclerotic plaque rupture and are less likely to be successfully managed by IA urokinase alone.2 Alternative methods of stratification may eliminate this bias. This retrospective study1 covers a period of 9 years, a time in which stent retriever technology has considerably evolved. In particular, the Trevo device has been associated with better recanalization rates and fewer complications compared with Merci.3 Given the inconsistencies in the device used and the fact that the Trevo device was used in most cases in this study, there may be an overestimation of benefit derived from this treatment modality as a consistent single device was not used. Restoration of cerebral perfusion alone may be insufficient to produce favorable outcomes4; thus, while initial results from this study are promising, it should prompt prospective trials with a larger patient cohort to evaluate the longterm benefit of IA therapy in acute BAO.

Clinician-directed improvement in the accuracy of hospital clinical coding

ABSTRACT ‘Payment by results’ (PbR) remuneration for healthcare services relies on the accurate conversion of diagnoses into Healthcare Resource Group (HRG) codes that are then reimbursed. Inconsistencies in documentation can result in inaccuracies in this process, with consequent implications for measuring activity, disease incidence and organisational performance. The aim of this study was to determine if clinician involvement increases accuracy in the coding of medical cases. Selected records of medical patients admitted to a London NHS trust between November and December 2016 were reviewed by a coding auditor and a clinician. Any changes to the codes and HRG tariff were noted. In total, 123 cases were considered. Changes in code were made on 68 instances, resulting in an overall increase in remuneration of £39,215; an average of £318 per patient. The primary HRG code was changed in 31 cases which accounted for £28,040 of the increase in tariff. In conclusion, clinician involvement can help with documentation ambiguities, thus improving the accuracy of the coding process in a medical setting. Although such collaborative working offers advantages for both the clinician and the coding team, further work is required to investigate the feasibility of this recommendation on a larger scale.

Development of a web-based tool for undergraduate engagement in medical research; the ProjectPal experience

BackgroundWe report the development and evaluation of a web-based tool designed to facilitate student extra-curricular engagement in medical research through project matching students with academic supervisors.UK based university students were surveyed to explore their perceptions of undergraduate research, barriers and facilitators to current engagement. Following this, an online web-based intervention (www.ProjectPal.org) was developed to support access of students to research projects and supervisors. A pilot intervention was undertaken across a London-based university in January 2013 to February 2016. In March 2016, anonymised data were extracted from the prospective data log for analysis of website engagement and usage. Supervisors were surveyed to evaluate the website and student outputs.ResultsFifty-one students responded to the electronic survey. Twenty-four (47%) reported frustration at a perceived lack of opportunities to carry out extra-curricular academic projects. Major barriers to engaging in undergraduate research reported were difficulties in identifying suitable supervisors (33/51; 65%) and time pressures (36/51; 71%) associated with this. Students reported being opportunistic in their engagement with undergraduate research. Following implementation of the website, 438 students signed up to ProjectPal and the website was accessed 1357 times. Access increased on a yearly basis. Overall, 70 projects were advertised by 35 supervisors. There were 86 applications made by students for these projects. By February 2016, the 70 projects had generated 5 peer-review publications with a further 7 manuscripts under peer-review, 14 national presentations, and 1 national prize.ConclusionThe use of an online platform to promote undergraduate engagement with extra-curricular research appears to facilitate extra-curricular engagement with research. Further work to understand the impact compared to normal opportunistic practices in enhancing student engagement is now underway.