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BackgroundAfter myocardial infarction, fibrosis and an ongoing dysregulated inflammatory response have been shown to lead to adverse cardiac remodeling. FDG PET is an imaging modality sensitive to inflammation as long as suppression protocols are observed while gadolinium enhanced MRI can be used to determine extracellular volume (ECV), a measure of fibrosis. In patients, glucose suppression is achieved variously through a high fat diet, fasting and injection of heparin. To emulate this process in canines, a heparin injection and lipid infusion are used, leading to similar fatty acids in the blood. The aim of this study was to examine the effect of glucose suppression on the uptake of FDG in the infarcted myocardial tissue and also on the determination of ECV in both the infarcted tissue and in the myocardium remote to the zone of infarction during a long constant infusion of FDG and Gd-DTPA.ResultsExtracellular volume was affected neither by suppression nor the length of the constant infusion in remote and infarcted tissue. Metabolic rate of glucose in infarcted tissue decreased during and after suppression of glucose uptake by lipid infusion and heparin injection. An increase in fibrosis and inflammatory cells was found in the center of the infarct as compared to remote tissue.ConclusionThe decrease in the metabolic rate of glucose in the infarcted tissue suggests that inflammatory cells may be affected by glucose suppression through heparin injection and lipid infusion.

Background There is an increased need for prevention and early intervention surrounding young people’s health and well-being. Schools offer a pivotal setting for this with evidence suggesting that focusing on health within schools improves educational attainment. One promising approach is the creation of School Health Research Networks which exist in Wales and Scotland, but are yet to be developed and evaluated in England. Methods This qualitative process evaluation aimed to identify the main barriers and facilitators to implementing a pilot School Health Research Network in the South West of England (SW-SHRN). Semi-structured interviews were conducted with school staff, local authority members, and other key stakeholders. Interview data were analysed using the 7-stage framework analysis approach. Results Four main themes were identified from the data: (1) ‘Key barriers to SW-SHRN’ (competing priorities of academic attainment and well-being, schools feeling overwhelmed with surveys and lack of school time and resource); (2) ‘Key facilitators to SW-SHRN: providing evidence-based support to schools’ (improved knowledge to facilitate change, feedback reports and benchmarking and data to inform interventions); (3) ‘Effective dissemination of findings’ (interpretation and implementation, embedding findings with existing evidence and policy, preferences for an online platform as well personalised communication and the importance of involving young people and families); and (4) ‘Longer-term facilitators: ensuring sustainability’ (keeping schools engaged, the use of repeat surveys to evaluate impact, informing school inspection frameworks and expanding reach of the network). Conclusion This study identifies several barriers to be addressed and facilitators to be enhanced in order to achieve successful implementation of School Health Research Networks in England which include providing a unique offering to schools that is not too burdensome, supporting schools to take meaningful action with their data and to work closely with existing organisations, services and providers to become meaningfully embedded in the system.

BackgroundEcological studies hypothesise a ‘safety in numbers’ (SiN) effect whereby road safety for bicycles and other micromobility users improves as their numbers increase, due to behavioural changes of motorists. Causal interpretation of these studies is difficult due to confounding and reverse causation. The introduction of electric scooter (e-scooter) rental schemes in selected districts in England meant an increase in micromobility users in these areas, which presented an opportunity to test the SiN hypothesis using a natural experiment.MethodsTime-series analysis of police data on road collisions in local authorities (LAs) in Great Britain, 2015–2023. Random-effects Poisson regression time-series models compared collision rates in LA districts with an e-scooter trial (n=41) versus matched control districts (n=41). Primary outcomes were all road collisions and bicycle collisions. Models adjusted for time; seasonality; baseline collision rate; COVID-19 period; and preintervention/postintervention period (proxied by intervention group/COVID-19 period interaction).ResultsThe rate of bicycle collisions reduced following the introduction of the schemes, compared with control districts (incidence rate ratio (IRR) 0.78, 95% CI 0.68 to 0.89 during peak COVID-19; IRR 0.87, 95% CI 0.77 to 0.99 in the post-COVID-19 period). This effect was specific to bicycle collisions and strongest in the subgroup of serious/fatal collisions.ConclusionsFindings suggest that the increase of a new and sustainable mode of transport, e-scooters, may have reduced bicycle collisions. This could have far-reaching benefits including reduced injuries, safer environments, and public health and environmental benefits if more people choose bicycles and micromobility over car transport. Findings should be verified in further work.

Background Children with special educational needs and disabilities (SEND), particularly those from families with low-income, experience inequities across educational and health outcomes. The school holidays are difficult for families with low-income, prompting UK government programmes including the Holiday Activity and Food (HAF) clubs. Little is known about how inclusive these holiday clubs are for children with SEND, despite this being a group who may particularly benefit. This study is embedded within a wider project on the HAF programme to explore the challenges and opportunities for inclusive and accessible holiday club provision and provides recommendations for the HAF Toolkit. Methods Participant experiences were captured using two qualitative methods: 1) interviews with holiday programme delivery staff and parents of attendees (staff n=28, parents n=10); 2) focus group discussions at creative workshops with parents whose children are eligible for the holiday programme but do not attend (n=22). The Framework Method and Reflexive Thematic Analysis were used.  Methods Participant experiences were captured using two qualitative methods: (1) interviews with holiday programme delivery staff and parents of attendees (staff n  = 28, parents n  = 10); (2) focus group discussions at creative workshops with parents whose children are eligible for the holiday programme but do not attend ( n  = 22). The Framework Method and Reflexive Thematic Analysis were used. Results Findings reveal challenges and opportunities around accessing and experiencing the holiday clubs for children with SEND. Access subthemes included: lack of clarity in advertising whether clubs welcome children with SEND; frequent non-disclosure from parents of their child’s needs; accessible transportation; and additional resources needed for SEND provision. Experience subthemes included: food provision for children with SEND; training and staffing that covers the range of needs; and the experiences of children within mainstream provision versus specialist providers of SEND clubs. All participant groups illuminated areas where holiday clubs could be improved to ensure an enjoyable and equitable experience for children with SEND. However, wider debates around ableism and the challenges children with SEND face in society broadly were also illustrated in data. Further, the current economic context and the additional resources needed to support inclusive holiday club provision underpinned much of the data. Opportunities were highlighted such as parent volunteers and external investment, that could maximise the potential of the current government funding. Conclusions Our findings highlight issues in access and experience of holiday clubs for children with SEND and provide potential avenues for promoting inclusivity, including how adaptations to the Toolkit could specifically improve HAF. There are considerable challenges to achieving inclusive holiday clubs (financial or otherwise) but if we are to reduce inequities, addressing these should be a public health priority.

Background Improving the health and well-being of young people is a public health priority. Schools present an ideal setting to implement strategies to improve young people’s health and well-being. A key strategy involves conducting surveys to assess student health needs, inform interventions, and monitor health over time. Conducting research in schools is, however, challenging. Schools can find it difficult to participate and adhere to research processes, even when they are keen to be involved in research, because of competing priorities (e.g., attendance and educational achievement), as well as time and resource constraints. There is a lack of literature on the perspectives of school staff and other key stakeholders working in young people’s health on how best to work with schools to conduct health research, and in particular, health surveys. Methods Participants ( n  = 26) included members of staff from 11 secondary schools (covering students aged 11–16 years), 5 local authority professionals, and 10 wider key stakeholders in young people's health and well-being (e.g., a school governor, a national government member), based in South West England. Participants took part in semi-structured interviews that were conducted either over the phone or via an online platform. Data were analysed using the Framework Method. Results Three main themes were identified: Recruitment and Retention, Practicalities of Data Collection in Schools, and Collaboration from Design to Dissemination. It is important to acknowledge the role of local authorities and academy trusts in the English education system, and work closely with these when conducting school-based health surveys. School staff prefer to be contacted about research via email and in the summer term, following exams. Researchers should contact a member of staff involved in student health/well-being, as well as senior leadership, during recruitment. Data collection during the start and end of the school year is undesirable. Research should be collaborative with school staff and young people, consistent with school priorities and values, and flexible and tailored to school timetables and resources. Conclusions Overall the findings demonstrate that survey-based research methods should be school-led and tailored to each school.

BackgroundImproving the health and well-being of young people is a public health priority. Schools present an ideal setting to implement strategies to improve young people’s health and well-being. Conducting health improvement research in schools is, however, challenging. Schools can find it difficult to participate and adhere to research processes because of competing priorities, as well as time and resource constraints. There is a lack of literature on the perspectives of school staff and other key stakeholders in young people’s health on how best to work with schools to improve health outcomes in young people. This study aimed to explore the perspectives of key stakeholders in young people’s health on how best to work with schools to conduct health research relating to young people. The study aimed to provide key practical and logistical guidance for collaborating with schools and stakeholders for school-based health research.MethodsA total of 26 semi-structured interviews were conducted with school staff (n=11, 80% female), local authority professionals (n=5, 40% female), and key wider stakeholders (n=10, 80% female), based in South West England. Interview data were analysed using the 7-stage Framework Method.ResultsThe three main themes identified from the data were 1) recruitment and retention; 2) practicalities of data collection in schools; and 3) collaboration from design to dissemination. The results showed that research should be collaborative with school staff and young people, consistent with school priorities and values, and flexible and tailored to school timetables and resources.ConclusionOverall the findings demonstrated that researchers must acknowledge the role of local authorities and academy trusts in the English education system, and work closely with these when conducting school-based health research. Research should be school-led and tailored to each school, and researchers should aim to develop a collaborative learning network with schools.

BackgroundSchools offer a valuable setting to promote good health and mental well-being amongst young people. Schools are complex systems and as such systems interventions are needed to improve student health and well-being. Despite an increase in the use of systems-based approaches in public health research, there remain limited examples of applying systems thinking to school health promotion interventions. This study aimed to use a systems perspective to evaluate the South West - School Health Research Network to develop a school systems map for England and to understand how the network could contribute to system-wide change.MethodsThis is a qualitative process evaluation comprising of 26 semi-structured interviews. Interview participants consisted of school staff (n=11), local authority staff (n=5), and wider key stakeholders (n=10), including policy makers, governors, academics, charity leaders and school-based NHS staff. A 7-stage framework approach was used to analyse the interview data.ResultsThree main themes were developed from the framework analysis; 1) Fitting in with the wider landscape (England’s education system as a key challenge for systems based approaches, the need to address changing needs and political interest, the importance of linking in with existing networks, services and intervention providers and reflections on a regional vs. national network); 2) Partnership working (the importance of representation in school, Ofsted: opportunities and challenges and sharing data and practice across systems); 3) Informing policy and allocation of resources (informing policy and guidance and targeted distribution of funding and resource).ConclusionThe findings of this study highlight the vital nature of multi-sector partnership working and intervening and monitoring at multiple levels to improve adolescent health and well-being through a school health research network. The findings also draw attention to the complexity of the current landscape of school health promotion in England and the need to take a systems approach. School health research networks can play a key role in facilitating the needs within the system including collaboration, identifying local need, better targeting of resources, sharing data and best practice across different parts of the system and informing regional and national policy.

Schools play a significant role in promoting health and well-being and the reciprocal links between health and educational attainment are well-evidenced. Despite recognition of the beneficial impact of school-based health improvement programmes, significant barriers to improving health and well-being within schools remain. This study pilots a School Health Research Network in the South West of England (SW-SHRN), a systems-based health intervention bringing together schools, academic health researchers and public health and/or education teams in local authorities to share knowledge and expertise to improve the health and well-being of young people. A maximum of 20 secondary schools will be recruited to the pilot SW-SHRN. All students in Years 8 (age 12–13) and 10 (age 14–15) will be invited to complete a health and well-being questionnaire, generating a cohort of approximately 5000 adolescents. School environment questionnaires will also be completed with each school to build a regional picture of existing school health policies and programmes. Each school will be provided with a report summarising data for their students benchmarked against data for all schools in the network. Quantitative analysis will model associations between health risk behaviours and mental health outcomes and a qualitative process evaluation will explore the feasibility and sustainability of the network. This study will create adolescent health data to help provide schools and local authorities with timely and robust information on the health and well-being of their students and help them to identify areas in which public health interventions may be required. SW-SHRN will also help public health professionals focus their resources in the areas most at need.

SummaryA 7-month-old boy was referred to the Paediatric Gastroenterology Department with protracted diarrhoea, persistent hypo-albuminemia, electrolyte disbalance and failure to thrive. He had presented 2.5 months earlier with abdominal distention, pedal oedema, and generalized pallor. A mature cystic teratoma was found after a CT of the abdomen, followed by surgical resection. The histology was compatible with the above and the ascitic fluid had elements of a transudate. The initial oncologic investigations identified a low IgG serum level, with normal IgA and IgM, as well as low lymphocytes. Urine protein loss was out ruled. An oesophagus-gastro-duodenoscopy showed whitish mucosa in duodenum. Colonoscopy up to transverse colon was normal. The histology showed normal oesophagus. The stomach had vascular ectasia, mild oedema and congestions within the lamina propria. D1 normal. D2 small areas of the lamina propria appeared to be oedematous within the villous structures and a focal area of haemorrhage was noted. There was no obvious evidence of generalised dilated lacteals. The colonic biopsies were normal. He had a mildly raised faecal alfa-1-antitrypsin with normal faecal elastase. The initial management included Total Parental Nutrition and albumin infusions, followed by subcutaneous octreotide and tranexamic acid to reduce the albumin loss. After the patient’s albumin stabilized and gained weight, a low-fat diet with a MCT high-containing formula were started. At discharged the patient still required SC octreotide to keep normal level of serum albumin, which continued to receive for 12 months. After 1 year of treatment, the SC Octreotide was weaned off gradually until discontinued. The patient kept an adequate level of Albumin, his lymphopenia and hypogammaglobulinemia was resolved, and he thrived accordingly. He has been kept on low fat diet with high MCT formula to date. Accidentally, the patient ingested food with LCT (cross contamination) and developed profuse, auto-limited diarrhoea for 5 days without changes in his biochemistry. It was decided that the patient should remain on low fat diet for the foreseeable future.BackgroundProtein loosing enteropathy in children is a rare condition with major repercussions in nutrition and development. In early stages of life, congenital diarrhoea and cow’s milk allergy are the main causes. Coeliac disease and Cystic Fibrosis could also debut with such features. Intestinal lymphangiectasia, primary or secondary, is a rare condition without an established epidemiology to date. There is no predominance of gender or race. The cases reported have been of sporadic origin {1} without an identified genetic aetiology.The mean age of diagnosis is 12 years of age [1]. Primary causes include vascular malformations of childhood [2} and secondary causes follow a long list of pathologies that could result in lymphatic drainage blockage. The resulting ectasia causes dilatation of the lymphatics with loss of lymph leakage into the bowel leading to hypoproteinaemia, oedema, lymphocytopenia, hypogammaglobinaemia – accompanied with immunological abnormalities – as well as micronutrients deficiency including calcium, iron and fat-soluble vitamins, among others {4}The symptoms of Intestinal Lymphangiectasia may include chronic diarrhoea, limb oedema, ascites and pleural effusions. Chylothorax could be a rare presentation {2}.Diagnosis is made through endoscopy and histological findings that confirmed the dilated lymphatics.The management includes dietary modification with high doses of medium-chain triglycerides, total parenteral nutrition, albumin infusions and, in some series, octreotide, tranexamic acid, corticosteroids and surgery have been reported {3}.We report a case of intestinal lymphangiectasia clinically presenting as persistent hypoalbuminemia, protracted diarrhoea and failure to thrive. The endoscopic findings were in keeping with the disease and the management of this case involved the participation of gastroenterologist, immunologist and dietitians.Case reportA 7-month-old boy who was diagnosed with a mature cystic teratoma after presenting acutely ill to his local hospital. His initial complaints were swollen abdomen and feet, pallor and vomiting. Term born via caesarean, he had a hyper-sensitive gag reflex and frequent episodes of vomiting. During his recovery from surgery he developed diarrhoea, up to 10 a day, with persistent hypoalbuminemia that did not improve to albumin infusions and diuretics, as well as electrolyte disturbances that required often supplementation. At admission his weight was static but progressively he started to emaciate.InvestigationsAbstract G1 Table 1Biochemistry and imaging investigations from diagnosis, discharge, and outpatient follow-up. (NB: empty cells are investigations not performed at the time) Parameter At diagnosis On TPN + High MCT formula + low fat diet Octreotide BD +Tranexamic Acid OFF Octreotide Octreotide OD OFFOctreotide LCT accidental ingestion WCC (x10’9/L) 6.0 6.4 3.8 4.7 3.8 4.2 5.6 8.4 Lymphocytes (x10’9/L) 0.75 0.96 0.69 0.98 1.06 1.78 1.84 1.45 Albumin (g/L) 11 17 27 20 13 29 40 42 ALT (IU/L) 68 42 21 23 21 37 35 33 Ionized Calcium (mmol/L) 1.11 1.86 2.31 2.13 2.35 2.35 2.01 2.1 Total IgG <0.40 F. Elastase (ug/g) 248 >500 Alpha-1-Antrypsin (0.00- 0.49 mg/g ) 0.69 CT Abdomen (before surgery) Large predominantly cystic mass lesion in the left abdomen with a prominent fatty component and calcifications within the adjacent mass-effect. Displacement of the surrounding structures namely the spleen superiorly, left kidney posteroinferiorly, stomach and pancreas anteromedially and the bowel loops in the right abdomen. Aorta and its major abdominal branches are also displaced by the lesion. The infrahepatic IVC is stretched and mildly thinned out along the inner aspect of the lesion. Normal liver, gall bladder, and portal flow. No bowel wall thickening seen. CT Abdomen (1 month after surgery) Small bowel and colon appear similar than previous study. There is the suggestion of subtle diffuse bowel wall thickening and the impression of diffuse increased density in the bowel wall. Unremarkable appearance of the mesentery. No lymphadenopathy. The liver demonstrates diffuse lower attenuation than expected. This could reflex oedema, without enlargement. Findings of the bowel are non-specific and could reflect intestinal lymphangiectasia. TreatmentInitially the patient received albumin infusions and diuretics. He remained on breastfeeds and age-appropriate purees. Additionally, he was started on enteral feeds via NG with an extensively hydrolysed formula with MCT that he failed to tolerate (vomiting). After referral to Gastroenterology he was started on total parental nutrition. Initially the lipids were restricted due to the severity of the liver derangement and progressively introduced later when the latter was resolved. However, despite adequate levels of nutrients and resolution of diarrhoea and vomiting his albumin levels remained low requiring albumin infusions. After a multidisciplinary discussion with the Immunology department and Dietitians the patient was started on subcutaneous octreotide looking to lower the lymph flow and losses in the bowel. He was started at a 100µg/kg dose, twice a day. During the initial 3 weeks of treatment the patient still required weekly albumin infusions. Tranexamic acid was later started without satisfactory results 1 week after treatment and therefore it was stopped.Outcome and follow-upAt discharge the patient was reviewed weekly in the Day-case unit with albumin measurements that remained as of discharge between 17 and 20 for 4 weeks. These static changes led to the decision to stop the octreotide. Within 7 days the patient gained 2 kg in average and required an intravenous infusion of albumin as it dropped to 13 with clinically evident oedema. He was also re-commenced on octreotide SC OD only. The following 4 weeks showed progressive normalization of albumin levels building up to 40 when titration of octreotide by 20 mcg/weekly was started. The results of the titration were favourable and the patient kept normal albumin levels, without diarrhoea until complete withdrawal of Octreotide.The patient achieved full growth (weight and height) for his age, adequate neurological development and normalization of all his serological values (immunoglobulins and lymphocytes).Accidentally, the patient ingested food with LCT (cross contamination) and developed profuse, auto-limited diarrhoea for 5 days without changes in his biochemistry. It was decided that the patient should remain on low fat diet for the foreseeable future.DiscussionIntestinal lymphangiectasia still possess a challenging physiopathology to diagnose and treat. Multiple case reports and cohort studies have summarized the diagnostic features of primary and secondary IL reflected in serology and endoscopy {1, 5, 6}.The limitation on large series makes the different treatment modalities more of anecdotical than factual experience. However, adequate response in both the short and long term have been achieved with the use of octreotide. Table 2 summarizes the different studies and doses used (when available).Abstract G1 Table 2Octreotide management in Intestinal Lymphangiectasia (modified from Alshikho, 2016) Author Year Age Gender Indication Outcome Bac DJ et al 1995 38 M Hypoalbuminemia Improvement Kuroiwa G et al. 2001 21 M Hypoalbuminemia Improvement Klingenberg RD et al. 2003 27 F Generalized hydrops May be effective Filik L et al. 2004 25 F Severe oedema and diarrhoea Improvement Makhija S et al. 2004 - - Severe oedema No improvement Balboa A et al. 2004 - - oedema, diarrhoea Improvement Altit G et al. 2012 15 M Hypoalbuminemia Improvement Suehiro K et al. 2012 63 M Oedema, diarrhoea Improvement Al Siani S et al. 2012 Baby - Edema Improvement Prasad et al. 2018 Various M-F Edema Improvement Tranexamic acid was only reported in one pu