The 100 most-cited articles in BMJ Open, 2017

BACKGROUND: The use of telehealth steadily increases as it has become a viable modality to patient care. Early adopters attempt to use telehealth to deliver high-quality care. Patient satisfaction is a key indicator of how well the telemedicine modality met patient expectations. OBJECTIVE: The objective of this systematic review and narrative analysis is to explore the association of telehealth and patient satisfaction in regards to effectiveness and efficiency. METHODS: Boolean expressions between keywords created a complex search string. Variations of this string were used in Cumulative Index of Nursing and Allied Health Literature and MEDLINE. RESULTS: 2193 articles were filtered and assessed for suitability (n=44). Factors relating to effectiveness and efficiency were identified using consensus. The factors listed most often were improved outcomes (20%), preferred modality (10%), ease of use (9%), low cost 8%), improved communication (8%) and decreased travel time (7%), which in total accounted for 61% of occurrences. CONCLUSION: This review identified a variety of factors of…

OBJECTIVE: To describe the average primary care physician consultation length in economically developed and low-income/middle-income countries, and to examine the relationship between consultation length and organisational-level economic, and health outcomes. DESIGN AND OUTCOME MEASURES: This is a systematic review of published and grey literature in English, Chinese, Japanese, Spanish, Portuguese and Russian languages from 1946 to 2016, for articles reporting on primary care physician consultation lengths. Data were extracted and analysed for quality, and linear regression models were constructed to examine the relationship between consultation length and health service outcomes. RESULTS: One hundred and seventy nine studies were identified from 111 publications covering 28 570 712 consultations in 67 countries. Average consultation length differed across the world, ranging from 48 s in Bangladesh to 22.5 min in Sweden. We found that 18 countries representing about 50% of the global population spend 5 min or less with their primary care physicians. We also found significant…

PURPOSE: The National Health Insurance Service-Health Screening Cohort (NHIS-HEALS) is a cohort of participants who participated in health screening programmes provided by the NHIS in the Republic of Korea. The NHIS constructed the NHIS-HEALS cohort database in 2015. The purpose of this cohort is to offer relevant and useful data for health researchers, especially in the field of non-communicable diseases and health risk factors, and policy-maker. PARTICIPANTS: To construct the NHIS-HEALS database, a sample cohort was first selected from the 2002 and 2003 health screening participants, who were aged between 40 and 79 in 2002 and followed up through 2013. This cohort included 514 866 health screening participants who comprised a random selection of 10% of all health screening participants in 2002 and 2003. FINDINGS TO DATE: The age-standardised prevalence of anaemia, diabetes mellitus, hypertension, obesity, hypercholesterolaemia and abnormal urine protein were 9.8%, 8.2%, 35.6%, 2.7%, 14.2% and 2.0%, respectively. The age-standardised mortality rate for the first 2 years (through…

OBJECTIVES: Social prescribing is a way of linking patients in primary care with sources of support within the community to help improve their health and well-being. Social prescribing programmes are being widely promoted and adopted in the UK National Health Service and so we conducted a systematic review to assess the evidence for their effectiveness. SETTING/DATA SOURCES: Nine databases were searched from 2000 to January 2016 for studies conducted in the UK. Relevant reports and guidelines, websites and reference lists of retrieved articles were scanned to identify additional studies. All the searches were restricted to English language only. PARTICIPANTS: Systematic reviews and any published evaluation of programmes where patient referral was made from a primary care setting to a link worker or facilitator of social prescribing were eligible for inclusion. Risk of bias for included studies was undertaken independently by two reviewers and a narrative synthesis was performed. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes of interest were any measures of health and…

OBJECTIVES: To summarise logistical aspects of recently completed systematic reviews that were registered in the International Prospective Register of Systematic Reviews (PROSPERO) registry to quantify the time and resources required to complete such projects. DESIGN: Meta-analysis. DATA SOURCES AND STUDY SELECTION: All of the 195 registered and completed reviews (status from the PROSPERO registry) with associated publications at the time of our search (1 July 2014). DATA EXTRACTION: All authors extracted data using registry entries and publication information related to the data sources used, the number of initially retrieved citations, the final number of included studies, the time between registration date to publication date and number of authors involved for completion of each publication. Information related to funding and geographical location was also recorded when reported. RESULTS: The mean estimated time to complete the project and publish the review was 67.3 weeks (IQR=42). The number of studies found in the literature searches ranged from 27 to 92 020; the mean yield…

OBJECTIVES: Detection of dementia is essential for improving the lives of patients but the extent of underdetection worldwide and its causes are not known. This study aimed to quantify the prevalence of undetected dementia and to examine its correlates. METHODS/SETTING/PARTICIPANTS: A systematic search was conducted until October 2016 for studies reporting the proportion of undetected dementia and/or its determinants in either the community or in residential care settings worldwide. Random-effects models calculated the pooled rate of undetected dementia and subgroup analyses were conducted to identify determinants of the variation. PRIMARY AND SECONDARY OUTCOME MEASURES: The outcome measures of interest were the prevalence and determinants of undetected dementia. RESULTS: 23 studies were eligible for inclusion in this review. The pooled rate of undetected dementia was 61.7% (95% CI 55.0% to 68.0%). The rate of underdetection was higher in China and India (vs Europe and North America), in the community setting (vs residential/nursing care), age of <70 years, male gender and diagnosis…

OBJECTIVES: Designing studies with an internal pilot phase may optimise the use of pilot work to inform more efficient randomised controlled trials (RCTs). Careful selection of preagreed decision or 'progression' criteria at the juncture between the internal pilot and main trial phases provides a valuable opportunity to evaluate the likely success of the main trial and optimise its design or, if necessary, to make the decision not to proceed with the main trial. Guidance on the appropriate selection and application of progression criteria is, however, lacking. This paper outlines the key issues to consider in the optimal development and review of operational progression criteria for RCTs with an internal pilot phase. DESIGN: A structured literature review and exploration of stakeholders' opinions at a Medical Research Council (MRC) Hubs for Trials Methodology Research workshop. Key stakeholders included triallists, methodologists, statisticians and funders. RESULTS: There is considerable variation in the use of progression criteria for RCTs with an internal pilot phase, although 3…

BACKGROUND: Substantial amounts of public funds are invested in health research worldwide. Publicly funded randomised controlled trials (RCTs) often recruit participants at a slower than anticipated rate. Many trials fail to reach their planned sample size within the envisaged trial timescale and trial funding envelope. OBJECTIVES: To review the consent, recruitment and retention rates for single and multicentre randomised control trials funded and published by the UK's National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme. DATA SOURCES AND STUDY SELECTION: HTA reports of individually randomised single or multicentre RCTs published from the start of 2004 to the end of April 2016 were reviewed. DATA EXTRACTION: Information was extracted, relating to the trial characteristics, sample size, recruitment and retention by two independent reviewers. MAIN OUTCOME MEASURES: Target sample size and whether it was achieved; recruitment rates (number of participants recruited per centre per month) and retention rates (randomised participants retained and…

OBJECTIVE: To provide an overview of non-pharmacological interventions for behavioural and psychological symptoms in dementia (BPSD). DESIGN: Systematic overview of reviews. DATA SOURCES: PubMed, EMBASE, Cochrane Database of Systematic Reviews, CINAHL and PsycINFO (2009-March 2015). ELIGIBILITY CRITERIA: Systematic reviews (SRs) that included at least one comparative study evaluating any non-pharmacological intervention, to treat BPSD. DATA EXTRACTION: Eligible studies were selected and data extracted independently by 2 reviewers.The AMSTAR checklist was used to assess the quality of the SRs. DATA ANALYSIS: Extracted data were synthesised using a narrative approach. RESULTS: 38 SRs and 129 primary studies were identified, comprising the following categories of non-pharmacological interventions: (1) sensory stimulation interventions (25 SRs, 66 primary studies) that encompassed: shiatsu and acupressure, aromatherapy, massage/touch therapy, light therapy, sensory garden and horticultural activities, music/dance therapy, dance therapy, snoezelen multisensory stimulation therapy,…

Design and objectives Every organisation has a unique culture. There is a widely held view that a positive organisational culture is related to positive patient outcomes. Following the Preferred Reporting Items for Systematic Review and Meta-Analyses statement, we systematically reviewed and synthesised the evidence on the extent to which organisational and workplace cultures are associated with patient outcomes. Setting A variety of healthcare facilities, including hospitals, general practices, pharmacies, military hospitals, aged care facilities, mental health and other healthcare contexts. Participants The articles included were heterogeneous in terms of participants. This was expected as we allowed scope for wide-ranging health contexts to be included in the review. Primary and secondary outcome measures Patient outcomes, inclusive of specific outcomes such as pain level, as well as broader outcomes such as patient experience. Results The search strategy identified 2049 relevant articles. A review of abstracts using the inclusion criteria yielded 204 articles eligible for…

OBJECTIVES: This study reviews the current state of the published peer-reviewed literature related to physician burnout and two quality of care dimensions. The purpose of this systematic literature review is to address the question, 'How does physician burnout affect the quality of healthcare related to the dimensions of acceptability and safety?' DESIGN: . SETTING: Physicians practicing in civilian settings. PARTICIPANTS: Practicing physicians who have completed training. PRIMARY AND SECONDARY OUTCOME MEASURES: Quality of healthcare related to acceptability (ie, patient satisfaction, physician communication and physician attitudes) and safety (ie, minimising risks or harm to patients). RESULTS: 4114 unique citations were identified. Of these, 12 articles were included in the review. Two studies were rated as having high risk of bias and 10 as having moderate risk. Four studies were conducted in North America, four in Europe, one in the Middle East and three in East Asia. Results of this systematic literature review suggest there is moderate evidence that burnout is associated with…

Objectives Depression and depressive symptoms are common mental disorders that have a considerable effect on patients’ health-related quality of life and satisfaction with medical care, but the prevalence of these conditions varies substantially between published studies. The aim of this study is to conduct a systematic review and meta-analysis to provide a precise estimate of the prevalence of depression or depressive symptoms among outpatients in different clinical specialties. Design Systematic review and meta-analysis. Data sources and eligibility criteria The PubMed and PsycINFO, EMBASE and Cochrane Library databases were searched to identify observational studies that contained information on the prevalence of depression and depressive symptoms in outpatients. All studies included were published before January 2016. Data characteristics were extracted independently by two investigators. The point prevalence of depression or depressive symptoms was measured using validated self-report questionnaires or structured interviews. Assessments were pooled using a random-effects model.…

OBJECTIVE: Recent clinical studies have shown that anticoagulant therapy might be effective only in specific at-risk subgroups of patients with sepsis and coagulation dysfunction. The definition of sepsis was recently modified, and as such, old scoring systems may no longer be appropriate for the diagnosis of sepsis-associated coagulopathy. The aim of this study was to evaluate prognostic factors in patients diagnosed with sepsis and coagulopathy according to the new sepsis definition and assess their accuracy in comparison with existing models. DESIGN: Retrospective analysis of the nationwide survey for recombinant human soluble thrombomodulin. SETTING: General emergency and critical care centres in secondary and tertiary care hospitals. PARTICIPANTS: We evaluated the prognostic value of the newly proposed diagnostic criteria for sepsis-induced coagulopathy (SIC). A total of 1498 Japanese patients with sepsis and coagulopathy complications who were treated with recombinant thrombomodulin were analysed in this study. MAIN OUTCOME MEASURES: The platelet count, prothrombin time (PT)…

OBJECTIVES: Locally led health research in low and middle income countries (LMICs) is critical for overcoming global health challenges. Yet, despite over 25 years of international efforts, health research capacity in LMICs remains insufficient and development attempts continue to be fragmented. The aim of this systematic review is to identify and critically examine the main approaches and trends in health research capacity development and consolidate key thinking to identify a more coherent approach. METHODS: This review includes academic and grey literature published between January 2000 and July 2013. Using a predetermined search strategy, we systematically searched PubMed, hand-searched Google Scholar and checked reference lists. This process yielded 1668 papers. 240 papers were selected based on a priori criteria. A modified version of meta-narrative synthesis was used to analyse the papers. RESULTS: 3 key narratives were identified: the effect of power relations on capacity development; demand for stronger links between research, policy and practice and the importance of a…

OBJECTIVES: Antenatal care (ANC) is an essential part of primary healthcare and its provision has expanded worldwide. There is limited evidence of large-scale cross-country studies on the impact of ANC offered to pregnant women on child health outcomes. We investigate the association of ANC in low-income and middle-income countries with short- and long-term mortality and nutritional child outcomes. SETTING: We used nationally representative health and welfare data from 193 Demographic and Health Surveys conducted between 1990 and 2013 from 69 low-income and middle-income countries for women of reproductive age (15-49 years), their children and their respective household. PARTICIPANTS: The analytical sample consisted of 752 635 observations for neonatal mortality, 574 675 observations for infant mortality, 400 426 observations for low birth weight, 501 484 observations for stunting and 512 424 observations for underweight. MAIN OUTCOMES AND MEASURES: Outcome variables are neonatal and infant mortality, low birth weight, stunting and underweight. RESULTS: At least one ANC visit was…

OBJECTIVES: To estimate the prevalence of and associations between anxiety, depression, post-traumatic stress disorder (PTSD), low subjective well-being (SWB), potential traumas and postmigration stress among refugees from Syria resettled in Sweden. DESIGN: A cross-sectional and population-based questionnaire study based on a known and complete sample frame. The survey included multiple measures of mental ill health and factors of particular relevance for refugees. Weighted analyses were conducted to calculate representative prevalence rates and associations. Associations were investigated through a series of logistic regression analyses. All analyses were supplemented with robust 95% CIs. SETTING: Sweden. PARTICIPANTS: A random sample of 1215 individuals (response rate 30.4%) from Syria aged 18-64 years that were granted residency in Sweden on grounds of asylum between 2011 and 2013. MAIN OUTCOME MEASURES: Anxiety, depression, PTSD and low SWB were assessed through Hopkins Symptom Checklist, Harvard Trauma Questionnaire and WHO-5 Well-being Index, using established cut-offs.…

OBJECTIVES: Heterozygous familial hypercholesterolaemia (FH) confers a significant risk for premature cardiovascular disease (CVD). However, the estimated prevalence of FH varies substantially among studies. We aimed to provide a summary estimate of FH prevalence in the general population and assess variations in frequency across different sociodemographic characteristics. SETTING, PARTICIPANTS AND OUTCOME MEASURES: We searched MEDLINE, EMBASE, Global Health, the Cochrane Library, PsycINFO and PubMed for peer-reviewed literature using validated strategies. Results were limited to studies published in English between January 1990 and January 2017. Studies were eligible if they determined FH prevalence using clinical criteria or DNA-based analyses. We determined a pooled point prevalence of FH in adults and children and assessed the variation of the pooled frequency by age, sex, geographical location, diagnostic method, study quality and year of publication. Estimates were pooled using random-effects meta-analysis. Differences by study-level characteristics were investigated through…

OBJECTIVES: Implementation studies are often poorly reported and indexed, reducing their potential to inform the provision of healthcare services. The Standards for Reporting Implementation Studies (StaRI) initiative aims to develop guidelines for transparent and accurate reporting of implementation studies. METHODS: An international working group developed the StaRI guideline informed by a systematic literature review and e-Delphi prioritisation exercise. Following a face-to-face meeting, the checklist was developed iteratively by email discussion and critical review by international experts. RESULTS: The 27 items of the checklist are applicable to the broad range of study designs employed in implementation science. A key concept is the dual strands, represented as 2 columns in the checklist, describing, on the one hand, the implementation strategy and, on the other, the clinical, healthcare or public health intervention being implemented. This explanation and elaboration document details each of the items, explains the rationale and provides examples of good reporting practice.…

OBJECTIVE: To investigate the relationship between job satisfaction, work stress, work-family conflict and turnover intention, and explore factors associated with turnover intention, among physicians in Guangdong Province, China. METHODS: From August to October 2013, physicians completed questionnaires and scales with regard to their job satisfaction, work stress, work-family conflict, and turnover intention. Binary logistic regression and structural equation modelling (SEM) were used in data analysis. RESULTS: A total of 3963 physicians were approached, with 3563 completing the questionnaire. The mean score of the overall perception of turnover intention of physicians who worked in Guangdong was 2.71 on a scale ranging from 1 to 6. Hours worked per week, working in an urban/rural area, type of institution, and age significantly impacted on turnover intention. Turnover intention was directly and negatively related to job satisfaction, and it was directly, indirectly and positively related to work stress and work-family conflict. CONCLUSION: Job satisfaction, work stress, work-family…

OBJECTIVE: To investigate associations between adverse childhood experiences (ACEs) and later-life depressive symptoms; and to explore whether perceived social support (PSS) moderates these. METHOD: We analysed baseline data from the Mitchelstown (Ireland) 2010-2011 cohort of 2047 men and women aged 50-69 years. Self-reported measures included ACEs (Centre for Disease Control ACE questionnaire), PSS (Oslo Social Support Scale) and depressive symptoms (CES-D). The primary exposure was self-report of at least one ACE. We also investigated the effects of ACE exposure by ACE scores and ACE subtypes abuse, neglect and household dysfunction. Associations between each of these exposures and depressive symptoms were estimated using logistic regression, adjusted for socio-demographic factors. We tested whether the estimated associations varied across levels of PSS (poor, moderate and strong). RESULTS: 23.7% of participants reported at least one ACE (95% CI 21.9% to 25.6%). ACE exposures (overall, subtype or ACE scores) were associated with a higher odds of depressive symptoms, but only among…

Physical activity (PA), including engagement in structured exercise, has a key role in the management of hip and knee osteoarthritis (OA). However, maintaining a physically active lifestyle is a challenge for people with OA. PA determinants in this population need to be understood better so that they can be optimised by public health or healthcare interventions and social policy changes. OBJECTIVES: The primary aim of this study is to conduct a systematic review of the existing qualitative evidence on barriers and facilitators of PA for patients with hip or knee OA. Secondary objective is to explore differences in barriers and facilitators between (1) lifestyle PA and exercise and (2) PA uptake and maintenance. METHODS: Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus, Scopus, Grey literature and qualitative journals were searched. Critical Appraisal Skills Programme-Qualitative checklist and Lincoln and Guba's criteria were used for quality appraisal. Thematic synthesis was applied. FINDINGS: Ten studies were included, seven…

INTRODUCTION: Proximity and access to water have long been central to human culture and accordingly deliver countless societal benefits. Over 200 million people live on Europe's coastline, and aquatic environments are the top recreational destination in the region. In terms of public health, interactions with 'blue space' (eg, coasts, rivers, lakes) are often considered solely in terms of risk (eg, drowning, microbial pollution). Exposure to blue space can, however, promote health and well-being and prevent disease, although underlying mechanisms are poorly understood. AIMS AND METHODS: The BlueHealth project aims to understand the relationships between exposure to blue space and health and well-being, to map and quantify the public health impacts of changes to both natural blue spaces and associated urban infrastructure in Europe, and to provide evidence-based information to policymakers on how to maximise health benefits associated with interventions in and around aquatic environments. To achieve these aims, an evidence base will be created through systematic reviews, analyses of…

OBJECTIVES: The objective of this review is to explore interactions between physicians and the pharmaceutical industry including sales representatives and their impact on physicians' attitude and prescribing habits. DATA SOURCES: PubMed, Embase, Cochrane Library and Google scholar electronic databases were searched from 1992 to August 2016 using free-text words and medical subject headings relevant to the topic. STUDY SELECTION: Studies included cross-sectional studies, cohort studies, randomised trials and survey designs. Studies with narrative reviews, case reports, opinion polls and letters to the editor were excluded from data synthesis. DATA EXTRACTION: Two reviewers independently extracted the data. Data on study design, study year, country, participant characteristics, setting and number of participants were collected. DATA SYNTHESIS: Pharmaceutical industry and pharmaceutical sales representative (PSR) interactions influence physicians' attitudes and their prescribing behaviour and increase the number of formulary addition requests for the company's drug. CONCLUSION:…

OBJECTIVE: The increasingly high levels of overweight and obesity among the workforce are accompanied by a hidden cost burden due to losses in productivity. This study reviews the extent of indirect cost of overweight and obesity. METHODS: A systematic search was conducted in eight electronic databases (PubMed, Cochrane Library, Web of Science Core Collection, PsychInfo, Cinahl, EconLit and ClinicalTrial.gov). Additional studies were added from reference lists of original studies and reviews. Studies were eligible if they were published between January 2000 and June 2017 and included monetary estimates of indirect costs of overweight and obesity. The authors reviewed studies independently and assessed their quality. RESULTS: Of the 3626 search results, 50 studies met the inclusion criteria. A narrative synthesis of the reviewed studies revealed substantial costs due to lost productivity among workers with obesity. Especially absenteeism and presenteeism contribute to high indirect costs. However, the methodologies and results vary greatly, especially regarding the cost of…

BACKGROUND: Many adolescent girls in low-income and middle-income countries lack appropriate facilities and support in school to manage menstruation. Little research has been conducted on how menstruation affects school absence. This study examines the association of menstrual hygiene management knowledge, facilities and practice with absence from school during menstruation among Bangladeshi schoolgirls. METHODS: We conducted a nationally representative, cross-sectional study in Bangladeshi schools from March to June 2013 among girls 11 to 17 years old who reached menarche. We sampled 700 schools from 50 urban and 50 rural clusters using a probability proportional to size technique. We interviewed 2332 schoolgirls and conducted spot checks in each school for menstrual hygiene facilities. To assess factors associated with reported school absence, we estimated adjusted prevalence difference (APD) for controlling confounders' effect using generalised estimating equations to account for school-level clustering. RESULTS: Among schoolgirls who reached menarche, 41% (931) reported missing…

PURPOSE: Ethnic minority groups usually have a more unfavourable disease risk profile than the host population. In Europe, ethnic inequalities in health have been observed in relatively small studies, with limited possibilities to explore underlying causes. The aim of the Healthy Life in an Urban Setting (HELIUS) study is to investigate the causes of (the unequal burden of) diseases across ethnic groups, focusing on three disease categories: cardiovascular diseases, mental health and infectious diseases. PARTICIPANTS: The HELIUS study is a prospective cohort study among six large ethnic groups living in Amsterdam, the Netherlands. Between 2011 and 2015, a total 24 789 participants (aged 18-70 years) were included at baseline. Similar-sized samples of individuals of Dutch, African Surinamese, South-Asian Surinamese, Ghanaian, Turkish and Moroccan origin were included. Participants filled in an extensive questionnaire and underwent a physical examination that included the collection of biological samples (biobank). FINDINGS TO DATE: Data on physical, behavioural, psychosocial and…

Objective To evaluate ‘days at home up to 30 days after surgery’ (DAH 30 ) as a patient-centred outcome measure. Design Prospective cohort study. Data source Using clinical trial data (seven trials, 2109 patients) we calculated DAH 30 from length of stay, readmission, discharge destination and death up to 30 days after surgery. Main outcome The association between DAH 30 and serious complications after surgery. Results One or more complications occurred in 263 of 1846 (14.2%) patients, including 19 (1.0%) deaths within 30 days of surgery; 245 (11.6%) patients were discharged to a rehabilitation facility and 150 (7.1%) were readmitted to hospital within 30 days of surgery. The median DAH 30 was significantly less in older patients (p<0.001), those with poorer physical functioning (p<0.001) and in those undergoing longer operations (p<0.001). Patients with serious complications had less days at home than patients without serious complications (20.5 (95% CI 19.1 to 21.9) vs 23.9 (95% CI 23.8 to 23.9) p<0.001), and had higher rates of readmission (16.0% vs 5.9%; p<0.001). After…

OBJECTIVES: Assess the longitudinal association between polypharmacy and falls and examine the differences in this association by different thresholds for polypharmacy definitions in a nationally representative sample of adults aged over 60 years from England. DESIGN: Longitudinal cohort study. SETTING: The English Longitudinal Study of Ageing waves 6 and 7. PARTICIPANTS: 5213 adults aged 60 or older. MAIN OUTCOME MEASURES: Rates, incidence rate ratio (IRR) and 95% CI for falls in people with and without polypharmacy. RESULTS: A total of 5213 participants contributed 10 502 person-years of follow-up, with a median follow-up of 2.02 years (IQR 1.9-2.1 years). Of the 1611 participants with polypharmacy, 569 reported at least one fall within the past 2 years (rate: 175 per 1000 person-years, 95% CI 161 to 190), and of the 3602 participants without polypharmacy 875 reported at least one fall (rate: 121 per 1000 person-years, 95% CI 113 to 129). The rate of falls was 21% higher in people with polypharmacy compared with people without polypharmacy (adjusted IRR 1.21, 95% CI 1.11 to 1.31).…

OBJECTIVES: To thematically synthesise primary qualitative studies that explore challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers in high-income countries. DESIGN: Systematic review and qualitative thematic synthesis. METHODS: Searches of MEDLINE, EMBASE, PsycINFO, CINAHL and Web of Science. Search terms were combined for qualitative research, primary healthcare professionals, refugees and asylum seekers, and were supplemented by searches of reference lists and citations. Study selection was conducted by two researchers using prespecified selection criteria. Data extraction and quality assessment using the Critical Appraisal Skills Programme tool was conducted by the first author. A thematic synthesis was undertaken to develop descriptive themes and analytical constructs. RESULTS: Twenty-six articles reporting on 21 studies and involving 357 participants were included. Eleven descriptive themes were interpreted, embedded within three analytical constructs: healthcare encounter (trusting relationship, communication,…

OBJECTIVE: To examine the relationship between glycated haemoglobin A1c (HbA1c) levels and the risk of cardiovascular outcomes and all-cause mortality based on data from observational studies and to determine the optimal levels of HbA1c for preventing cardiovascular events and/or mortality in diabetic and non-diabetic populations. REVIEW METHODS: We systematically searched Medline, Embase, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews and Web of Science databases, from inception to July 2016, for observational studies addressing the association of HbA1c levels with mortality and cardiovascular outcomes. Random effects models were used to compute pooled estimates of HR and respective 95% CI for all-cause mortality, cardiovascular mortality and risk of cardiovascular events, separately for people with and without diabetes. RESULTS: Seventy-four published studies were included in the systematic review, but only 46 studies could be incorporated in the meta-analysis. In both diabetic and non-diabetic populations, there was an increase in…

OBJECTIVES: To summarise incidence and prevalence of diabetic ketoacidosis (DKA) in adults with type 1 diabetes (T1D) for the overall patient population and different subgroups (age, sex, geographical region, ethnicity and type of insulin administration). DESIGN: Systematic literature review (SLR). DATA SOURCES: Medline (via PubMed) and Embase (1 January 2000 to 23 June 2016). STUDY SELECTION: Peer-reviewed observational studies with reported data on the incidence or prevalence of DKA in T1D adults were included. A single reviewer completed the study screening and selection process and a second reviewer performed an additional screening of approximately 20% of the publications; two reviewers independently conducted the quality assessment; the results were narratively synthesised. RESULTS: Out of 1082 articles, 19 met the inclusion and exclusion criteria, with two additional studies identified that did not specify the patient age range and are therefore not included in the SLR. Overall, eight studies reported incidence with a range of 0-56 per 1000 person-years (PYs), with one…

OBJECTIVES: To investigate mortality and its causes in adults over the age of 20 years with intellectual disability (ID). DESIGN, SETTING AND PARTICIPANTS: Retrospective population-based standardised mortality of the ID and Comparison cohorts. The ID cohort comprised 42 204 individuals who registered for disability services with ID as a primary or secondary diagnosis from 2005 to 2011 in New South Wales (NSW). The Comparison cohort was obtained from published deaths in NSW from the Australian Bureau of Statistics (ABS) from 2005 to 2011. MAIN OUTCOME MEASURES: We measured and compared Age Standardised Mortality Rate (ASMR), Comparative Mortality Figure (CMF), years of productive life lost (YPLL) and proportion of deaths with potentially avoidable causes in an ID cohort with an NSW general population cohort. RESULTS: There were 19 362 adults in the ID cohort which experienced 732 (4%) deaths at a median age of 54 years. Age Standardised Mortality Rates increased with age for both cohorts. Overall comparative mortality figure was 1.3, but was substantially higher for the 20-44 (4.0)…

OBJECTIVES: Over two million people in the UK are living with and beyond cancer. A third report diminished quality of life. DESIGN: A review of published systematic reviews to identify effective non-pharmacological interventions to improve the quality of life of cancer survivors. DATA SOURCES: Databases searched until May 2017 included PubMed, Cochrane Central, EMBASE, MEDLINE, Web of Science, the Cumulative Index to Nursing and Allied Health Literature, and PsycINFO. STUDY SELECTION: Published systematic reviews of randomised trials of non-pharmacological interventions for people living with and beyond cancer were included; included reviews targeted patients aged over 18. All participants had already received a cancer diagnosis. Interventions located in any healthcare setting, home or online were included. Reviews of alternative therapies or those non-English reports were excluded. Two researchers independently assessed titles, abstracts and the full text of papers, and independently extracted the data. OUTCOMES: The primary outcome of interest was any measure of global (overall)…

OBJECTIVES: To describe the experiences of patients with long-term conditions who are referred to and engage with a Link Worker social prescribing programme and identify the impact of the Link Worker programme on health and well-being. DESIGN: Qualitative study using semistructured interviews with thematic analysis of the data. INTERVENTION: Link Worker social prescribing programme comprising personalised support to identify meaningful health and wellness goals, ongoing support to achieve agreed objectives and linkage into appropriate community services. SETTING: Inner-city area in West Newcastle upon Tyne, UK (population n=132 000) ranked 40th most socioeconomically deprived in England, served by 17 general practices. PARTICIPANTS: Thirty adults with long-term conditions, 14 female, 16 male aged 40-74 years, mean age 62 years, 24 white British, 1 white Irish, 5 from black and minority ethnic communities. RESULTS: Most participants experienced multimorbidity combined with mental health problems, low self-confidence and social isolation. All were adversely affected physically,…

OBJECTIVE: Proton pump inhibitors (PPIs) are widely used, and their use is associated with increased risk of adverse events. However, whether PPI use is associated with excess risk of death is unknown. We aimed to examine the association between PPI use and risk of all-cause mortality. DESIGN: Longitudinal observational cohort study. SETTING: US Department of Veterans Affairs. PARTICIPANTS: Primary cohort of new users of PPI or histamine H2 receptor antagonists (H2 blockers) (n=349 312); additional cohorts included PPI versus no PPI (n=3 288 092) and PPI versus no PPI and no H2 blockers (n=2 887 030). MAIN OUTCOME MEASURES: Risk of death. RESULTS: Over a median follow-up of 5.71 years (IQR 5.11-6.37), PPI use was associated with increased risk of death compared with H2 blockers use (HR 1.25, CI 1.23 to 1.28). Risk of death associated with PPI use was higher in analyses adjusted for high-dimensional propensity score (HR 1.16, CI 1.13 to 1.18), in two-stage residual inclusion estimation (HR 1.21, CI 1.16 to 1.26) and in 1:1 time-dependent propensity score-matched cohort (HR 1.34, CI…

OBJECTIVE: . DESIGN: The electronic health record system at Cleveland Clinic was used to create a cross-sectional summary of actively managed patients meeting minimum primary care physician visit frequency requirements. Eligible patients were stratified by BMI categories, based on most recent weight and median of all recorded heights obtained on or before the index date of 1July 2015. Relationships between patient characteristics and BMI categories were tested. SETTING: A large US integrated health system. RESULTS: A total of 324 199 active patients with a recorded BMI were identified. There were 121 287 (37.4%) patients found to be overweight (BMI ≥25 and <29.9), 75 199 (23.2%) had BMI 30-34.9, 34 152 (10.5%) had BMI 35-39.9 and 25 137 (7.8%) had BMI ≥40. There was a higher prevalence of type 2 diabetes, pre-diabetes, hypertension and cardiovascular disease (P value<0.0001) within higher BMI compared with lower BMI categories. In patients with a BMI >30 (n=134 488), only 48% (64 056) had documentation of an obesity ICD-9 code. In those patients with a BMI >40, only 75% had an…

OBJECTIVE: To understand how prepared UK medical graduates are for practice and the effectiveness of workplace transition interventions. DESIGN: A rapid review of the literature (registration #CRD42013005305). DATA SOURCES: Nine major databases (and key websites) were searched in two timeframes (July-September 2013; updated May-June 2014): CINAHL, Embase, Educational Resources Information Centre, Health Management Information Consortium, MEDLINE, MEDLINE in Process, PsycINFO, Scopus and Web of Knowledge. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Primary research or studies reporting UK medical graduates' preparedness between 2009 and 2014: manuscripts in English; all study types; participants who are final-year medical students, medical graduates, clinical educators, patients or NHS employers and all outcome measures. DATA EXTRACTION: At time 1, three researchers screened manuscripts (for duplicates, exclusion/inclusion criteria and quality). Remaining 81 manuscripts were coded. At time 2, one researcher repeated the process for 2013-2014 (adding six manuscripts). Data were…

OBJECTIVES: To summarise the evidence for generic prognostic factors across a range of musculoskeletal (MSK) conditions. SETTING: primary care. METHODS AND OUTCOMES: Comprehensive systematic literature review. MEDLINE, CINAHL, PsychINFO and EMBASE were searched for prospective cohort studies, based in primary care (search period-inception to December 2015). Studies were included if they reported on adults consulting with MSK conditions and provided data on associations between baseline characteristics (prognostic factors) and outcome. A prognostic factor was identified as generic when significantly associated with any outcome for 2 or more different MSK conditions. Evidence synthesis focused on consistency of findings and study quality. RESULTS: 14 682 citations were identified and 78 studies were included (involving more than 48 000 participants with 18 different outcome domains). 51 studies were on spinal pain/back pain/low back pain, 12 on neck/shoulder/arm pain, 3 on knee pain, 3 on hip pain and 9 on multisite pain/widespread pain. Total quality scores ranged from 5 to 14 (mean…

OBJECTIVES: Rates of youth suicide in Australian Indigenous communities are 4 times the national youth average and demand innovative interventions. Historical and persistent disadvantage is coupled with multiple barriers to help seeking. Mobile phone applications offer the opportunity to deliver therapeutic interventions directly to individuals in remote communities. The pilot study aimed to evaluate the effectiveness of a self-help mobile app (ibobbly) targeting suicidal ideation, depression, psychological distress and impulsivity among Indigenous youth in remote Australia. SETTING: Remote and very remote communities in the Kimberley region of North Western Australia. PARTICIPANTS: Indigenous Australians aged 18-35 years. INTERVENTIONS: 61 participants were recruited and randomised to receive either an app (ibobbly) which delivered acceptance-based therapy over 6 weeks or were waitlisted for 6 weeks and then received the app for the following 6 weeks. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the Depressive Symptom Inventory-Suicidality Subscale (DSI-SS) to…

OBJECTIVE: To obtain evidence whether the online pulmonary rehabilitation(PR) programme 'my-PR' is non-inferior to a conventional face-to-face PR in improving physical performance and symptom scores in patients with COPD. DESIGN: A two-arm parallel single-blind, randomised controlled trial. SETTING: The online arm carried out pulmonary rehabilitation in their own homes and the face to face arm in a local rehabilitation facility. PARTICIPANTS: 90 patients with a diagnosis of chronic obstructive pulmonary disease (COPD), modified Medical Research Council score of 2 or greater referred for pulmonary rehabilitation (PR), randomised in a 2:1 ratio to online (n=64) or face-to-face PR (n=26). Participants unable to use an internet-enabled device at home were excluded. MAIN OUTCOME MEASURES: Coprimary outcomes were 6 min walk distance test and the COPD assessment test (CAT) score at completion of the programme. INTERVENTIONS: A 6-week PR programme organised either as group sessions in a local rehabilitation facility, or online PR via log in and access to 'myPR'. RESULTS: The adjusted mean…

OBJECTIVE: To evaluate the clinical efficacy and effectiveness of using 3D printing to develop medical devices across all medical fields. DESIGN: Systematic review compliant with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. DATA SOURCES: PubMed, Web of Science, OVID, IEEE Xplore and Google Scholar. METHODS: A double-blinded review method was used to select all abstracts up to January 2017 that reported on clinical trials of a three-dimensional (3D)-printed medical device. The studies were ranked according to their level of evidence, divided into medical fields based on the International Classification of Diseases chapter divisions and categorised into whether they were used for preoperative planning, aiding surgery or therapy. The Downs and Black Quality Index critical appraisal tool was used to assess the quality of reporting, external validity, risk of bias, risk of confounding and power of each study. RESULTS: Of the 3084 abstracts screened, 350 studies met the inclusion criteria. Oral and maxillofacial surgery contained 58.3% of studies, and 23.7% covered…

OBJECTIVES: Compare the safety of antiepileptic drugs (AEDs) on neurodevelopment of infants/children exposed in utero or during breast feeding. DESIGN AND SETTING: Systematic review and Bayesian random-effects network meta-analysis (NMA). MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched until 27 April 2017. Screening, data abstraction and quality appraisal were completed in duplicate by independent reviewers. PARTICIPANTS: 29 cohort studies including 5100 infants/children. INTERVENTIONS: Monotherapy and polytherapy AEDs including first-generation (carbamazepine, clobazam, clonazepam, ethosuximide, phenobarbital, phenytoin, primidone, valproate) and newer-generation (gabapentin, lamotrigine, levetiracetam, oxcarbazepine, topiramate, vigabatrin) AEDs. Epileptic women who did not receive AEDs during pregnancy or breast feeding served as the control group. PRIMARY AND SECONDARY OUTCOME MEASURES: Cognitive developmental delay and autism/dyspraxia were primary outcomes. Attention-deficit hyperactivity disorder, language delay, neonatal seizures,…

INTRODUCTION: Social isolation and loneliness affect approximately one-third to one-half of the elderly population and have a negative impact on their physical and mental health. Group-based interventions where facilitators are well trained and where the elderly are actively engaged in their development seem to be more effective, but conclusions have been limited by weak study designs. We aim to conduct a systematic review to assess the effectiveness of health promotion interventions on social isolation or loneliness in older people. METHODS AND ANALYSIS: A systematic review was conducted in Medline, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Applied Social Sciences Index and Abstracts, LILACS, OpenGrey and the Cochrane Library on peer-reviewed studies and doctoral theses published between 1995 and 2016 evaluating the impact of health promotion interventions on social isolation and/or loneliness for individuals aged 60 and over. Two reviewers will independently assess each study for inclusion and disagreements will be resolved by a third reviewer.…

BACKGROUND: Workplace violence (WPV) against healthcare workers is known as violence in healthcare settings and referring to the violent acts that are directed towards doctors, nurses or other healthcare staff at work or on duty. Moreover, WPV can cause a large number of adverse outcomes. However, there is not enough evidence to test the link between exposure to WPV against doctors, psychological stress, sleep quality and health status in China. OBJECTIVES: This study had three objectives: (1) to identify the incidence rate of WPV against doctors under a new classification, (2) to examine the association between exposure to WPV, psychological stress, sleep quality and subjective health of Chinese doctors and (3) to verify the partial mediating role of psychological stress. DESIGN: A cross-sectional online survey study. SETTING: The survey was conducted among 1740 doctors in tertiary hospitals, 733 in secondary hospital and 139 in primary hospital across 30 provinces of China. PARTICIPANTS: A total of 3016 participants were invited. Ultimately, 2617 doctors completed valid…

OBJECTIVES: We sought to use natural language processing to develop a suite of language models to capture key symptoms of severe mental illness (SMI) from clinical text, to facilitate the secondary use of mental healthcare data in research. DESIGN: Development and validation of information extraction applications for ascertaining symptoms of SMI in routine mental health records using the Clinical Record Interactive Search (CRIS) data resource; description of their distribution in a corpus of discharge summaries. SETTING: Electronic records from a large mental healthcare provider serving a geographic catchment of 1.2 million residents in four boroughs of south London, UK. PARTICIPANTS: The distribution of derived symptoms was described in 23 128 discharge summaries from 7962 patients who had received an SMI diagnosis, and 13 496 discharge summaries from 7575 patients who had received a non-SMI diagnosis. OUTCOME MEASURES: Fifty SMI symptoms were identified by a team of psychiatrists for extraction based on salience and linguistic consistency in records, broadly categorised under…

OBJECTIVE: To systematically review the available evidence on paediatric early warning systems (PEWS) for use in acute paediatric healthcare settings for the detection of, and timely response to, clinical deterioration in children. METHOD: The electronic databases PubMed, MEDLINE, CINAHL, EMBASE and Cochrane were searched systematically from inception up to August 2016. Eligible studies had to refer to PEWS, inclusive of rapid response systems and teams. Outcomes had to be specific to the identification of and/or response to clinical deterioration in children (including neonates) in paediatric hospital settings (including emergency departments). 2 review authors independently completed the screening and selection process, the quality appraisal of the retrieved evidence and data extraction; with a third reviewer resolving any discrepancies, as required. Results were narratively synthesised. RESULTS: From a total screening of 2742 papers, 90 papers, of varied designs, were identified as eligible for inclusion in the review. Findings revealed that PEWS are extensively used…

Abstract Objectives To examine age related differences in self-reported sleep quality and their associations with health outcomes across four domains: Physical Health, Cognitive Health, Mental Health and Neural Health. Setting Cam-CAN is a cohort study in East Anglia/England, which collected self-reported health and lifestyle questions as well as a range of objective measures from healthy adults. Participants 2406 healthy adults (age 18-98) answered questions about their sleep quality (Pittsburgh Sleep Quality Index) and measures of Physical, Cognitive, Mental, and Neural Health. A subset of 641 individuals provided measures of brain structure. Main outcome measures Pittsburgh Sleep Quality Index scores (PSQI) of sleep, and scores across tests within the four domains of health. Latent Class Analysis (LCA) is used to identify sleep types across the lifespan. Bayesian regressions quantify the presence, and absence, of relationships between sleep quality and health measures. Results Better sleep is generally associated with better health outcomes, strongly so for mental health,…

OBJECTIVES: To investigate beliefs about medicines and their association with medicine adherence in patients with chronic diseases in China. DESIGN: A cross-sectional questionnaire-based study SETTING: Two large urban hospitals in Hefei and Tianjin, China PARTICIPANTS: Hospital inpatients (313 stroke patients) and outpatients (315 diabetic patients and 339 rheumatoid arthritis (RA) patients) were recruited between January 2014 and September 2014. OUTCOME MEASURES: The Beliefs about Medicines Questionnaire (BMQ), assessing patients' beliefs about the specific medicine (Specific-Necessity and Specific-Concerns) prescribed for their conditions (stroke/diabetes/RA) and more general background beliefs about pharmaceuticals as a class of treatment (BMQ-General Benefit, Harm and Overuse); the Perceived Sensitivity to Medicines scale (PSM) assessed patients' beliefs about how sensitive they were to the effects of medicines and the Medication Adherence Report Scale. The association between non-adherence and beliefs about medicines was assessed using a logistic regression model. RESULTS:…

OBJECTIVE: Proton pump inhibitors (PPIs) are among the most commonly prescribed drugs. Concerns have been raised about a potentially increased risk of gastric cancer following long-term use. Our aim is to assess the risk of gastric cancer associated with PPI use, taking into account underlying indications. DESIGN: This is a population-based cohort study. Standardised incidence ratios (SIRs) and 95% CIs were calculated to compare the risk of gastric cancer among long-term PPI users with the corresponding background population, while taking confounding by indication into account. SETTING: Population-based study in Sweden (2005-2012). PARTICIPANTS: This study included virtually all adults residing in Sweden exposed to maintenance therapy with PPIs. EXPOSURE/INTERVENTION: Maintenance use of PPIs, defined as at least 180 days during the study period. Maintenance use of histamine 2 receptor antagonist was evaluated for comparison reasons. OUTCOME MEASURES: Gastric cancer (cardia and non-cardia), and subgroup analysis for gastric adenocarcinoma, as defined by the Swedish Cancer Registry.…

OBJECTIVES: To evaluate the effect of pioglitazone in people with insulin resistance, pre-diabetes and type 2 diabetes. DESIGN AND SETTING: Systematic review and meta-analysis of randomised, controlled trials. DATA SOURCES: Literature searches were performed across PubMed, EMBASE, MEDLINE and Cochrane Central Register of Controlled Trials from 1966 to May 2016 to identify randomised, controlled trials with more than 1 year follow-up. OUTCOME MEASURES: Relative risk (RR) with 95% CI was used to evaluate the association between pioglitazone and the risk of major adverse cardiovascular events (MACE: composite of non-fatal myocardial infarction, non-fatal stroke and cardiovascular death) and safety outcomes, after pooling data across trials in a fixed-effects model. RESULTS: Nine trials with 12 026 participants were enrolled in the current meta-analysis. Pioglitazone therapy was associated with a lower risk of MACE in patients with pre-diabetes or insulin resistance (RR 0.77, 95% CI 0.64 to 0.93), and diabetes (RR 0.83, 95% CI 0.72 to 0.97). Risks of heart failure (RR 1.32; CI 1.14 to…

OBJECTIVES: We examined major issues associated with sharing of individual clinical trial data and developed a consensus document on providing access to individual participant data from clinical trials, using a broad interdisciplinary approach. DESIGN AND METHODS: This was a consensus-building process among the members of a multistakeholder task force, involving a wide range of experts (researchers, patient representatives, methodologists, information technology experts, and representatives from funders, infrastructures and standards development organisations). An independent facilitator supported the process using the nominal group technique. The consensus was reached in a series of three workshops held over 1 year, supported by exchange of documents and teleconferences within focused subgroups when needed. This work was set within the Horizon 2020-funded project CORBEL (Coordinated Research Infrastructures Building Enduring Life-science Services) and coordinated by the European Clinical Research Infrastructure Network. Thus, the focus was on non-commercial trials and the…

OBJECTIVE: To clarify the causes of deaths among patients with Itai-itai disease and severe cadmium (Cd) poisoning. DESIGN: Nested case-control analysis of a population-based cohort study. SETTING: Database of patients with Itai-itai disease and residents of Cd-polluted areas, maintained by the Ministry of Environment, Japan. PARTICIPANTS: Subjects included 142 women with Itai-itai disease, 111 women with Cd-induced renal tubular dysfunction and 253 controls matched for sex, age and occupation. All subjects participated in a health impact survey between 1979 and 1984 and were followed until 30 November 2005. MAIN OUTCOMES AND MEASURES: Adjusted HRs with 95% CIs for cause of death in women with Itai-itai disease and screened female cases with tubular dysfunction were compared with matched pair controls, using Cox's proportional hazard model. Vital statistics data were used to determine cause of death. Direct causes of death from autopsy records were used in 29 patients who died from Cd poisoning. RESULTS: The most common cause of death among patients with Itai-itai disease was…

BACKGROUND: Implementing research findings into practice is a complex process that is not well understood. Facilitation has been described as a key component of getting research findings into practice. The literature on facilitation as a practice innovation is growing. This review aimed to identify facilitator roles and to describe characteristics of facilitation that may be associated with successful research use by healthcare professionals. METHODS: We searched 10 electronic databases up to December 2016 and used predefined criteria to select articles. We included conceptual papers and empirical studies that described facilitator roles, facilitation processes or interventions, and that focused on healthcare professionals and research use. We used content and thematic analysis to summarise data. Rogers' five main attributes of an innovation guided our synthesis of facilitation characteristics. RESULTS: Of the 38 488 articles identified from our online and manual search, we included 195 predominantly research studies. We identified nine facilitator roles: opinion leaders, coaches,…

OBJECTIVES: This study aims to summarise the evidence on more than 140 pharmacological and non-pharmacological treatment options for major depressive disorder (MDD) and to evaluate the confidence that patients and clinicians can have in the underlying science about their effects. DESIGN: This is a review of systematic reviews. DATA SOURCES: This study used MEDLINE, Embase, Cochrane Library, PsycINFO and Epistemonikos from 2011 up to February 2017 for systematic reviews of randomised controlled trials in adult patients with acute-phase MDD. METHODS: We dually reviewed abstracts and full-text articles, rated the risk of bias of eligible systematic reviews and graded the strength of evidence. RESULTS: Nineteen systematic reviews provided data on 28 comparisons of interest. For general efficacy, only second-generation antidepressants were supported with high strength evidence, presenting small beneficial treatment effects (standardised mean difference: -0.35; 95% CI -0.31 to -0.38), and a statistically significantly higher rate of discontinuation because of adverse events than patients…

Objective A systematic review and meta-analysis to investigate the impact of electronic nicotine delivery systems (ENDS) and/or electronic non-nicotine delivery systems (ENNDS) versus no smoking cessation aid, or alternative smoking cessation aids, in cigarette smokers on long-term tobacco use. Data sources Searches of MEDLINE, EMBASE, PsycInfo, CINAHL, CENTRAL and Web of Science up to December 2015. Study selection Randomised controlled trials (RCTs) and prospective cohort studies. Data extraction Three pairs of reviewers independently screened potentially eligible articles, extracted data from included studies on populations, interventions and outcomes and assessed their risk of bias. We used the Grading of Recommendations Assessment, Development and Evaluation approach to rate overall certainty of the evidence by outcome. Data synthesis Three randomised trials including 1007 participants and nine cohorts including 13 115 participants proved eligible. Results provided by only two RCTs suggest a possible increase in tobacco smoking cessation with ENDS in comparison with ENNDS (RR…

OBJECTIVES: An increased risk of tuberculosis (TB) has been reported in patients treated with TNF-α antagonists, an issue that has been highlighted in a WHO black box warning. This review aimed to assess the risk of TB in patients undergoing TNF-α antagonists treatment. METHODS: A systematic literature search for randomised controlled trials (RCTs) was performed in MEDLINE, Embase and Cochrane library and studies selected for inclusion according to predefined criteria. ORs with 95% CIs were calculated using the random-effect model. Subgroup analyses considered the effects of drug type, disease and TB endemicity. The quality of evidence was assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. RESULTS: 29 RCTs involving 11 879 patients were included (14 for infliximab, 9 for adalimumab, 2 for golimumab, 1 for etanercept and 3 for certolizumab pegol). Of 7912 patients allocated to TNF-α antagonists, 45 (0.57%) developed TB, while only 3 cases occurred in 3967 patients allocated to control groups, resulting in an OR of 1.94 (95% CI 1.10…

OBJECTIVES: To examine the association between coffee, including caffeinated and decaffeinated coffee, with hepatocellular carcinoma (HCC) and assess the influence of HCC aetiology and pre-existing liver disease. DESIGN: We performed a systematic review and meta-analysis. We calculated relative risks (RRs) of HCC according to caffeinated and decaffeinated coffee consumption using a random-effects dose-response meta-analysis. We tested for modification of the effect estimate by HCC aetiology and pre-existing liver disease. We judged the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. RESULTS: We found 18 cohorts, involving 2 272 642 participants and 2905 cases, and 8 case-control studies, involving 1825 cases and 4652 controls. An extra two cups per day of coffee was associated with a 35% reduction in the risk of HCC (RR 0.65, 95% CI 0.59 to 0.72). The inverse association was weaker for cohorts (RR 0.71, 95% CI 0.65 to 0.77), which were generally of higher quality than case-control studies (RR 0.53, 95% CI 0.41 to…

BACKGROUND: The majority of people with dementia have other long-term diseases, the presence of which may affect the progression and management of dementia. This study aimed to identify subgroups with higher healthcare needs, by analysing how primary care consultations, number of prescriptions and hospital admissions by people with dementia varies with having additional long-term diseases (comorbidity). METHODS: A retrospective cohort study based on health data from the Clinical Practice Research Datalink (CPRD) was conducted. Incident cases of dementia diagnosed in the year starting 1/3/2008 were selected and followed for up to 5 years. The number of comorbidities was obtained from a set of 34 chronic health conditions. Service usage (primary care consultations, hospitalisations and prescriptions) and time-to-death were determined during follow-up. Multilevel negative binomial regression and Cox regression, adjusted for age and gender, were used to model differences in service usage and death between differing numbers of comorbidities. RESULTS: Data from 4999 people (14 866…

OBJECTIVES: To explore the existence and strength of a relationship between hospital volume and mortality, to estimate minimum volume thresholds and to assess the potential benefit of centralisation of services. DESIGN: Observational population-based study using complete German hospital discharge data (Diagnosis-Related Group Statistics (DRG Statistics)). SETTING: All acute care hospitals in Germany. PARTICIPANTS: All adult patients hospitalised for 1 out of 25 common or medically important types of inpatient treatment from 2009 to 2014. MAIN OUTCOME MEASURE: Risk-adjusted inhospital mortality. RESULTS: Lower inhospital mortality in association with higher hospital volume was observed in 20 out of the 25 studied types of treatment when volume was categorised in quintiles and persisted in 17 types of treatment when volume was analysed as a continuous variable. Such a relationship was found in some of the studied emergency conditions and low-risk procedures. It was more consistently present regarding complex surgical procedures. For example, about 22 000 patients receiving open repair…

OBJECTIVES: This systematic review and meta-analysis provides a quantitative summary of the literature exploring the relationship between maternal diet quality during pregnancy and child cognitive and affective outcomes. We investigate whether there are indications for robust associations and aim to identify methodological strengths and challenges of the current research to provide suggestions of improvement for future research. DESIGN AND PARTICIPANTS: Relevant studies were identified through a systematic literature search in relevant databases. All studies investigating maternal diet quality during pregnancy in relation to child cognitive or affective functioning in children of elementary school age or younger were assessed for inclusion. RESULTS: 18 relevant studies, comprising 63 861 participants were identified. The results indicated a small positive association between better maternal diet quality during pregnancy and child functioning. We observed publication bias and significant heterogeneity between studies, where type of diet classification, publication year and outcome…

OBJECTIVE: To determine the risk of recurrent spontaneous preterm birth (sPTB) following sPTB in singleton pregnancies. DESIGN: Systematic review and meta-analysis using random effects models. DATA SOURCES: An electronic literature search was conducted in OVID Medline (1948-2017), Embase (1980-2017) and ClinicalTrials.gov (completed studies effective 2017), supplemented by hand-searching bibliographies of included studies, to find all studies with original data concerning recurrent sPTB. STUDY ELIGIBILITY CRITERIA: Studies had to include women with at least one spontaneous preterm singleton live birth (<37 weeks) and at least one subsequent pregnancy resulting in a singleton live birth. The Newcastle-Ottawa Scale was used to assess study quality. RESULTS: Overall, 32 articles involving 55 197 women, met all inclusion criteria. Generally studies were well conducted and had a low risk of bias. The absolute risk of recurrent sPTB at <37 weeks' gestation was 30% (95% CI 27% to 34%). The risk of recurrence due to preterm premature rupture of membranes (PPROM) at <37 weeks gestation was…

OBJECTIVES: Patients with advanced disease sometimes express a wish to hasten death (WTHD). In 2012, we published a systematic review and meta-ethnography of qualitative studies examining the experience and meaning of this phenomenon. Since then, new studies eligible for inclusion have been reported, including in Europe, a region not previously featured, and specifically in countries with different legal frameworks for euthanasia and assisted suicide. The aim of the present study was to update our previous review by including new research and to conduct a new analysis of available data on this topic. SETTING: Eligible studies originated from Australia, Canada, China, Germany, The Netherlands, Switzerland, Thailand and USA. PARTICIPANTS: Studies of patients with life-threatening conditions that had expressed the WTHD. DESIGN: . Quality assessment was done using the Critical Appraisal Skills Programme checklist. RESULTS: 14 studies involving 255 participants with life-threatening illnesses were identified. Five themes emerged from the analysis: suffering (overarching theme), reasons…

OBJECTIVE: Late diagnosis of Alzheimer's disease (AD) may be due to diagnostic uncertainties. We aimed to determine the sequence and timing of the appearance of established early signs and symptoms in people who are subsequently diagnosed with AD. METHODS: We used systematic review methodology to investigate the existing literature. Articles were reviewed in May 2016, using the following databases: MEDLINE, PsycINFO, CINAHL, British Nursing Index, PubMed central and the Cochrane library, with no language restriction. Data from the included articles were extracted independently by two authors and quality assessment was undertaken with the quality assessment and diagnostic accuracy tool-2 (QUADAS tool-2 quality assessment tool). RESULTS: We found that depression and cognitive impairment were the first symptoms to appear in 98.5% and 99.1% of individuals in a study with late-onset AD (LOAD) and 9% and 80%, respectively, in early-onset AD (EOAD). Memory loss presented early and was experienced 12 years before the clinically defined AD dementia in the LOAD. However, the rapidly…

OBJECTIVE: In the 10 most common primary types with bone metastases, we aimed to examine survival, further stratifying on bone metastases only or with additional synchronous metastases. METHODS: We included all patients aged 18 years and older with incident hospital diagnosis of solid cancer between 1994 and 2010, subsequently diagnosed with BM until 2012. We followed patients from date of bone metastasis diagnosis until death, emigration or 31 December 2012, whichever came first. We computed 1-year, 3-year and 5-year survival (%) and the corresponding 95% CIs stratified on primary cancer type. Comparing patients with bone metastasis only and patients with other synchronous metastases, we estimated crude and adjusted HRs and corresponding 95% CI for mortality. RESULTS: We included 17 251 patients with bone metastasis. The most common primary cancer types with bone metastasis were prostate (34%), breast (22%) and lung (20%). One-year survival after bone metastasis diagnosis was lowest in patients with lung cancer (10%, 95% CI 9% to 11%) and highest in patients with breast cancer…

OBJECTIVE: This study aimed to conduct a meta-analysis to explore and summarise the evidence regarding the association between obstructive sleep apnoea (OSA) and the subsequent risk of vascular outcomes and all-cause mortality. METHODS: Electronic databases PubMed, Embase and the Cochrane Library were searched to identify studies conducted through May 2016. Prospective cohort studies that reported effect estimates with 95% CIs of major adverse cardiac events (MACEs), coronary heart disease (CHD), stroke, cardiac death, all-cause mortality and heart failure for different levels versus the lowest level of OSA were included. RESULTS: A total of 16 cohort studies reporting data on 24 308 individuals were included. Of these, 11 studies reported healthy participants, and the remaining five studies reported participants with different diseases. Severe OSA was associated with an increased risk of MACEs (relative risk (RR): 2.04; 95% CI 1.56 to 2.66; P<0.001), CHD (RR: 1.63; 95% CI 1.18 to 2.26; P=0.003), stroke (RR: 2.15; 95% CI 1.42 to 3.24; P<0.001), cardiac death (RR: 2.96; 95% CI 1.45…

OBJECTIVE: To examine the prevalence and trends in overweight and obesity among non-pregnant urban women in Africa over the past two and a half decades. DESIGN: Cross-sectional surveys conducted between 1991 and 2014. SETTINGS: Demographic and Health Surveys (DHS), repeated cross-sectional data collected in 24 African countries. PARTICIPANTS: ). RESULTS: The prevalence of overweight and obesity among women increased in all the 24 countries. Trends were statistically significant in 17 of the 24 countries in the case of obesity and 13 of the 24 for overweight. In Ghana, overweight almost doubled (p=0.001) while obesity tripled (p=0.001) between 1993 and 2014. Egypt has the highest levels of overweight and obesity at 44% (95% CI 42%, 46.5%) and 39% (95% CI 36.6%, 41.8%), respectively, in 2014 and the trend showed significant increase (p=0.005) from 1995 levels. Also, obesity doubled in Kenya, Benin, Niger, Rwanda, Ivory Coast and Uganda, while tripled in Zambia, Burkina Faso, Mali, Malawi and Tanzania. Ethiopia and Madagascar had the lowest prevalence of both obesity and overweight,…

OBJECTIVE: This scoping study has been conducted to map the literature and provide a descriptive synthesis on the barriers and facilitators of the integration of oral health into primary care. METHODS: six-stage framework, we performed a systematic search of electronic databases, organisational websites and grey literature from 1978 to April 2016. All publications with a focus on the integration of oral health into primary care were included except commentaries and editorials. Thematic analyses were performed to synthesise the results. RESULTS: From a total of 1619 citations, 58 publications were included in the review. Barrier-related themes included: lack of political leadership and healthcare policies; implementation challenges; discipline-oriented education; lack of continuity of care and services and patients' oral healthcare needs. The facilitators of integration were supportive policies and resources allocation, interdisciplinary education, collaborative practices between dental and other healthcare professionals, presence of local strategic leaders and geographical…

BACKGROUND: Co-production is defined as the voluntary or involuntary involvement of users in the design, management, delivery and/or evaluation of services. Interest in co-production as an intervention for improving healthcare quality is increasing. In the acute healthcare context, co-production is promoted as harnessing the knowledge of patients, carers and staff to make changes about which they care most. However, little is known regarding the impact of co-production on patient, staff or organisational outcomes in these settings. AIMS: To identify and appraise reported outcomes of co-production as an intervention to improve quality of services in acute healthcare settings. DESIGN: Rapid evidence synthesis. DATA SOURCES: . STUDY SELECTION: Studies reporting patient, staff or organisational outcomes associated with using co-production in an acute healthcare setting. FINDINGS: 712 titles and abstracts were screened; 24 papers underwent full-text review, and 11 papers were included in the evidence synthesis. One study was a feasibility randomised controlled trial, three were process…

Objectives To determine the effects of low-to-moderate levels of maternal alcohol consumption in pregnancy on pregnancy and longer-term offspring outcomes. Search strategy Medline, Embase, Web of Science and Psychinfo from inception to 11 July 2016. Selection criteria Prospective observational studies, negative control and quasiexperimental studies of pregnant women estimating effects of light drinking in pregnancy (≤32 g/week) versus abstaining. Pregnancy outcomes such as birth weight and features of fetal alcohol syndrome were examined. Data collection and analysis One reviewer extracted data and another checked extracted data. Random effects meta-analyses were performed where applicable, and a narrative summary of findings was carried out otherwise. Main results 24 cohort and two quasiexperimental studies were included. With the exception of birth size and gestational age, there was insufficient data to meta-analyse or make robust conclusions. Odds of small for gestational age (SGA) and preterm birth were higher for babies whose mothers consumed up to 32 g/week versus none, but…

OBJECTIVE: Digital innovations with internet/mobile phones offer a potential cost-saving solution for overburdened health systems with high service delivery costs to improve efficiency of HIV/STI (sexually transmitted infections) control initiatives. However, their overall evidence has not yet been appraised. We evaluated the feasibility and impact of all digital innovations for all HIV/STIs. DESIGN: Systematic review. SETTING/PARTICIPANTS: All settings/all participants. INTERVENTION: We classified digital innovations into (1) mobile health-based (mHealth: SMS (short message service)/phone calls), (2) internet-based mobile and/or electronic health (mHealth/eHealth: social media, avatar-guided computer programs, websites, mobile applications, streamed soap opera videos) and (3) combined innovations (included both SMS/phone calls and internet-based mHealth/eHealth). PRIMARY AND SECONDARY OUTCOME MEASURES: Feasibility, acceptability, impact. METHODS: We searched databases MEDLINE via PubMed, Embase, Cochrane CENTRAL and Web of Science, abstracted data, explored heterogeneity, performed…

INTRODUCTION: While some evidence exists that real-time remote symptom monitoring devices can decrease morbidity and prevent unplanned admissions in oncology patients, overall, these studies have significant methodological weaknesses. The electronic Symptom Management using the Advanced Symptom Management System (ASyMS) Remote Technology (eSMART) study is designed to specifically address these weaknesses with an appropriately powered, repeated-measures, parallel-group stratified randomised controlled trial of oncology patients. METHODS AND ANALYSIS: A total of 1108 patients scheduled to commence first-line chemotherapy (CTX) for breast, colorectal or haematological cancer will be recruited from multiple sites across five European countries.Patients will be randomised (1:1) to the ASyMS intervention (intervention group) or to standard care currently available at each site (control group). Patients in the control and intervention groups will complete a demographic and clinical questionnaire, as well as a set of valid and reliable electronic patient-reported outcome measures at…

Objectives The objective of this study was to examine if, in the general population, physically active adults have less body fat after taking body mass index (BMI) into account. Design A cross-sectional analysis of participants recruited into UK Biobank in 2006–2010. Setting UK Biobank assessment centres throughout the UK. Participants 119 230 men and 140 578 women aged 40–69 years, with complete physical activity information, and without a self-reported long-term illness, disability or infirmity. Exposures Physical activity measured as excess metabolic equivalent (MET)-hours per week, estimated from a combination of walking, and moderate and vigorous physical activity. BMI from measured height and weight. Main outcome measure Body fat percentage estimated from bioimpedance. Results BMI and body fat percentage were highly correlated (r=0.85 in women; r=0.79 in men), and both were inversely associated with physical activity. Compared with <5 excess MET-hours/week at baseline, ≥100 excess MET-hours/week were associated with a 1.1 kg/m 2 lower BMI (27.1 vs 28.2 kg/m 2 ) and 2.8…

OBJECTIVE: It remains unclear whether Tai Chi is effective for preventing falls in older adults. We undertook this systematic review to evaluate the preventive effect of Tai Chi by updating the latest trial evidence. DESIGN: Systematic review and meta-analysis. METHODS: The Cochrane Library, MEDLINE and EMBASE were searched up to February 2016 to identify randomised trials evaluating Tai Chi for preventing falls in older adults. We evaluated the risk of bias of included trials using the Cochrane Collaboration's tool. Results were combined using random effects meta-analysis. OUTCOME MEASURES: Number of fallers and rate of falls. RESULTS: 18 trials with 3824 participants were included. The Tai Chi group was associated with significantly lower chance of falling at least once (risk ratio (RR) 0.80, 95% CI 0.72 to 0.88) and rate of falls (incidence rate ratio (IRR) 0.69, 95% CI 0.60 to 0.80) than the control group. Subgroup analyses suggested that the preventive effect was likely to increase with exercise frequency (number of fallers: p=0.001; rate of falls: p=0.007) and Yang style Tai…

BACKGROUND: There is not yet a comprehensive evidence-based epidemiological report on type 2 diabetes mellitus (T2DM) in Nigeria. We aimed to estimate country-wide and zonal prevalence, hospitalisation and mortality rates of T2DM in Nigeria. METHODS: We searched MEDLINE, EMBASE, Global Health, Africa Journals Online (AJOL) and Google Scholar for population and hospital-based studies on T2DM in Nigeria. We conducted a random-effects meta-analysis on extracted crude estimates, and applied a meta-regression epidemiological model, using the United Nations demographics for Nigeria in 1990 and 2015 to determine estimates of diabetes in Nigeria for the two years. RESULTS: 42 studies, with a total population of 91 320, met our selection criteria. Most of the studies selected were of medium quality (90.5%). The age-adjusted prevalence rates of T2DM in Nigeria among persons aged 20-79 years increased from 2.0% (95% CI 1.9% to 2.1%) in 1990 to 5.7% (95% CI 5.5% to 5.8%) in 2015, accounting for over 874 000 and 4.7 million cases, respectively. The pooled prevalence rate of impaired glucose…

OBJECTIVE: Since 2010, England has experienced relative constraints in public expenditure on healthcare (PEH) and social care (PES). We sought to determine whether these constraints have affected mortality rates. METHODS: We collected data on health and social care resources and finances for England from 2001 to 2014. Time trend analyses were conducted to compare the actual mortality rates in 2011-2014 with the counterfactual rates expected based on trends before spending constraints. Fixed-effects regression analyses were conducted using annual data on PES and PEH with mortality as the outcome, with further adjustments for macroeconomic factors and resources. Analyses were stratified by age group, place of death and lower-tier local authority (n=325). Mortality rates to 2020 were projected based on recent trends. RESULTS: Spending constraints between 2010 and 2014 were associated with an estimated 45 368 (95% CI 34 530 to 56 206) higher than expected number of deaths compared with pre-2010 trends. Deaths in those aged ≥60 and in care homes accounted for the majority. PES was more…

OBJECTIVE: To compare loneliness, depressive symptoms and major depressive episodes between empty-nest and not-empty-nest older adults in rural areas of Liuyang city, Hunan, China. METHODS: A cross-sectional multi-stage random cluster survey was conducted from November 2011 to April 2012 in Liuyang, China. A total of 839 rural older residents aged 60 or above completed the survey (response rate 97.6%). In line with the definition of empty nest, 25 participants who had no children were excluded from the study, while the remaining 814 elderly adults with at least one child were included for analysis. Loneliness and depressive symptoms in rural elderly parents were assessed using the short-form UCLA Loneliness Scale (ULS-6) and the Geriatric Depression Scale (GDS). Major depressive episodes were diagnosed using the Structured Clinical Interview for DSM-IV (SCID-I). RESULTS: Significant differences were found between empty-nest and not-empty-nest older adults regarding loneliness (16.19±3.90 vs. 12.87±3.02, Cohen's d=0.97), depressive symptoms (8.50±6.26 vs. 6.92±5.19, Cohen's d=0.28)…

OBJECTIVES: To explore the status of patient safety culture in Arab countries based on the findings of the Hospital Survey on Patient Safety Culture (HSPSC). DESIGN: Systematic review. METHODS: We performed electronic searches of the MEDLINE, EMBASE, CINAHL, ProQuest and PsychINFO, Google Scholar and PubMed databases, with manual searches of bibliographies of included articles and key journals. We included studies that were conducted in the Arab countries that were focused on patient safety culture. 2 reviewers independently verified that the studies met the inclusion criteria and critically assessed the quality of the studies. RESULTS: 18 studies met our inclusion criteria. The review identified that non-punitive response to error is seen as a serious issue which needs to be improved. Healthcare professionals in the Arab countries tend to think that a 'culture of blame' still exists that prevents them from reporting incidents. We found an overall similarity between the reported composite score for dimension of teamwork within units in all of the reviewed studies. Teamwork within…

OBJECTIVES: The aim of this study was to determine the association between women's decision-making power and utilisation of maternal healthcare services (MHS) among Bangladeshi women. SETTINGS: This is a nationally representative survey that encompassed Dhaka, Rajshahi, Rangpur, Chittagong, Khulna, Barisal and Sylhet in Bangladesh. Sample households were selected by a two-stage stratification technique. First, 207 clusters in urban areas and 393 in rural areas were selected for 600 enumeration areas with proportional probability. In the second stage, on average 30 households were selected systematically from the enumeration areas. Finally, 17 989 households were selected for the survey of which 96% were interviewed successfully. PARTICIPANTS: Cross-sectional data on 4309 non-pregnant women were collected from Bangladesh demographic and health survey 2014. Decision-making status on respondent's own healthcare, large household purchases, having a say on child's healthcare and visiting to family or relatives were included in the analysis. RESULTS: Prevalence of at least four antenatal…

Background There is considerable evidence of the favourable role of more physical activity (PA) in fighting against dementia. However, the shape of the dose–response relationship is still unclear. Objective To quantitatively investigate the relationship between dementia and PA. Design PubMed, EMBASE, Ovid and the Cochrane Library were searched for prospective studies published from 1 January 1995 to 15 October 2016. Two types of meta-analyses were performed with a focus on the dose–response relationship using two stage generalised least squares regression. Results The primary analysis exhibited a dose–response trend for all-cause dementia (ACD), Alzheimer’s disease (AD) but not for vascular dementia (VD). In the dose–response analysis, either ACD (p trend <0.005; p non-linearity =0.87) or AD (p trend <0.005; p non-linearity =0.10) exhibited a linear relationship with leisure time PA (LTPA) over the observed range (0–2000 kcal/week or 0–45 metabolic equivalent of task hours per week (MET-h/week)). Specifically, for every 500 kcal or 10 MET-h increase per week, there was, on average,…

OBJECTIVE: To estimate obesity prevalence among healthcare professionals in England and compare prevalence with those working outside of the health services. DESIGN: Cross-sectional study based on data from 5 years (2008-2012) of the nationally representative Health Survey for England. SETTING: England. PARTICIPANTS: 20 103 adults aged 17-65 years indicating they were economically active at the time of survey classified into four occupational groups: nurses (n=422), other healthcare professionals (n=412), unregistered care workers (n=736) and individuals employed in non-health-related occupations (n=18 533). OUTCOME MEASURE: Prevalence of obesity defined as body mass index ≥30.0 with 95% CIs and weighted to reflect the population. RESULTS: Obesity prevalence was high across all occupational groups including: among nurses (25.1%, 95% CI 20.9% to 29.4%); other healthcare professionals (14.4%, 95% CI 11.0% to 17.8%); non-health-related occupations (23.5%, 95% CI 22.9% to 24.1%); and unregistered care workers who had the highest prevalence of obesity (31.9%, 95% CI 28.4% to 35.3%). A…

Objective To investigate the effectiveness of different treatments for gestational diabetes mellitus (GDM). Design Systematic review, meta-analysis and network meta-analysis. Methods Data sources were searched up to July 2016 and included MEDLINE and Embase. Randomised trials comparing treatments for GDM (packages of care (dietary and lifestyle interventions with pharmacological treatments as required), insulin, metformin, glibenclamide (glyburide)) were selected by two authors and double checked for accuracy. Outcomes included large for gestational age, shoulder dystocia, neonatal hypoglycaemia, caesarean section and pre-eclampsia. We pooled data using random-effects meta-analyses and used Bayesian network meta-analysis to compare pharmacological treatments (ie, including treatments not directly compared within a trial). Results Forty-two trials were included, the reporting of which was generally poor with unclear or high risk of bias. Packages of care varied in their composition and reduced the risk of most adverse perinatal outcomes compared with routine care (eg, large for…

OBJECTIVES: To conduct a systematic review of interventions used to improve exercise adherence in older people, to assess the effectiveness of these interventions and to evaluate the behavioural change techniques underpinning them using the Behaviour Change Technique Taxonomy (BCTT). DESIGN: Systematic review. METHODS: A search was conducted on AMED, BNI, CINAHL, EMBASE, MEDLINE and PsychINFO databases. Randomised controlled trials that used an intervention to aid exercise adherence and an exercise adherence outcome for older people were included. Data were extracted with the use of a preprepared standardised form. Risk of bias was assessed with the Cochrane Collaboration's tool for assessing risk of bias. Interventions were classified according to the BCTT. RESULTS: Eleven studies were included in the review. Risk of bias was moderate to high. Interventions were classified into the following categories: comparison of behaviour, feedback and monitoring, social support, natural consequences, identity and goals and planning. Four studies reported a positive adherence outcome following…

OBJECTIVES: To assess the benefits and harms of exercise in patients with depression. DESIGN: Systematic review DATA SOURCES: Bibliographical databases were searched until 20 June 2017. ELIGIBILITY CRITERIA AND OUTCOMES: Eligible trials were randomised clinical trials assessing the effect of exercise in participants diagnosed with depression. Primary outcomes were depression severity, lack of remission and serious adverse events (eg, suicide) assessed at the end of the intervention. Secondary outcomes were quality of life and adverse events such as injuries, as well as assessment of depression severity and lack of remission during follow-up after the intervention. RESULTS: Thirty-five trials enrolling 2498 participants were included. The effect of exercise versus control on depression severity was -0.66 standardised mean difference (SMD) (95% CI -0.86 to -0.46; p<0.001; grading of recommendations assessment, development and evaluation (GRADE): very low quality). Restricting this analysis to the four trials that seemed less affected of bias, the effect vanished into -0.11 SMD (-0.41…

Objectives In older adults, there is a blunted responsiveness to resistance training and reduced muscle hypertrophy compared with younger adults. There is evidence that both exercise training and vitamin D supplementation may benefit musculoskeletal health in older adults, and it is plausible that in combination their effects may be additive. The aim of this systematic review was to evaluate the effectiveness of combined resistance exercise training and vitamin D 3 supplementation on musculoskeletal health in older adults. Data sources A comprehensive search of electronic databases, including Science Direct, Medline, PubMed, Google Scholar and Cochrane Central Register of Controlled Trials (Cochrane CENTRAL accessed by Wiley Science) was conducted. Eligible studies were randomised controlled trials including men and women (aged ≥65 years or mean age ≥65 years); enlisting resistance exercise training and vitamin D 3 supplementation; including outcomes of muscle strength, function, muscle power, body composition, serum vitamin D/calcium status or quality of life comparing results with…

OBJECTIVE: To systematically search for research about the effectiveness of mandatory reporting of child maltreatment and to synthesise qualitative research that explores mandated reporters' (MRs) experiences with reporting. DESIGN: As no studies assessing the effectiveness of mandatory reporting were retrieved from our systematic search, we conducted a meta-synthesis of retrieved qualitative research. Searches in Medline (Ovid), Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Sociological Abstracts, Education Resources Information Center, Criminal Justice Abstracts and Cochrane Library yielded over 6000 citations, which were deduplicated and then screened by two independent reviewers. English-language, primary qualitative studies that investigated MRs' experiences with reporting of child maltreatment were included. Critical appraisal involved a modified checklist from the Critical Appraisal Skills Programme and qualitative meta-synthesis was used to combine results from the primary studies. SETTING: All healthcare and social-service settings implicated…

OBJECTIVE: This study is a systematic review of the peer-reviewed literature to identify the correlates of mobile screen media use among children aged 8 years and less. SETTING: Home or community-based studies were included in this review while child care or school-based studies were excluded. PARTICIPANTS: Children aged 8 years or less were the study population. Studies that included larger age groups without subgroup analysis specific to the 0-8 years category were excluded. Eight electronic databases were searched for peer-reviewed English language primary research articles published or in press between January 2009 and March 2017 that have studied correlates of mobile screen media use in this age group. OUTCOME MEASURE: Mobile screen media use was the primary outcome measure. Mobile screen media use refers to children's use of mobile screens, such as mobile phones, electronic tablets, handheld computers or personal digital assistants. RESULTS: Thirteen studies meeting the inclusion criteria were identified of which a total of 36 correlates were examined. Older children, children…

OBJECTIVES: Explore the experience of patients undergoing colorectal surgery within an Enhanced Recovery After Surgery (ERAS) programme. Use these experiential data to inform the development of a framework to support ongoing, meaningful patient engagement in ERAS. DESIGN: Qualitative patient-led study using focus groups and narrative interviews. Data were analysed iteratively using a Participatory Grounded Theory approach. SETTING: Five tertiary care centres in Alberta, Canada, following the ERAS programme. PARTICIPANTS: Twenty-seven patients who had undergone colorectal surgery in the last 12 months were recruited through purposive sampling. Seven patients participated in a codesign focus group to set and prioritise the research direction. Narrative interviews were conducted with 20 patients. RESULTS: Patients perceived that an ERAS programme should not be limited to the perioperative period, but should encompass the journey from diagnosis to recovery. Practical recommendations to improve the patient experience across the surgical continuum, and enhance patient engagement within…

OBJECTIVES: Several studies have found that inappropriate workstations are associated with musculoskeletal disorders. The present cross-sectional study aimed to identify the risk factors of non-specific neck pain (NP) and low back pain (LBP) among computer-using workers. DESIGN: Observational study with a cross-sectional sample. SETTING: This study surveyed 15 companies in Zhejiang province, China. PARTICIPANTS: After excluding participants with missing variables, 417 office workers, including 163 men and 254 women, were analyzed. OUTCOME MEASURES: Demographic information was collected by self-report. The standard Northwick Park Neck Pain Questionnaire and Oswestry Low Back Pain Disability Index, along with other relevant questions, were used to assess the presence of potential occupational risk factors and the perceived levels of pain. Multinomial logistic regression analysis, adjusted for age, sex, body mass index, education, marital status and neck/low back injury, was performed to identify significant risk factors. RESULTS: Compared with low-level NP, the computer location…

OBJECTIVES: The objective of the present study was to estimate the proportion of older adults with non-communicable disease (NCD) multimorbidity, its correlates and implications in selected Indian states. METHODS: The study used data of 9852 older adults (≥60 years) (men 47%, mean age 68 years) collected by the United Nations Population Fund from seven selected Indian states. Multiple logistic regression analysis was used to assess the correlates of NCD multimorbidity and hospitalisation. RESULTS: NCD multimorbidity was reported by 30.7% (95% CI 29.8 to 31.7). Those in the highest wealth group, aged ≥70 years, alcohol users, women and tobacco users were more likely to report NCD multimorbidity compared to those without any NCD and single NCD. Those with multimorbidity, the wealthiest, ever tobacco users and those who had formal education were more likely to be hospitalised compared to their counterparts after adjusting for age, sex and ever use of alcohol. CONCLUSIONS: Multimorbidity needs to be considered for planning NCD healthcare services provision particularly inpatient…

OBJECTIVES: To identify features of programmes and approaches to make healthcare delivery in secondary healthcare settings more dementia-friendly, providing a context-relevant understanding of how interventions achieve outcomes for people living with dementia. DESIGN: A realist review conducted in three phases: (1) stakeholder interviews and scoping of the literature to develop an initial programme theory for providing effective dementia care; (2) structured retrieval and extraction of evidence; and (3) analysis and synthesis to build and refine the programme theory. DATA SOURCES: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, NHS Evidence, Scopus and grey literature. ELIGIBILITY CRITERIA: Studies reporting interventions and approaches to make hospital environments more dementia-friendly. Studies not reporting patient outcomes or contributing to the programme theory were excluded. RESULTS: Phase 1 combined findings from 15 stakeholder interviews and 22 publications to develop candidate programme theories. Phases 2 and 3 identified and…

INTRODUCTION: Bipolar disorder is an often disabling mental illness with a lifetime prevalence of 1%-2%, a high risk of recurrence of manic and depressive episodes, a lifelong elevated risk of suicide and a substantial heritability. The course of illness is frequently characterised by progressive shortening of interepisode intervals with each recurrence and increasing cognitive dysfunction in a subset of individuals with this condition. Clinically, diagnostic boundaries between bipolar disorder and other psychiatric disorders such as unipolar depression are unclear although pharmacological and psychological treatment strategies differ substantially. Patients with bipolar disorder are often misdiagnosed and the mean delay between onset and diagnosis is 5-10 years. Although the risk of relapse of depression and mania is high it is for most patients impossible to predict and consequently prevent upcoming episodes in an individual tailored way. The identification of objective biomarkers can both inform bipolar disorder diagnosis and provide biological targets for the development of new…

OBJECTIVES: Thromboembolic events are the major factor affecting the prognosis of patients with chronic kidney disease (CKD). Haemostatic alterations are possible causes of these complications, but their roles remain poorly characterised. In the prospective observational study, we investigated the entire coagulation process in patients with CKD to elucidate the mechanisms of their high thromboembolic risk. METHODS: A total of 95 patients with CKD and 20 healthy controls who met the inclusion criteria were consecutively recruited from September 2015 to March 2016. The platelet count, platelet aggregation, von Willebrand factor antigen (vWF:Ag), vWF ristocetin cofactor activity (vWF:RCo), fibrinogen, factor V (FV), FVII, FVIII, antithrombin III, protein C, protein S, D-dimer, standard coagulation tests and thromboelastography were measured in patients with CKD and controls. Associations between the estimated glomerular filtration rate (eGFR) and haemostatic biomarkers were tested using multivariable linear regression. RESULTS: The adjusted and unadjusted levels of vWF:Ag, vWF:RCo,…

OBJECTIVES: Our study aimed to distinguish the ability of anthropometric indices to assess the risk of metabolic syndrome (MetS). DESIGN: Prospective cohort study. SETTING: Shenyang, China. PARTICIPANTS: A total of 379 residents aged between 40 and 65 were enrolled. 253 of them were free of MetS and had been followed up for 4.5 years. METHODS: At baseline, all the participants underwent a thorough medical examination. A variety of anthropometric parameters were measured and calculated, including waist circumference (WC), body mass index (BMI), a body shape index (ABSI), abdominal volume index (AVI), body adiposity index, body roundness index, conicity index, waist-to-hip ratio and visceral adiposity index (VAI). After 4.5 year follow-up, we re-examined whether participants were suffering from MetS. A receiver operating characteristic (ROC) curve was applied to examine the potential of the above indices to identify the status and risk of MetS. OUTCOMES: Occurrence of MetS. RESULTS: At baseline, 33.2% participants suffered from MetS. All of the anthropometric indices showed clinical…

Objectives To provide an accurate, web-based tool for stratifying patients with atrial fibrillation to facilitate decisions on the potential benefits/risks of anticoagulation, based on mortality, stroke and bleeding risks. Design The new tool was developed, using stepwise regression, for all and then applied to lower risk patients. C-statistics were compared with CHA 2 DS 2 -VASc using 30-fold cross-validation to control for overfitting. External validation was undertaken in an independent dataset, Outcome Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Participants Data from 39 898 patients enrolled in the prospective GARFIELD-AF registry provided the basis for deriving and validating an integrated risk tool to predict stroke risk, mortality and bleeding risk. Results The discriminatory value of the GARFIELD-AF risk model was superior to CHA 2 DS 2 -VASc for patients with or without anticoagulation. C-statistics (95% CI) for all-cause mortality, ischaemic stroke/systemic embolism and haemorrhagic stroke/major bleeding (treated patients) were: 0.77 (0.76 to…

OBJECTIVE: To assess the relative effects of individual testosterone products among hypogonadal men. DESIGN: Systematic review and network meta-analysis. METHODS: We searched MEDLINE, Embase, Cochrane CENTRAL, and grey literature (25 May 2017) for randomised-controlled trials (RCTs) and non-randomised studies (NRS) that involved hypogonadal men given testosterone replacement therapy (TRT) for ≥3 months. Comparators were placebo, another TRT, or the same product at a different dose. Outcomes were quality of life, depression, libido, erectile function, activities of daily living and testosterone levels, as well as cardiovascular death, myocardial infarction, stroke, prostate cancer, heart disease, diabetes, serious adverse events, withdrawals due to adverse events and erythrocytosis. RCT data were pooled via meta-analysis and network meta-analysis. Risk of bias was assessed using Cochrane's risk of bias tool (RCTs) andScottish Intercollegiate Guidelines Network (SIGN)50 (NRS). RESULTS: Eighty-seven RCTs and 51 NRS were included. Most were at high or unclear risk of bias, with short…

OBJECTIVES: To examine the mental health of unaccompanied refugee minors prospectively during the asylum-seeking process, with a focus on specific stages in the asylum process, such as age assessment, placement in a supportive or non-supportive facility and final decision on the asylum applications. DESIGN: This was a2½ year follow-up study of unaccompanied minors (UM) seeking asylum in Norway. Data were collected within three weeks (n=138) and at 4 months (n=101), 15 months (n=84) and 26 months (n=69) after arrival. SETTING: Initially in an observation and orientation centre for unaccompanied asylum-seeking adolescents, and subsequently wherever the UM were located in other refugee facilities in Norway. PARTICIPANTS: Male UM from Afghanistan, Somalia, Algeria and Iran. MAIN OUTCOME MEASURES: Mental health symptoms assessed by Hopkins Symptom Checklist-25 and Harvard Trauma Questionnaire. RESULTS: At the group level, the young asylum seekers reported high levels of psychological distress on arrival and symptom levels that stayed relatively unchanged over time. According to…

OBJECTIVES: To assess the effect of non-pharmacological self-management interventions against usual care, and to explore different components and delivery methods within those interventions PARTICIPANTS: People living with migraine and/or tension-type headache INTERVENTIONS: Non-pharmacological educational or psychological self-management interventions; excluding biofeedback and physical therapy.We assessed the overall effectiveness against usual care on headache frequency, pain intensity, mood, headache-related disability, quality of life and medication consumption in meta-analysis.We also provide preliminary evidence on the effectiveness of intervention components and delivery methods. RESULTS: We found a small overall effect for the superiority of self-management interventions over usual care, with a standardised mean difference (SMD) of -0.36 (-0.45 to -0.26) for pain intensity; -0.32 (-0.42 to -0.22) for headache-related disability, 0.32 (0.20 to 0.45) for quality of life and a moderate effect on mood (SMD=0.53 (-0.66 to -0.40)). We did not find an effect on headache frequency…

OBJECTIVE: Better knowledge of hepatitis C virus (HCV) seroprevalence at the national level can help to implement pertinent strategies to address the HCV-related burden. The aim of this paper was to estimate the seroprevalence of HCV infection in Cameroon. DESIGN: Systematic review and meta-analysis. PARTICIPANTS: People residing in Cameroon. DATA SOURCES: Electronic databases including PubMed/MEDLINE, AJOL, WHO-Afro Library, Africa Index Medicus, National Institute of Statistics and National AIDS Control Committee, Cameroon from 1 January 2000 to 15 December 2016 were searched. English and French languages papers were considered. Two independent investigators selected studies. The methodological quality of the studies was assessed using the Newcastle-Ottawa scale. RESULTS: 31 studies including 36 407 individuals were finally considered. There was no national representative study. The overall pooled prevalence was 6.5% (95% CI 4.5% to 8.8%; I²=98.3%). A sensitivity analysis of individuals at low risk of HCV infection showed a pooled prevalence of 3.6% (95% CI 2.3% to 5.2%, I²=97.7%,…

OBJECTIVE: Antidepressant use during gestation has been associated with risk of major congenital malformations but estimates can lack statistical power or be confounded by maternal depression. We aimed to determine the association between first-trimester exposure to antidepressants and the risk of major congenital malformations in a cohort of depressed/anxious women. SETTING AND PARTICIPANTS: Data were obtained from the Quebec Pregnancy Cohort (QPC). All pregnancies with a diagnosis of depression or anxiety, or exposed to antidepressants in the 12 months before pregnancy, and ending with a live-born singleton were included. OUTCOME MEASURES: Antidepressant classes (selective serotonin reuptake inhibitors (SSRI), serotonin-norepinephrine reuptake inhibitors (SNRI), tricyclic antidepressants (TCA) and other antidepressants) and types were individually compared with non-exposure during the first trimester (depressed untreated). Major congenital malformations overall and organ-specific malformations in the first year of life were identified. RESULTS: 18 487 pregnant women were included.…

BACKGROUND: Malnutrition is one of the leading causes of morbidity and mortality among children under the age of 5 years in low and middle income countries like Nepal. Children with severe acute malnutrition (SAM) are nine times more likely to die than children without malnutrition. The prevalence of SAM has increased in Nepal over the past 15 years; however, the determinants of SAM have not been clearly assessed in the country. OBJECTIVE: To assess the determinants of SAM among children aged 6-59 months in the Bara district of Nepal. SETTING: A community-based case-control study was conducted in 12 randomly selected Village Development Committees (VDCs) of the Bara district of Nepal. PARTICIPANTS: A random sample of 292 children aged 6-59 months (146 as cases and 146 as controls) from 12 VDCs were included in this study. RESULTS: The prevalence of SAM among children under the age of 5 years was 4.14%. The following factors were significantly associated with SAM: low socioeconomic status (adjusted odds ratio (AOR) 17.13, 95% CI 5.85 to 50.13); mother's age at birth <20 or >35 years…