bluuebunny/crossref_metadata_2025 huggingface dataset:
Identifying admitted patients at risk of dying: a prospective observational validation of four biochemical scoring systems
Authors: Brabrand Mikkel , Knudsen Torben , Hallas Jesper
Published: June 2013

Objectives

Risk assessment is an important part of emergency patient care. Risk assessment tools based on biochemical data have the advantage that calculation can be automated and results can be easily provided. However, to be used clinically, existing tools have to be validated by independent researchers. This study involved an independent external validation of four risk stratification systems predicting death that rely primarily on biochemical variables.

Design

Prospective observational study.

Setting

The medical admission unit at a regional teaching hospital in Denmark.

Participants

Of 5894 adult (age 15 or above) acutely admitted medical patients, 205 (3.5%) died during admission and 46 died (0.8%) within one calendar day.

Interventions

None.

Main outcome measures

The main outcome measure was the ability to identify patients at an increased risk of dying (discriminatory power) as area under the receiver-operating characteristic curve (AUROC) and the accuracy of the predicted probability (calibration) using the Hosmer-Lemeshow goodness-of-fit test. The endpoint was all-cause mortality, defined in accordance with the original manuscripts.

Results

Using the original coefficients, all four systems were excellent at identifying patients at increased risk (discriminatory power, AUROC ≥0.80). The accuracy was poor (we could assess calibration for two systems, which failed). After recalculation of the coefficients, two systems had improved discriminatory power and two remained unchanged. Calibration failed for one system in the validation cohort.

Conclusions

Four biochemical risk stratification systems can risk-stratify the acutely admitted medical patients for mortality with excellent discriminatory power. We could improve the models for use in our setting by recalculating the risk coefficient for the chosen variables.
Effect of occupation on risk of developing MS: an insurance cohort study
Authors: Horwitz Henrik , Ahlgren Birgitte , Nærum Elisabeth
Published: June 2013

Objective

The aim of this study was to estimate the occupational risks in relation to multiple sclerosis (MS). The immediate background for this research was our finding that there had been a high number of critical illness insurance claims by patients diagnosed with MS within the agricultural segment of a Danish pension fund.

Design

An open insurance cohort. All payouts for the critical illness insurance from 2002 to 2011 were continuously registered.

Settings

PensionDanmark; one of Denmark's largest pension funds.

Participants

PensionDanmark insures more than 300 000 members of the Danish Confederation of Trade Unions against critical illness. All members are insured, and all policies are identical. The total exposure is 3.3 million person-years.

Primary outcome measures

The incidence of MS.

Results

During the 10-year period, 389 persons were diagnosed with MS. The crude incidence rate for men was 10.2/100 000; the corresponding figure for women was 16.1/100 000. We found signs of an overall effect of occupation on the risk of developing MS, and the high frequency found within the agricultural segment was attributed to dairy operators, who had an incidence of MS 2.0 times higher than the rest of the study's population (95% CI=1.2 to 3.0).

Conclusions

Our results indicate some occupational risk factors in MS, and this should be investigated further.
Azithromycin and survival inStreptococcus pneumoniaepneumonia: a retrospective study
Authors: Shorr Andrew F , Zilberberg Marya D , Kan Jason , Hoffman Justin , Micek Scott T , Kollef Marin H
Published: June 2013

Objective

Streptococcus pneumoniae(SP) represents a major pathogen in pneumonia. The impact of azithromycin on mortality in SP pneumonia remains unclear. Recent safety concerns regarding azithromycin have raised alarm about this agent's role with pneumonia. We sought to clarify the relationship between survival and azithromycin use in SP pneumonia.

Design

Retrospective cohort.

Setting

Urban academic hospital.

Participants

Adults with a diagnosis of SP pneumonia (January–December 2010). The diagnosis of pneumonia required a compatible clinical syndrome and radiographic evidence of an infiltrate.

Intervention

None.

Primary and secondary outcome measures

Hospital mortality served as the primary endpoint, and we compared patients given azithromycin with those not treated with this. Covariates of interest included demographics, severity of illness, comorbidities and infection-related characteristics (eg, appropriateness of initial treatment, bacteraemia). We employed logistic regression to assess the independent impact of azithromycin on hospital mortality.

Results

The cohort included 187 patients (mean age: 67.0±8.2 years, 50.3% men, 5.9% admitted to the intensive care unit). The most frequently utilised non-macrolide antibiotics included: ceftriaxone (n=111), cefepime (n=31) and moxifloxacin (n=22). Approximately two-thirds of the cohort received azithromycin. Crude mortality was lower in persons given azithromycin (5.6% vs 23.6%, p<0.01). The final survival model included four variables: age, need for mechanical ventilation, initial appropriate therapy and azithromycin use. The adjusted OR for mortality associated with azithromycin equalled 0.26 (95% CI 0.08 to 0.80, p=0.018).

Conclusions

SP pneumonia generally remains associated with substantial mortality while azithromycin treatment is associated with significantly higher survival rates. The impact of azithromycin is independent of multiple potential confounders.
Sedentary behaviours and obesity in adults: the Cardiovascular Risk in Young Finns Study
Authors: Heinonen I , Helajärvi H , Pahkala K , Heinonen O J , Hirvensalo M , Pälve K , Tammelin T , Yang X , Juonala M , Mikkilä V , Kähönen M , Lehtimäki T , Viikari J , Raitakari O T
Published: June 2013

Objective

Sedentary behaviour may contribute to the development of obesity. We investigated the relations between different types of sedentary behaviour and adiposity markers in a well-characterised adult population after controlling for a wide range of potential confounders.

Design

Cross-sectional study.

Setting

The Cardiovascular Risk in Young Finns Multicenter Study. Participants Sedentary time (TV viewing, computer time, reading, music/radio listening and other relaxation) was assessed with a questionnaire for 1084 women and 909 men aged 30–45 years. Other study variables included occupational and leisure-time physical activity, sleep duration, socioeconomic status, smoking, alcohol consumption, energy intake, adherence to the recommended diet, multiple individual food items, age and genetic variants associated with body mass index (BMI). Primary outcome measures BMI in kg/m2and waist circumference (WC in cm).

Results

Of the different sedentary behaviour types, TV viewing was most consistently related to higher BMI and WC, both in men and women. One additional daily TV hour was associated with a 1.81±0.44 cm larger WC in women and 2 cm±0.44 cm in men (both p<0.0001). The association with TV was diluted, but remained highly significant after adjustments with all measured covariates, including several potentially obesogenic food items associated with TV viewing. The intakes of food items such as sausage, beer and soft drinks were directly associated with TV viewing, while the intakes of oat and barley, fish, and fruits and berries were associated indirectly. After these adjustments, non-TV sedentary behaviour remained associated with adiposity indices only in women.

Conclusions

Out of the different types of sedentary behaviour, TV viewing was most consistently associated with adiposity markers in adults. Partial dilution of these associations after adjustments for covariates suggests that the obesogenic effects of TV viewing are partly mediated by other lifestyle factors.
Development of an economic evaluation of diagnostic strategies: the case of monogenic diabetes
Authors: Peters Jaime L , Anderson Rob , Hyde Chris
Published: June 2013

Objectives

To describe the development process for defining an appropriate model structure for the economic evaluation of test–treatment strategies for patients with monogenic diabetes (caused by mutations in the GCK, HNF1A or HNF4A genes).

Design

Experts were consulted to identify and define realistic test–treatment strategies and care pathways. A systematic assessment of published diabetes models was undertaken to inform the model structure.

Setting

National Health Service in England and Wales.

Participants

Experts in monogenic diabetes whose collective expertise spans the length of the patient care pathway.

Primary and secondary outcomes

A defined model structure, including the test–treatment strategies, and the selection of a published diabetes model appropriate for the economic evaluation of strategies to identify patients with monogenic diabetes.

Results

Five monogenic diabetes test–treatment strategies were defined: no testing of any kind, referral for genetic testing based on clinical features as noted by clinicians, referral for genetic testing based on the results of a clinical prediction model, referral for genetic testing based on the results of biochemical and immunological tests, referral for genetic testing for all patients with a diagnosis of diabetes under the age of 30 years. The systematic assessment of diabetes models identified the IMS CORE Diabetes Model (IMS CDM) as a good candidate for modelling the long-term outcomes and costs of the test–treatment strategies for monogenic diabetes. The short-term test–treatment events will be modelled using a decision tree which will feed into the IMS CDM.

Conclusions

Defining a model structure for any economic evaluation requires decisions to be made. Expert consultation and the explicit use of critical appraisal can inform these decisions. Although arbitrary choices have still been made, decision modelling allows investigation into such choices and the impact of assumptions that have to be made due to a lack of data.
From never to daily smoking in 30 months: the predictive value of tobacco and non-tobacco advertising exposure
Authors: Morgenstern Matthis , Sargent James D , Isensee Barbara , Hanewinkel Reiner
Published: June 2013

Objective

To test the specificity of the association between tobacco advertising and youth smoking initiation.

Design

Longitudinal survey with a 30 month interval.

Setting

21 public schools in three German states.

Participants

A total of 1320 sixth-to-eighth grade students who were never-smokers at baseline (age range at baseline, 10–15 years; mean, 12.3 years).

Exposures

Exposure to tobacco and non-tobacco advertisements was measured at baseline with images of six tobacco and eight non-tobacco advertisements; students indicated the number of times they had seen each ad and the sum score over all advertisements was used to represent inter-individual differences in the amount of advertising exposure.

Primary and secondary outcome measures

Established smoking, defined as smoked >100 cigarettes during the observational period, and daily smoking at follow-up. Secondary outcome measures were any smoking and smoking in the last 30 days.

Results

During the observation period, 5% of the never-smokers at baseline smoked more than 100 cigarettes and 4.4% were classified as daily smokers. After controlling for age, gender, socioeconomic status, school performance, television screen time, personality characteristics and smoking status of peers and parents, each additional 10 tobacco advertising contacts increased the adjusted relative risk for established smoking by 38% (95% CI 16% to 63%; p<0.001) and for daily smoking by 30% (95% CI 3% to 64%; p<0.05). No significant association was found for non-tobacco advertising contact.

Conclusions

The study confirms a content-specific association between tobacco advertising and smoking behaviour and underlines that tobacco advertising exposure is not simply a marker for adolescents who are generally more receptive or attentive towards marketing.
A population-based cross-sectional study of the association between facial morphology and cardiometabolic risk factors in adolescence
Authors: Djordjevic Jelena , Lawlor Debbie A , Zhurov Alexei I , Toma Arshed M , Playle Rebecca , Richmond Stephen
Published: June 2013

Objective

To determine whether facial morphology is associated with fasting insulin, glucose and lipids independent of body mass index (BMI) in adolescents.

Design

Population-based cross-sectional study.

Setting

Avon Longitudinal Study of Parents and Children (ALSPAC), South West of England.

Participants

From the ALSPAC database of 4747 three-dimensional facial laser scans, collected during a follow-up clinic at the age of 15, 2348 white British adolescents (1127 males and 1221 females) were selected on the basis of complete data on cardiometabolic parameters, BMI and Tanner's pubertal stage.

Main outcome measures

Fasting insulin, glucose and lipids (triglycerides, high-density lipoprotein cholesterol (HDLc) and low-density lipoprotein cholesterol (LDLc)).

Results

On the basis of the collection of 63 x, y and z coordinates of 21 anthropometric landmarks, 14 facial principal components (PCs) were identified. These components explained 82% of the variation in facial morphology and were used as exposure variables. With adjustment for age, gender and pubertal stage, seven PCs were associated with fasting insulin, none with glucose, three with triglycerides, three with HDLc and four with LDLc. After additional adjustment for BMI, four PCs remained associated with fasting insulin, one with triglycerides and two with LDLc. None of these associations withstood adjustment for multiple comparisons.

Conclusions

These initial hypotheses generating analyses provide no evidence that facial morphology is importantly related to cardiometabolic outcomes. Further examination might be warranted. Facial morphology assessment may have value in identifying other areas of disease risk.
‘I can't be an addict. I am.’ Over-the-counter medicine abuse: a qualitative study
Authors: Cooper Richard J
Published: June 2013

Objectives

Over-the-counter (OTC) pharmacy medicines are considered relatively safe in contrast to prescribed and illicit substances, but their abuse and addiction potential is increasingly recognised. Those affected represent a hard to reach group, with little known about their experiences. Study objectives were to describe the experiences and views of those self-reporting OTC medicine abuse, and why medicines were taken, how they were obtained and associated treatment and support sought.

Design

Qualitative study using in-depth mainly telephone interviews.

Participants

A purposive sample of 25 adults, aged 20–60s, 13 women.

Setting

UK, via two internet support groups.

Results

Individuals considered themselves ‘addicted’, but socially and economically active and different from illicit substance misusers. They blamed themselves for losing control over their medicine use, which usually began for genuine medical reasons and not experimentation and was often linked to the cessation of, or ongoing, medical prescribing. Codeine, in compound analgesics, was the main medicine implicated with three distinct dose ranges emerging with decongestant and sedative antihistamine abuse also being reported. Subsequent use was for the ‘buzz’ or similar effects of the opiate, which was obtained unproblematically by having lists of pharmacies to visit and occasionally using internet suppliers. Perceived withdrawal symptoms were described for all three dose ranges, and work and health problems were reported with higher doses. Mixed views about different treatment and support options emerged with standard drug treatment services being considered inappropriate for OTC medicines and concerns that this ‘hidden addiction’ was recorded in medical notes. Most supported the continued availability of OTC medicines with appropriate addiction warnings.

Conclusions

Greater awareness of the addiction potential of OTC medicines is needed for the public, pharmacists and medical prescribers, along with appropriate communication about, and reviews of, treatment and support options, for this distinct group.
The role of gender in housing for individuals with severe mental illness: a qualitative study of the Canadian service context
Authors: Kidd Sean A , Virdee Gursharan , Krupa Terry , Burnham Darrell , Hemingway Dawn , Margolin Indrani , Patterson Michelle , Zabkiewicz Denise
Published: June 2013

Objective

This study was undertaken to examine the role of gender as it relates to access to housing among individuals with severe mental illness (SMI) in Canada.

Design

An exploratory, qualitative approach was used to assess the perspectives of Canadian housing experts. The focus of inquiry was on the role of gender and associated intersections (eg, ethnicity) in pathways to housing access and housing needs for individuals with SMI.

Setting

A purposeful sampling strategy was undertaken to access respondents across all Canadian geographic regions, with diversity across settings (urban and rural) and service sectors (hospital based and community based).

Participants

–29 individuals (6 men and 23 women) considered to be experts in a housing service context as it pertains to SMI were recruited. On average, participants had worked for 15 years in services that specialised in the support and delivery of housing services to people with SMI.

Measures

Semistructured interviews with participants focused on the role gender plays in access to housing in their specific context. Barriers and facilitators were examined as were intersections with other relevant factors, such as ethnicity, poverty and parenthood. Quantitative ratings of housing accessibility as a function of gender were also collected.

Results

Participants across geographic contexts described a lack of shelter facilities for women, leading to a reliance on exploitative circumstances. Other findings included a compounding of discrimination for ethnic minority women, the unique resource problems faced in rural contexts, and the difficulties that attend access to shelter and housing for parents with SMI.

Conclusions

These findings suggest that, along with a generally poor availability of housing stock for individuals with SMI, access problems are compounded by a lack of attention to the unique needs and illness trajectories that attend gender.
Changes in smoking behaviours following a smokefree legislation in parks and on beaches: an observational study
Authors: Okoli Chizimuzo , Johnson Andrew , Pederson Ann , Adkins Sarah , Rice Wendy
Published: June 2013

Objective

To examine the effect of an outdoor smokefree law in parks and on beaches on observed smoking in selected venues.

Methods

The study involved repeated observations in selected parks and beaches in Vancouver, British Columbia, Canada. The main outcome measure was changes in observed smoking rates in selected venues from prelaw to 12 months postlaw.

Results

No venue was 100% smokefree at the 12-month postlaw observation time point. There was a significant decrease in observed smoking rates in all venues from prelaw to 12-month postlaw (prelaw mean smoking rate=20.5 vs 12-month mean smoking rate=4.7, p=0.04). In stratified analysis by venue, the differences between the prelaw and 12-month smoking rates decreased significantly in parks (prelaw mean smoking rate=37.1 vs 12-month mean smoking rate=6.5, p=0.01) but not in beaches (prelaw mean smoking rate=2.9 vs 12-month mean smoking rate=1.0, p=0.1).

Conclusions

Smokefree policies in outdoor recreational venues have the potential to decrease smoking in these venues. The effectiveness of such policies may differ by the type and usage of the venue; for instance, compliance may be better in venues that are used more often and have enforcement. Future studies may further explore factors that limit and foster the enforcement of such policies in parks and beaches.
Predictors of good functional outcome in counterpulsation-treated recent ischaemic stroke patients
Authors: Lin Wenhua , Han Jinghao , Chen Xiangyan , Xiong Li , Leung Ho Wan , Leung Thomas W , Soo Yannie , Wong Lawrence Ka Sing
Published: June 2013

Objectives

External counterpulsation (ECP) is a non-invasive method being investigated for ischaemic stroke. We aimed to explore predictors of good functional outcome for ECP-treated ischaemic stroke patients who completed a minimum of 10 sessions.

Methods

We analysed our ECP registry of ischaemic stroke patients with cerebral large artery stenosis who underwent ECP therapy at the Prince of Wales Hospital from 2004 to 2010. We included 155 patients who completed at least 10 sessions of ECP and had 3-month follow-up data as well as 52 medical controls. Functional outcomes were dichotomised into good outcome (modified Rankin Scale (mRS) 0–2) and bad outcome (mRS 3–6). We compared the differences in two groups in terms of demographics, medical history and parameters of ECP treatment.

Results

At 3 months after stroke, 70.5% of patients who finished the whole course of ECP had a good outcome (only 46.5% in the unfinished group and 38.5% in the medical group). Among all 207 recruited cases, 119 (57.5%) patients had a good outcome at 3 months after stroke. Compared with the bad outcome group, patients in the good outcome group were younger and had a lower baseline National Institutes of Health Stroke Scale (NIHSS) and longer ECP therapy duration. Multivariate logistic regression showed that ECP duration (OR 1.032), baseline NIHSS (OR 0.734) and age (OR 0.961) were independent predictors for a favourable outcome.

Conclusions

Duration of ECP therapy is first found to be an important predictor for good outcome of ECP-treated ischaemic stroke patients, in addition to the well-known prognostic factors such as age and NIHSS.
Effect of low-protein diet on kidney function in diabetic nephropathy: meta-analysis of randomised controlled trials
Authors: Nezu Uru , Kamiyama Hiroshi , Kondo Yoshinobu , Sakuma Mio , Morimoto Takeshi , Ueda Shinichiro
Published: June 2013

Objective

To evaluate the effect of low-protein diet on kidney function in patients with diabetic nephropathy.

Design

A systematic review and a meta-analysis of randomised controlled trials.

Data sources

MEDLINE, EMBASE, Cochrane Library, ClinicalTrials.gov, International Standard Randomised Controlled Trial Number (ISRCTN) Register and University Hospital Medical Information Network-Clinical Trials Registry (UMIN-CTR) from inception to 10 December 2012. Internet searches were also carried out with general search engines (Google and Google Scholar).

Study selection

Randomised controlled trials that compared low-protein diet versus control diet and assessed the effects on kidney function, proteinuria, glycaemic control or nutritional status.

Primary and secondary outcome measures and data synthesis

The primary outcome was a change in the glomerular filtration rate (GFR). The secondary outcomes were changes in proteinuria, post-treatment value of glycated haemoglobin A1C (HbA1c) and post-treatment value of serum albumin. The results were summarised as the mean difference for continuous outcomes and pooled by the random effects model. Subgroup analyses and sensitivity analyses were conducted regarding patient characteristics, intervention period, methodological quality and assessment of diet compliance. The assessment of diet compliance was performed based on the actual protein intake ratio (APIR) of the low-protein diet group to the control group.

Results

We identified 13 randomised controlled trials enrolling 779 patients. A low-protein diet was associated with a significant improvement in GFR (5.82 ml/min/1.73 m2, 95% CI 2.30 to 9.33, I2=92%; n=624). This effect was consistent across the subgroups of type of diabetes, stages of nephropathy and intervention period. However, GFR was improved only when diet compliance was fair (8.92, 95% CI 2.75 to 15.09, I2=92% for APIR <0.9 and 0.03, 95% CI −1.49 to 1.56, I2=90% for APIR ≥0.9). Proteinuria and serum albumin were not differed between the groups. HbA1c was slightly but significantly decreased in the low-protein diet group (−0.26%, 95% CI −0.35 to −0.18, I2=0%; n=536).

Conclusions

Low-protein diet was significantly associated with improvement of diabetic nephropathy. The adverse effects of low-protein diet were not apparent such as worsening of glycaemic control and malnutrition.
Surveys of the salt content in UK bread: progress made and further reductions possible
Authors: Brinsden Hannah C , He Feng J , Jenner Katharine H , MacGregor Graham A
Published: June 2013

Objectives

To explore the salt reductions made over time in packaged bread sold in the UK, the biggest contributor of salt to the UK diet.

Study design

Cross-sectional surveys were carried out on the salt content of breads available in UK supermarkets in 2001(40 products), 2006 (138) and 2011 (203).

Main outcome measures

The primary outcome measure was the change in salt content per 100 g over time. Further measures included the proportion of products meeting salt targets and differences between brands and bread types.

Results

The average salt level of bread was 1.23±0.19 g/100 g in 2001, 1.05±0.16 in 2006 and 0.98±0.13 in 2011. This shows a reduction in salt/100 g of ≈20% between 2001 and 2011. In the 18 products which were surveyed in all 3 years, there was a significant reduction of 17% (p<0.05). Supermarket own brand bread was found to be lower in salt compared with branded bread (0.95 g/100 g compared with 1.04 g/100 g in 2011). The number of products meeting the 2012 targets increased from 28% in 2001 to 71% in 2011 (p<0.001).

Conclusions

This study shows that the salt content of bread has been progressively reduced over time, contributing to the evidence base that a target-based approach to salt reduction can lead to reductions being made. A wide variation in salt levels was found with many products already meeting the 2012 targets, indicating that further reductions can be made. This requires further progressive lower targets to be set, so that the UK can continue to lead the world in salt reduction and save the maximum number of lives.
An exploratory study of cannabis withdrawal among Indigenous Australian prison inmates: study protocol
Authors: Rogerson Bernadette , Copeland Jan , Buttner Petra , Bohanna India , Cadet-James Yvonne , Sarnyai Zoltan , Clough Alan R
Published: June 2013

Introduction

Cannabis use and dependence is a serious health and criminal justice issue among incarcerated populations internationally. Upon abrupt, enforced cessation of cannabis, prisoners may suffer irritability and anger that can lead to threatening behaviour, intimidation, violence, sleep disturbances and self-harm. Cannabis withdrawal syndrome, proposed for inclusion in the Diagnostic and Statistical Manual of Mental Disorders in 2013, has not been examined in Indigenous populations. Owing to the exceptionally high rates of cannabis use in the community, high proportions of Australian Indigenous prisoners may suffer from withdrawal upon entry to custody.

Methods and analysis

60 male and 60 female Indigenous prisoners (18–40 years) at a high risk of cannabis dependence will be recruited upon entry to custody. A pictorial representation of the standard Cannabis Withdrawal Scale will be tested for reliability and validity. Cortisol markers will be measured in saliva, as the indicators of onset and severity of cannabis withdrawal and psychological distress. The characteristics will be described as percentages and mean or median values with 95% CI. Receiver operator curve analysis will determine an ideal cut-off of the Cannabis Withdrawal Scale and generalised estimating equations modelling will test changes over time. The acceptability and efficacy of proposed resources will be assessed qualitatively using thematic analysis.

Outcomes

A valid and reliable measure of cannabis withdrawal for use with Indigenous populations, the onset and time course of withdrawal symptoms in this population and the development of culturally acceptable resources and interventions to identify and manage cannabis withdrawal.

Ethics and dissemination

The project has been approved by the James Cook University Human Research Ethics Committee (approval number H4651).The results will be reported via peer reviewed publications, conference, seminar presentations and on-line media for national and international dissemination.
Patients’ subjective concepts about primary healthcare utilisation: the study protocol of a qualitative comparative study between Norway and Germany
Authors: Herrmann Wolfram J , Haarmann Alexander , Flick Uwe , Bærheim Anders , Lichte Thomas , Herrmann Markus
Published: June 2013

Background

In Germany, utilisation of ambulatory healthcare services is high compared with other countries: While a study based on the process data of German statutory health insurances showed an average of 17.1 physician-patient-contacts per year, the comparable figure for Norway is about five. The usual models of healthcare utilisation, such as Rosenstock's Health Belief Model and Andersen's Behavioural Model, cannot explain these differences adequately. Organisational factors of the healthcare system, such as gatekeeping, do not explain the magnitude of the differences. Our hypothesis is that patients’ subjective concepts about primary healthcare utilisation play a major role in explaining different healthcare utilisation behaviour in different countries. Hence, the aim of this study is to explore these subjective concepts comparatively, between Germany and Norway.

Methods/design

With that aim in mind, we chose a comparative qualitative study design. In Norway and Germany, we are going to interview 20 patients each with qualitative episodic interviews. In addition, we are going to conduct participant observation in four German and four Norwegian primary care practices. The data will be analysed by thematic coding. Using selected categories, we are going to conduct comparative case and group analyses.

Ethics and dissemination

The study adheres to the Declaration of Helsinki. All interviewees will sign informed consent forms and all patients will be observed during consultation. Strict rules for data security will apply. Developed theory and policy implications are going to be disseminated by a workshop, presentations for experts and laypersons and publications.
Mobile phone text messages for improving adherence to antiretroviral therapy (ART): a protocol for an individual patient data meta-analysis of randomised trials
Authors: Mbuagbaw Lawrence , van der Kop Mia L , Lester Richard T , Thirumurthy Harsha , Pop-Eleches Cristian , Smieja Marek , Dolovich Lisa , Mills Edward J , Thabane Lehana
Published: June 2013

Introduction

Mobile phone text messaging is emerging as an important tool in the care of people living with HIV; however, reports diverge on its efficacy in improving adherence to antiretroviral therapy (ART), and little is known about which patient groups may benefit most from phone-based adherence interventions. We will conduct an individual patient data meta-analysis to investigate the overall and subgroup effects of text messaging in three recently published text-messaging randomised controlled trials.

Methods and analysis

Data from two Kenyan and one Cameroonian trial will be verified, reformatted and merged. We will determine pooled effect sizes for text messaging versus standard care for improving adherence to ART using individual patient random-effects meta-analysis. We will test for the interaction effects of age, gender, level of education and duration on ART. Sensitivity analyses will be conducted with regard to thresholds for adherence, methods of handling missing data and fixed-effects meta-analysis. Only anonymised data will be collected from the individual studies.

Ethics and dissemination

Ethical approval was obtained for the individual studies. The results of this paper will be disseminated as peer-reviewed publications, at conferences and as part of a doctoral thesis. This individual patient data meta-analysis may provide important insights into the effects of text messaging on ART adherence in different subpopulations, with important implications for programme implementation involving such interventions and future research.
Evidence of overtesting for vitamin D in Australia: an analysis of 4.5 years of Medicare Benefits Schedule (MBS) data
Authors: Bilinski Kellie , Boyages Steve
Published: June 2013

Objective

To comprehensively examine pathology test utilisation of 25-hydroxyvitamin D (25(OH)D) testing in each state of Australia to determine the cost impact and value and to add evidence to enable the development of vitamin D testing guidelines.

Design

Longitudinal analysis of all 25(OH)D pathology tests in Australia.

Setting

Primary and Tertiary Care.

Measurements

The frequency of 25(OH)D testing between 1 April 2006 and 30 October 2010 coded for each individual by provider, state and month between 2006 and 2010. Rate of tests per 100 000 individuals and benefit for 25(OH)D, full blood count (FBC) and bone densitometry by state and quarter between 2000 and 2010.

Results

4.5 million tests were performed between 1 April 2006 and 30 October 2010. 42.9% of individuals had more than one test with some individuals having up to 79 tests in that period. Of these tests, 80% were ordered by general practitioners and 20% by specialists. The rate of 25(OH)D testing increased 94-fold from 2000 to 2010. Rate varied by state whereby the most southern state represented the highest increase and northern state the lowest increase. In contrast, the rate of a universal pathology test such as FBC remained relatively stable increasing 2.5-fold. Of concern, a 0.5-fold (50%) increase in bone densitometry was seen.

Conclusions

The marked variation in the frequency of testing for vitamin D deficiency indicates that large sums of potentially unnecessary funds are being expended. The rate of 25(OH)D testing increased exponentially at an unsustainable rate. Consequences of such findings are widespread in terms of cost and effectiveness. Further research is required to determine the drivers and cost benefit of such expenditure. Our data indicate that adoption of specific guidelines may improve efficiency and effectiveness of 25(OH)D testing.
Home telemonitoring study for Japanese patients with heart failure (HOMES-HF): protocol for a multicentre randomised controlled trial
Authors: Kotooka Norihiko , Asaka Machiko , Sato Yasunori , Kinugasa Yoshiharu , Nochioka Kotaro , Mizuno Atsushi , Nagatomo Daisuke , Mine Daigo , Yamada Yoko , Eguchi Kazuo , Hanaoka Hideki , Inomata Takayuki , Fukumoto Yoshihiro , Yamamoto Kazuhiro , Tsutsui Hiroyuki , Masuyama Tohru , Kitakaze Masafumi , Inoue Teruo , Shimokawa Hiroaki , Momomura Shin-ichi , Seino Yoshihiko , Node Koichi ,   on behalf of the HOMES-HF study investigators
Published: June 2013

Introduction

Despite the encouraging results from several randomised controlled trials (RCTs) and meta-analyses, the ability of home telemonitoring for heart failure (HF) to improve patient outcomes remains controversial as a consequence of the two recent large-scale RCTs. However, it has been suggested that there is a subgroup of patients with HF who may benefit from telemonitoring. The aim of the present study was to investigate whether an HF management programme using telemonitoring could improve outcomes in patients with HF under the Japanese healthcare system.

Methods and analysis

The Home Telemonitoring Study for Japanese Patients with Heart Failure (HOMES-HF) study is a prospective, multicentre RCT to investigate the effectiveness of home telemonitoring on the primary composite endpoint of all-cause death and rehospitalisation due to worsening HF in recently admitted HF patients (aged 20 and older, New York Heart Association classes II–III). The telemonitoring system is an automated physiological monitoring system including body weight, blood pressure and pulse rate by full-time nurses 7 days a week. Additionally, the system was designed to make it a high priority to support patient's self-care instead of an early detection of HF decompensation. A total sample size of 420 patients is planned according to the Schoenfeld and Richter method. Eligible patients are randomly assigned via a website to either the telemonitoring group or the usual care group by using a minimisation method with biased-coin assignment balancing on age, left ventricular ejection fraction and a history of ischaemic heart disease. Participants will be enrolled until August 2013 and followed until August 2014. Time to events will be estimated using the Kaplan-Meier method, and HRs and 95% CIs will be calculated using the Cox proportional hazards models with stratification factors.

Trial Registration:The study is registered at UMIN Clinical Trials Registry (UMIN000006839).
Characteristics of paid malpractice claims settled in and out of court in the USA: a retrospective analysis
Authors: Rubin Jessica B , Bishop Tara F
Published: June 2013

Objective

An analysis of paid malpractice claims judged in court compared with those settled out of court may help explain perceptions of malpractice risk.

Design

A retrospective analysis and cross-sectional comparison of malpractice claims. Evaluated trends in the number and proportion of paid claims, and mean payment amount by resolution type; identified patient, physician and claim characteristics associated with each resolution type. Examined the effects of resolution type on payment amount and time to claim resolution.

Setting

Claims paid on behalf of US physicians reported in the National Practitioner Data Bank (NPDB) from 2005 to 2009.

Main outcome measures

Type of resolution, claim characteristics, payment amount and time to resolution.

Results

Between 2005 and 2009, there were 58 667 claims paid on behalf of US physicians. Of these paid claims, 56 850 (96.9%) were settled outside court, and 1817 (3.1%) were judged in court. There was no significant change in the proportion of paid claims resolved by settlement versus judgement over time (p=0.83); nor was there a significant change in the mean payment amount in either resolution group (settlement, p=0.94; judgement, p=0.36). The claims in which the physicians were under 50, had prior malpractice reports, which were paid by a state malpractice programme, for adverse events to a fetus, and for surgical or obstetric error were more likely to be judged in court. The mean payment amount (US$592 283 vs US$317 447, p<0.01), per cent of payments over US$1 million (41.82% vs 15.43%, p<0.01), and time to decision (6.50 years vs 4.93 years, p<0.01) were significantly higher in judged claims.

Conclusions

Although only a very small percentage of paid malpractice claims in the USA are judged in court, a number of characteristics differ between settled and judged claims. Such differences may influence perceptions of malpractice risk and future reform efforts.
Are there sleep-specific phenotypes in patients with chronic fatigue syndrome? A cross-sectional polysomnography analysis
Authors: Gotts Zoe M , Deary Vincent , Newton Julia , Van der Dussen Donna , De Roy Pierre , Ellis Jason G
Published: June 2013

Objectives

Despite sleep disturbances being a central complaint in patients with chronic fatigue syndrome (CFS), evidence of objective sleep abnormalities from over 30 studies is inconsistent. The present study aimed to identify whether sleep-specific phenotypes exist in CFS and explore objective characteristics that could differentiate phenotypes, while also being relevant to routine clinical practice.

Design

A cross-sectional, single-site study.

Setting

A fatigue clinic in the Netherlands.

Participants

A consecutive series of 343 patients meeting the criteria for CFS, according to the Fukuda definition.

Measures

Patients underwent a single night of polysomnography (all-night recording of EEG, electromyography, electrooculography, ECG and respiration) that was hand-scored by a researcher blind to diagnosis and patient history.

Results

Of the 343 patients, 104 (30.3%) were identified with a Primary Sleep Disorder explaining their diagnosis. A hierarchical cluster analysis on the remaining 239 patients resulted in four sleep phenotypes being identified at saturation. Of the 239 patients, 89.1% met quantitative criteria for at least one objective sleep problem. A one-way analysis of variance confirmed distinct sleep profiles for each sleep phenotype. Relatively longer sleep onset latencies, longer Rapid Eye Movement (REM) latencies and smaller percentages of both stage 2 and REM characterised the first phenotype. The second phenotype was characterised by more frequent arousals per hour. The third phenotype was characterised by a longer Total Sleep Time, shorter REM Latencies, and a higher percentage of REM and lower percentage of wake time. The final phenotype had the shortest Total Sleep Time and the highest percentage of wake time and wake after sleep onset.

Conclusions

The results highlight the need to routinely screen for Primary Sleep Disorders in clinical practice and tailor sleep interventions, based on phenotype, to patients presenting with CFS. The results are discussed in terms of matching patients’ self-reported sleep to these phenotypes in clinical practice.
Prognostication of recovery time after acute peripheral facial palsy: a prospective cohort study
Authors: Volk Gerd Fabian , Klingner Carsten , Finkensieper Mira , Witte Otto W , Guntinas-Lichius Orlando
Published: June 2013

Objective

Owing to a lack of prospective studies, our aim was to evaluate diagnostic factors, in particular, motor and non-motor function tests, for prognostication of recovery time in patients with acute facial palsy (AFP).

Design

Prospective cohort study.

Setting

University hospital.

Participants

259 patients with AFP.

Measurements

Clinical data, facial grading, electrophysiological motor function tests and other non-motor function tests were assessed for their contribution to recovery time.

Results

The predominant origin of AFP was idiopathic (59%) and traumatic (21%). At baseline, the House-Brackmann scale (HB) was >III in 46% of patients. Follow-up time was 5.6±9.8 months with a complete recovery rate of 49%. The median recovery time was 3.5 months (95% CI 2.2 to 4.7 months). The following variables were associated with faster recovery: Interval between onset of AFP and treatment <6 days versus ≥6 days (median recovery time in months 2.1 vs 6.5; p<0.0001); HB ≤III vs >III (2.2 vs 4.6; p=0.001); no versus presence of pathological spontaneous activity in first electromyography (EMG; 2.8 vs probability of recovery <50%; p<0.0001); no versus voluntary activity in EMG (probability of recovery <50% vs 3.1; p<0.0001); normal versus pathological ipsilateral electroneurography (1.9 vs 6.5; p=0.008), normal versus pathological stapedius reflexes (1.6 vs 3.3; p=0.003).

Conclusions

Start of treatment and grading, but most importantly EMG evaluated for pathological spontaneous activity and the stapedius reflex test are powerful prognosticators for estimating the recovery time from AFP. These results need confirmation in larger datasets.
An observational study of the hand hygiene initiative: a comparison of preintervention and postintervention outcomes
Authors: Mukerji Amit , Narciso Janet , Moore Christine , McGeer Allison , Kelly Edmond , Shah Vibhuti
Published: June 2013

Objectives

To evaluate the impact of implementing a simple, user-friendly eLearning module on hand hygiene (HH) compliance and infection rates.

Design

Preintervention and postintervention observational study.

Participants

All neonates admitted to the neonatal intensive care unit (NICU) over the study period were eligible for participation and were included in the analyses. A total of 3422 patients were admitted over a 36-month span (July 2009 to June 2012).

Interventions

In the preintervention and postintervention periods (phases I and II), all healthcare providers were trained on HH practices using an eLearning module. The principles of the ‘4 moments of HH’ and definition of ‘baby space’ were incorporated using interactive tools. The intervention then extended into a long-term sustainability programme (phase III), including the requirement of an annual recertification of the module and introduction of posters and screensavers throughout the NICU.

Primary and secondary outcome measures

The primary outcome was HH compliance rates among healthcare providers in the three phases. The secondary outcome was healthcare-associated infection rates in the NICU.

Results

HH compliance rates declined initially in phase II then improved in phase III with the addition of a long-term sustainability programme (76%, 67% and 76% in phases I, II and III, respectively (p<0.01). Infection rates showed an opposing, but concomitant trend in the overall population as well as in infants <1500 g and were 4%, 6% and 4% (p=0.02), and 11%, 21% and 16% (p<0.01), respectively, during the three phases.

Conclusions

Interventions to improve HH compliance are challenging to implement and sustain with the need for ongoing reinforcement and education.
Protocol for a longitudinal qualitative interview study: maintaining psychological well-being in advanced cancer—what can we learn from patients’ and carers’ own coping strategies?
Authors: Roberts Diane , Appleton Lynda , Calman Lynn , Large Paul , Grande Gunn , Lloyd-Williams Mari , Walshe Catherine
Published: June 2013

Introduction

People with advanced cancer and their carers experience stress and uncertainty which affects the quality of life and physical and mental health. This study aims to understand how patients and carers recover or maintain psychological well-being by exploring the strategies employed to self-manage stress and uncertainty.

Methods and analysis

A longitudinal qualitative interview approach with 30 patients with advanced cancer and 30 associated family or informal carers allows the exploration of contexts, mechanisms and outcomes at an individual level. Two interviews, 4–12 weeks apart, will not only enable the exploration of individuals’ evolving coping strategies in response to changing contexts but also how patients’ and carers’ strategies inter-relate. Patient and Carer focus groups will then consider how the findings may be used in developing an intervention. Recruiting through two major tertiary cancer centres in the North West and using deliberately broad and inclusive criteria will enable the sample to capture demographic and experiential breadth.

Ethics and dissemination

The research team will draw on their considerable experience to ensure that the study is sensitive to a patient and carer group, which may be considered vulnerable but still values being able to contribute its views. Public and patient involvement (PPI) is integral to the design and is evidenced by: a research advisory group incorporating patient and carers, prestudy consultations with the PPI group at one of the study sites and a user as the named applicant. The study team will use multiple methods to disseminate the findings to clinical, policy and academic audiences. A key element will be engaging health professionals in patient and carer ideas for promoting self-management of psychological well-being. The study has ethical approval from the North West Research Ethics Committee and the appropriate NHS governance clearance.

Registration

National Institute for Health Research (NIHR) Clinical Studies Portfolio, UK Clinical Research Network (UKCRN) Study number 11725.