bluuebunny/crossref_metadata_2025 huggingface dataset:
Varicella gangrenosum in adult: a fatal chickenpox complication
Authors: Sharma Ashish , Agarwal Samarth , Sharma Anamika , Kumar Manoj
Published: April 2019

Varicella gangrenosum is a gangrenous ulceration of varicella lesions involving the skin and soft tissues of the body. The term was coined more than 100 years ago. This occurs due to superimposed bacterial infection. The presentation of primary varicella in adults is more severe with catastrophic systemic complications as compared with children. These complications include necrotising fasciitis, disseminated intravascular coagulation, wet/dry gangrene and death, as was seen in our case. Survival is dependent on early diagnosis and treatment. Adequate antibiotic treatment and particularly early radical surgical debridement should be the cornerstone of management. Less than 10 such cases are reported in the literature.
Topical beclometasone dipropionate in the management of immune checkpoint inhibitor-induced microscopic colitis
Authors: Ibraheim Hajir , Green Michael , Papa Sophie , Powell Nick
Published: April 2019

Immune checkpoint inhibitors (ICPis) have revolutionised survival outcomes for cancer patients by bolstering anti-tumour immunity. However, immune activation also occurs in non-cancer tissue, and a significant proportion of patients develop immune-mediated colitis, which can be fatal if not promptly recognised and managed. Diagnosis is often made by inflammation observed during lower gastrointestinal endoscopy. Little is known about microscopic inflammation (histological findings of inflammation in the absence of overt mucosal injury). Management strategies beyond the use of systemic corticosteroids, which incur a high burden of deleterious side effects, have not been extensively explored. We describe the cases of two cancer patients with ICPi-induced colitis who had isolated histoloigical features of colitis in the absence of macroscopic disease. Sustained clinical and histological remission was induced with the topical steroid preparation, beclometasone dipropionate (Clipper), with no adverse effects.
Xtra focus pinhole IOL (Morchers GMBH) a novel approach to tackle irregular astigmatism and large pupillary defects with a single step surgery
Authors: Agarwal Prateek , Navon Samuel Edward
Published: April 2019

A 69-year-old patient presented to us with traumatic mydriasis with irregular pupil measuring 7 mm, with superior loss of iris tissue and large inferior peripheral iridotomy and pseudophakia. The patient had history of blunt trauma 3 years ago in a fire cracker injury. He was operated elsewhere primarily after the trauma for cataract surgery with intraocular lens implantation and had suboptimal visual outcome with glare and photophobia. He presented to us with irregular pupil and inferior iridectomy with pseudophakia. The uncorrected visual acuity was 20/150 improving to 20/50 with glasses. He had a history of cataract surgery with intraocular lens (IOL) implantation done elsewhere several years back. The patient was not a diabetic or hypertensive. There was a para central corneal scar causing irregular corneal astigmatism. Extra focus pinhole IOL was implanted in sulcus having a pinhole aperture 1.36 mm. Preoperative total corneal higher-order aberrations were 3.3 µ and total corneal coma was 0.97 µ. Postoperatively uncorrected distance visual acuity improved to 20/40 intermediate uncorrected visual acuity improved to 20/30 and uncorrected near visual acuity was J3.
Prevalence of cervical disease at age 20 after immunisation with bivalent HPV vaccine at age 12-13 in Scotland: retrospective population study
Authors: Palmer Tim , Wallace Lynn , Pollock Kevin G , Cuschieri Kate , Robertson Chris , Kavanagh Kim , Cruickshank Margaret
Published: April 2019

Objective

To quantify the effect on cervical disease at age 20 years of immunisation with bivalent human papillomavirus (HPV) vaccine at age 12-13 years.

Design

Retrospective population study, 1988-96.

Setting

National vaccination and cervical screening programmes in Scotland.

Participants

138 692 women born between 1 January 1988 and 5 June 1996 and who had a smear test result recorded at age 20.

Main outcome measures

Effect of vaccination on cytology results and associated histological diagnoses from first year of screening (while aged 20), calculated using logistic regression.

Results

138 692 records were retrieved. Compared with unvaccinated women born in 1988, vaccinated women born in 1995 and 1996 showed an 89% reduction (95% confidence interval 81% to 94%) in prevalent cervical intraepithelial neoplasia (CIN) grade 3 or worse (from 0.59% (0.48% to 0.71%) to 0.06% (0.04% to 0.11%)), an 88% reduction (83% to 92%) in CIN grade 2 or worse (from 1.44% (1.28% to 1.63%) to 0.17% (0.12% to 0.24%)), and a 79% reduction (69% to 86%) in CIN grade 1 (from 0.69% (0.58% to 0.63%) to 0.15% (0.10% to 0.21%)). Younger age at immunisation was associated with increasing vaccine effectiveness: 86% (75% to 92%) for CIN grade 3 or worse for women vaccinated at age 12-13 compared with 51% (28% to 66%) for women vaccinated at age 17. Evidence of herd protection against high grade cervical disease was found in unvaccinated girls in the 1995 and 1996 cohorts.

Conclusions

Routine vaccination of girls aged 12-13 years with the bivalent HPV vaccine in Scotland has led to a dramatic reduction in preinvasive cervical disease. Evidence of clinically relevant herd protection is apparent in unvaccinated women. These data are consistent with the reduced prevalence of high risk HPV in Scotland. The bivalent vaccine is confirmed as being highly effective vaccine and should greatly reduce the incidence of cervical cancer. The findings will need to be considered by cervical cancer prevention programmes worldwide.
Prediction of adverse motor outcome for neonates with punctate white matter lesions by MRI images using radiomics strategy: protocol for a prospective cohort multicentre study
Authors: Wang Miaomiao , Liu Heng , Liu Congcong , Li Xianjun , Jin Chao , Sun Qinli , Liu Zhe , Zheng Jie , Yang Jian
Published: April 2019

Introduction

Punctate white matter lesions (PWML) are prevalent white matter disease in preterm neonates, and may cause motor disorders and even cerebral palsy. However, precise individual-based diagnosis of lesions that result in an adverse motor outcome remains unclear, and an effective method is urgently needed to guide clinical diagnosis and treatment. Advanced radiomics for multiple modalities data can provide a possible look for biomarkers and determine prognosis quantitatively. The study aims to develop and validate a model for prediction of adverse motor outcomes at a corrected age (CA) of 24 months in neonates with PWML.

Methods and analysis

A prospective cohort multicentre study will be conducted in 11 Chinese hospitals. A total of 394 neonates with PWML confirmed by MRI will undergo a clinical assessment (modified Neonatal Behavioural Assessment Scale). At a CA of 18 months, the motor function will be assessed by Bayley Scales of Infant and Toddler Development-III (Bayley-III). Mild-to-severe motor impairments will be confirmed using the Bayley-III and Gross Motor Function Classification System at a CA of 24 months. During the data collection, the perinatal and clinical information will also be recorded. According to the radiomics strategy, the extracted imaging features and clinical information will be combined for exploratory analysis. After using multiple-modelling methodology, the accuracy, sensitivity and specificity will be computed. Internal and external validations will be used to evaluate the performance of the radiomics model.

Ethics and dissemination

This study has been approved by the institutional review board of The First Affiliated Hospital of Xi’an Jiaotong University (XJTU1AF2015LSK-172). All parents of eligible participants will be provided with a detailed explanation of the study and written consent will be obtained. The results of this study will be published in peer-reviewed journals and presented at local, national and international conferences.

Trial registration number

NCT02637817; Pre-results.
Does service heterogeneity have an impact on acute hospital length of stay in stroke? A UK-based multicentre prospective cohort study
Authors: Tørnes Michelle , McLernon David , Bachmann Max , Musgrave Stanley , Warburton Elizabeth A , Potter John F , Myint Phyo Kyaw
Published: April 2019

Objectives

To determine whether stroke patients’ acute hospital length of stay (AHLOS) varies between hospitals, over and above case mix differences and to investigate the hospital-level explanatory factors.

Design

A multicentre prospective cohort study.

Setting

Eight National Health Service acute hospital trusts within the Anglia Stroke & Heart Clinical Network in the East of England, UK.

Participants

The study sample was systematically selected to include all consecutive patients admitted within a month to any of the eight hospitals, diagnosed with stroke by an accredited stroke physician every third month between October 2009 and September 2011.

Primary and secondary outcome measures

AHLOS was defined as the number of days between date of hospital admission and discharge or death, whichever came first. We used a multiple linear regression model to investigate the association between hospital (as a fixed-effect) and AHLOS, adjusting for several important patient covariates, such as age, sex, stroke type, modified Rankin Scale score (mRS), comorbidities and inpatient complications. Exploratory data analysis was used to examine the hospital-level characteristics which may contribute to variance between hospitals. These included hospital type, stroke monthly case volume, service provisions (ie, onsite rehabilitation) and staffing levels.

Results

A total of 2233 stroke admissions (52% female, median age (IQR) 79 (70 to 86) years, 83% ischaemic stroke) were included. The overall median AHLOS (IQR) was 9 (4 to 21) days. After adjusting for patient covariates, AHLOS still differed significantly between hospitals (p<0.001). Furthermore, hospitals with the longest adjusted AHLOS’s had predominantly smaller stroke volumes.

Conclusions

We have clearly demonstrated that AHLOS varies between different hospitals, and that the most important patient-level explanatory variables are discharge mRS, dementia and inpatient complications. We highlight the potential importance of stroke volume in influencing these differences but cannot discount the potential effect of unmeasured confounders.
Recruitment strategies in randomised controlled trials of men aged 50 years and older: a systematic review
Authors: Bracken Karen , Askie Lisa , Keech Anthony C , Hague Wendy , Wittert Gary
Published: April 2019

Objectives

To identify and review evaluations of strategies to recruit men aged 50 years and over to randomised controlled trials (RCTs).

Design

Systematic review and narrative synthesis.

Data sources

MEDLINE, EMBASE, CINAHL and ORRCA databases were searched to 1 December 2017.

Eligibility criteria

Studies using quantitative methods to evaluate recruitment strategies to RCTs of men aged 50 years and older.

Data extraction and synthesis

A single reviewer extracted data (for each strategy, number of participants approached, screened and randomised, and cost). Study quality was assessed using National Heart, Lung and Blood Institute Quality Assessment Tools and considered study design, description of interventions, description and measurement of outcomes, completeness of outcome reporting, performance of statistical testing and consideration of confounders. Recruitment strategies were categorised by the recruitment stage they addressed.

Results

Sixteen studies (n >14 000) were included: one good quality, ten fair quality and five poor quality. Studies evaluated strategies to identify prospective participants, and to improve the processes for assessing participant eligibility, providing participant information and seeking consent. In good and fair quality studies, the most effective strategies for identifying participants were referral from an affiliated health service provider (two studies), mass mailing (five studies) and media coverage (two studies). Community outreach activities such as displaying posters and attending local community events were not effective (two studies). Trial-specific training of site recruitment staff, developed using qualitative analysis of recruitment visits (two studies), and provision of study information to prospective participants at a multidisciplinary, group information session (one study) both improved recruitment.

Conclusion

Improved engagement of men aged 50 years and older in RCTs is needed. A gender-sensitised approach to RCT recruitment may help to address this need. We have identified several promising recruitment strategies that merit further evaluation.

PROSPERO registration number

CRD42017060301.
Understanding perceptions of global healthcare experiences on provider values and practices in the USA: a qualitative study among global health physicians and program directors
Authors: Matthews-Trigg Nathaniel , Citrin David , Halliday Scott , Acharya Bibhav , Maru Sheela , Bezruchka Stephen , Maru Duncan
Published: April 2019

Objectives

The study aimed to qualitatively examine the perspectives of US-based physicians and academic global health programme leaders on how global health work shapes their viewpoints, values and healthcare practices back in the USA.

Design

A prospective, qualitative exploratory study that employed online questionnaires and open-ended, semi-structured interviews with two participant groups: (1) global health physicians and (2) global health programme leaders affiliated with USA-based academic medical centres. Open coding procedures and thematic content analysis were used to analyse data and derive themes for discussion.

Participants

159 global health physicians and global health programme leaders at 25 academic medical institutions were invited via email to take a survey and participate in a follow-up interview. Twelve participants completed online questionnaires (7.5% response rate) and eight participants (four survey participants and four additionally recruited participants) participated in in-depth, in-person or phone semi-structured interviews.

Results

Five themes emerged that highlight how global health physicians and academic global health programme leaders perceive global health work abroad in shaping USA-based medical practices: (1) a sense of improved patient rapport, particularly with low-income, refugee and immigrant patients, and improved and more engaged patient care; (2) reduced spending on healthcare services; (3) greater awareness of the social determinants of health; (4) deeper understanding of the USA’s healthcare system compared with systems in other countries; and (5) a reinforcement of values that initially motivated physicians to pursue work in global health.

Conclusions

A majority of participating global health physicians and programme leaders believed that international engagements improved patient care back in the USA. Participant responses relating to the five themes were contextualised by highlighting factors that simultaneously impinge on their ability to provide improved patient care, such as the social determinants of health, and the challenges of changing USA healthcare policy.
Electroacupuncture versus manual acupuncture in the treatment of plantar heel pain syndrome: study protocol for an upcoming randomised controlled trial
Authors: Wang Weiming , Liu Yan , Zhao Jie , Jiao Ruimin , Liu Zhishun
Published: April 2019

Introduction

Plantar heel pain syndrome(PHPS) is a common cause of heel pain. It may worsen a patient’s quality of life, and potentially lead to knee, hip or lower back problems. Previous studies have shown that electroacupuncture (EA) and manual acupuncture (MA) are effective treatments for relieving pain in patients with PHPS. However, little evidence supports the use of one intervention over the other.

Methods and analysis

A total of 92 patients diagnosed with PHPS will be recruited and randomly assigned to an EA group or an MA group at a ratio of 1:1. Patients in both groups will receive a 30 min acupuncture treatment (three times per week) for a total of 12 sessions over 4 weeks. The primary outcome will be the proportion of patients with at least 50% reduction from baseline in the worst pain intensity measured by visual analogue scale (0–100, higher scores signify worse pain) at first steps in the morning after 4-week treatment. The secondary outcomes will include change in worst pain intensity at first steps in the morning, change in mean pain intensity at first steps in the morning, change in worst pain intensity during the day, change in mean pain intensity during the day, change in the pressure pain threshold, change in ankle-dorsiflexion range of motion, change in Foot and Ankle Ability Measure total score and subscale scores, patients’ global improvement assessment, patients’ expectations for acupuncture and safety evaluation. We will perform all statistical analysis following the intention-to-treat principle.

Ethics and dissemination

The study has been approved by our ethics review board (Protocol Approval No. 2018–010-KY). The study findings will be disseminated through presentation at a high-impact medical journal, with online access. We also to plan to present it in select conferences and scientific meetings.

Trial registration

ChiCTR-1800016531; Pre-results.
Lifestyle and work ability in a general working population in Norway: a cross-sectional study
Authors: Oellingrath Inger M , De Bortoli Marit Müller , Svendsen Martin Veel , Fell Anne Kristin Møller
Published: April 2019

Objectives

The aim of this study was to investigate the association between multiple lifestyle-related risk factors (unhealthy diet, low leisure-time physical activity, overweight/obesity and smoking) and self-rated work ability in a general working population.

Setting

Population-based cross-sectional study, in Telemark County, Norway, 2013.

Participants

A random sample of 50 000 subjects was invited to answer a self-administered questionnaire and 16 099 responded. Complete data on lifestyle and work ability were obtained for 10 355 participants aged 18–50 years all engaged in paid work during the preceding 12 months.

Outcome measure

Work ability was assessed using the Work Ability Score (WAS)—the first question in the Work Ability Index. To study the association between multiple lifestyle risk factors and work ability, a lifestyle risk index was constructed and relationships examined using multiple logistic regression analysis.

Results

Low work ability was more likely among subjects with an unhealthy diet (ORadj1.3, 95% CI 1.02 to 1.5), inactive persons (ORadj1.4, 95% CI 1.2 to 1.6), obese respondents (ORadj1.5, 95% CI 1.3 to 1.7) and former and current smokers (ORadj1.2, 95% CI 1.1 to 1.4 and 1.3, 95% CI 1.2 to 1.5, respectively). An additive relationship was observed between the lifestyle risk index and the likelihood of decreased work ability (moderate-risk score: ORadj1.3; 95% CI 1.1 to 1.6; high-risk score: ORadj1.9; 95% CI 1.6 to 2.2; very high risk score: ORadj2.4; 95% CI 1.9 to 3.0). The overall population attributable fraction (PAF) of low work ability based on the overall risk index was 38%, while the PAFs of physical activity, smoking, body mass index and diet were 16%, 11%, 11% and 6%, respectively.

Conclusions

Lifestyle risk factors were associated with low work ability. An additive relationship was observed. The findings are considered relevant to occupational intervention programmes aimed at prevention and improvement of decreased work ability.
Young adult perceptions of JUUL and other pod electronic cigarette devices in California: a qualitative study
Authors: Keamy-Minor Emily , McQuoid Julia , Ling Pamela M
Published: April 2019

Objective

Electronic cigarettes (e-cigarettes) which utilise prefilled‘pods’(pod devices) entered the US market in 2015. One brand, JUUL, captured more than half the e-cigarette market in early 2018, and the US Food and Drug Administration recently warned its manufacturer about adolescent uptake. This is the first qualitative study to describe distinct features of pod devices that appear to contribute to their popularity among young people.

Design

Qualitative interview study of young adults who had used pod devices. Participants were recruited from Facebook, other social media, street recruitment and via snowball sampling.

Setting

Participants were from California, with most from the San Francisco Bay Area.

Participants

Young adults (aged 18–29 years) using multiple tobacco products (cigarettes, e-cigarettes and/or smokeless tobacco) were recruited. Of the sample of 60 participants, 24 were included in this analysis: 10 who reported experience with pod devices and 14 who used other non-pod e-cigarette devices.

Results

Ten participants had used a pod device in the past year. Of the pod device users, seven still used a pod device at the time of the interview and five did so daily. Nearly all (n=9) pod device users smoked cigarettes in the past month; none were daily smokers. The 14 participants who used non-pod devices provided a point of comparison. Participants highlighted some distinct aspects of pod devices that facilitated use, including their aesthetic similarity to personal electronics, high levels of nicotine delivery with distinct psychoactive effects, more discreet and shorter duration use sessions, and greater social acceptability than more ostentatious non-pod e-cigarettes.

Conclusions

Pod devices’ unique characteristics likely encourage pod device uptake among young people. Limitations on advertising in youth channels, flavours and distribution, and education about nicotine addiction may decrease initiation among young people and non-smokers.
Analysing cardiovascular risk factors and related outcomes in a middle-aged to older adults population in Iran: a cohort protocol of the Shiraz Heart Study (SHS)
Authors: Zibaeenezhad Mohammad Javad , Ghaem Haleh , Parsa Nader , Sayadi Mehrab , Askarian Mehrdad , Kasaei Mohammad , Sohrabi Zahra , Dehghani-Firouzabadi Azime , Nariman Ali , Radmanesh Salma , Mani Arya , Bahramali Ehsan , Nikoo Mohammad Hossein , Moaref Ali Reza , Razeghian-Jahromi Iman
Published: April 2019

Introduction

The significant increase in the rate of morbidity and mortality due to cardiovascular diseases has become a health challenge globally. Lack of enough knowledge on the underlying causes in Iran and taking the unique characteristics of the Shiraz metropolitan city (the capital city of Fars Province) into consideration prompted us to conduct the Shiraz Heart Study. The aim of this study is to determine the predisposing elements leading to coronary heart disease, cerebrovascular disease and peripheral arterial disease.

Methods and analysis

In this population-based, prospective study, family physician clinics will become the executive arms. Participants aged 40–70 years old will be recruited to achieve a sample size of 10 000. Socioeconomicta and anthropometric indices supplemented by physical activity, nutritional and psychological questionnaires, as well as routine blood laboratory tests, medical history and electrocardiographic records, will be collected at enrolment in clinics. In addition, blood samples will be obtained to explore the possible role of genetics in outcome occurrence. Follow-up with blood sampling, completion of a lifestyle questionnaire and evaluation of clinical risk factors will be carried out five times in a 2-year interval for all participants. Advanced statistical methods such as mixed model and time-to-event models will be used for data analysis.

Ethics and dissemination

This study is in accordance with the Helsinki Declaration and has been approved by the Research Ethics Committee of Shiraz University of Medical Sciences (No: 2017–358). Signing a written informed consent is the preliminary step. Participants are free to withdraw on their request at any time. Collected data are kept encrypted in a software with authorities’ access only. Findings of the study will be published at a national or international scale through peer-reviewed journals.
Efficacy of an educational intervention on students' attitudes regarding spirituality in healthcare: a cohort study in the USA
Authors: Smothers Zachary Paul Wargo , Tu Jennifer Young , Grochowski Colleen , Koenig Harold G
Published: April 2019

Objective

To determine if an educational intervention focused on the role of spirituality in healthcare positively affects medical students' attitudes and perceptions relating to this topic.

Design

A pre-post cohort study.

Setting

An undergraduate medical institution affiliated with an academic medical center in the USA.

Participants

A total of 110 medical students currently on their clinical rotations received the educational intervention, of whom 71 (65%) completed both the presurvey and postsurvey. Demographic variables did not significantly differ from the national average of medical students, or from a comparison group. All students who attended the intervention were given the opportunity to participate in the survey.

Interventions

The educational intervention consisted of a 60-minute lecture focusing on religion/spirituality (R/S) in healthcare, followed by a 90-minute case discussion in a small group setting.

Primary and secondary outcome measures

Assessment consisted of 18-item preintervention and postintervention survey quantifying student’s attitudes towards, comfort with, and perceptions of R/S in healthcare.

Results

Attitudes towards, comfort with, and perceptions of R/S in healthcare were generally positive preintervention. Following the intervention, students expressed an increased willingness to include R/S competency in their future practice (p=0.001), were more comfortable sharing their own R/S beliefs with a patient when appropriate (p=0.02), and were more willing to approach a patient with R/S concern (p=0.04). The other surveyed attitudes demonstrated positive, but non-significant improvement.

Conclusion

An educational intervention focusing on approaching patients with R/S concerns has the ability to improve the attitudes and comfort of medical students. By incorporating a total of 150 minutes of education about R/S, medical schools can help develop this particular area of cultural competence, preparing a generation of physicians to professionally approach R/S concerns of patients. Future research should move beyond quantifying attitudes and strive to understand changes in knowledge and student behaviour.
Opioid use disorder in chronic non-cancer pain in Germany: a cross sectional study
Authors: Just Johannes Maximilian , Schwerbrock Fabian , Bleckwenn Markus , Schnakenberg Rieke , Weckbecker Klaus
Published: April 2019

Objectives

The DSM-5 diagnosis ‘opioid use disorder’ (OUD) was established to better describe and detect significant impairment or distress related to opioid use. There is no data on rates of OUD in chronic non-cancer pain (CNCP) in European countries. Therefore, our objective was to screen patients in specialised pain centres for signs of OUD.

Design

Cross-sectional questionnaire study.

Setting

Four outpatient pain clinics in the area of Bonn, Germany.

Participants

n=204 patients participated in the study (response rate: 87.9%). All adult patients with opioid pain therapy >6 months for CNCP were included. Excluded were patients with malignant disease, patients who could not collect their prescription themselves due to age or multimorbidity and patients on opioid-maintenance therapy.

Primary and secondary outcome measure

Primary outcome measure was the proportion of patients with mild to severe OUD.

Results

One-fourth (26.5%) of participants were diagnosed with OUD. Moderate to severe disorder was found in 9.3. Young age was the only connected risk factor (OR 0.96 [95% CI 0.94 to 0.99], p: 0.003).

Conclusions

OUD is a relevant diagnosis in patients on long-term opioid therapy for CNCP in the Bonn area. Careful follow-up by the attending physicians is advisable, especially in patients with moderate or severe disorder.
Study protocol for a non-inferiority randomised controlled trial of SKY breathing meditation versus cognitive processing therapy for PTSD among veterans
Authors: Mathersul Danielle C , Tang Julia S , Schulz-Heik R Jay , Avery Timothy J , Seppälä Emma M , Bayley Peter J
Published: April 2019

Introduction

Post-traumatic stress disorder (PTSD) is a debilitating, highly prevalent condition. Current clinical practice guidelines recommend trauma-focused psychotherapy (eg, cognitive processing therapy; CPT) as the first-line treatment for PTSD. However, while these treatments show clinically meaningful symptom improvement, the majority of those who begin treatment retain a diagnosis of PTSD post-treatment. Perhaps for this reason, many individuals with PTSD have sought more holistic, mind–body, complementary and integrative health (CIH) interventions. However, there remains a paucity of high-quality, active controlled efficacy studies of CIH interventions for PTSD, which precludes their formal recommendation.

Methods and analyses

We present the protocol for an ongoing non-inferiority parallel group randomised controlled trial (RCT) comparing the efficacy of a breathing meditation intervention (Sudarshan Kriya Yoga [SKY]) to a recommended evidence-based psychotherapy (CPT) for PTSD among veterans. Assessors are blinded to treatment group. The primary outcome measure is the PTSD Checklist-Civilian Version and a combination of clinical, self-report, experimental and physiological outcome measures assess treatment-related changes across each of the four PTSD symptom clusters (re-experiencing, avoidance, negative cognitions or mood and hyperarousal/reactivity). Once the RCT is completed, analyses will use both an intent-to-treat (using the ‘last observation carried forward’ for missing data) and a per-protocol or ‘treatment completers’ procedure, which is the most rigorous approach to non-inferiority designs.

Ethics and dissemination

To the best of our knowledge, this is this first non-inferiority RCT of SKY versus CPT for PTSD among veterans. The protocol is approved by the Stanford University Institutional Review Board. All participants provided written informed consent prior to participation. Results from this RCT will inform future studies including larger multi-site efficacy RCTs of SKY for PTSD and other mental health conditions, as well as exploration of cost-effectiveness and evaluation of implementation issues. Results will also inform evidence-based formal recommendations regarding CIH interventions for PTSD.

Trial registration number

NCT02366403; Pre-results.
Psychometric properties of knee proprioception tests targeting healthy individuals and those with anterior cruciate ligament injury managed with or without reconstruction: a systematic review protocol
Authors: Arumugam Ashokan , Strong Andrew , Tengman Eva , Röijezon Ulrik , Häger Charlotte K
Published: April 2019

Introduction

An anterior cruciate ligament (ACL) injury affects knee proprioception and sensorimotor control and might contribute to an increased risk of a second ACL injury and secondary knee osteoarthritis. Therefore, there is a growing need for valid, reliable and responsive knee proprioception tests. No previous study has comprehensively reviewed all the relevant psychometric properties (PMPs) of these tests together. The aim of this review protocol is to narrate the steps involved in synthesising the evidence for the PMPs of specific knee proprioception tests among individuals with an ACL injury and knee-healthy controls.

Methods and analysis

The Preferred Reporting Items for Systematic reviews and Meta-Analyses will be followed to report the review. A combination of four conceptual groups of terms—(1) construct (knee proprioception), (2) target population (healthy individuals and those with an ACL injury managed conservatively or with a surgical reconstruction), (3) measurement instrument (specific knee proprioception tests) and (4) PMPs (reliability, validity and responsiveness)—will be used for electronic databases search. PubMed, AMED, CINAHL, SPORTDiscus, Web of Science, Scopus, the Cochrane Central Register of Controlled Trials and ProQuest will be searched from their inception to November 2018. Two reviewers will independently screen titles, abstracts and full text articles, extract data and perform risk of bias assessment using the updated COnsensus-based Standards for the selection of health Measurement INstruments risk of bias checklist for the eligible studies. A narrative synthesis of the findings and a meta-analysis will be attempted as appropriate. Each PMP of knee proprioception tests will be classified as ‘sufficient’, ‘indeterminate’ or ‘insufficient’. The overall level of evidence will be ascertained using an established set of criteria.

Ethics and dissemination

Ethical approval or patient consent is not required for a systematic review. The review findings will be submitted as a series of manuscripts for peer-review and publication in scientific journals.

PROSPERO registration number

CRD42018108014.
Spatial distribution and determinant factors of anaemia among women of reproductive age in Ethiopia: a multilevel and spatial analysis
Authors: Kibret Kelemu Tilahun , Chojenta Catherine , D’Arcy Ellie , Loxton Deborah
Published: April 2019

Objective

The aim of this study was to assess the spatial distribution and determinant factors of anaemia among reproductive age women in Ethiopia.

Methods

An in-depth analysis of the 2016 Ethiopian Demographic and Health Survey data was undertaken. Getis-Ord Gi* statistics were used to identify the hot and cold spot areas for anaemia among women of reproductive age. A multilevel logistic regression model was used to identify independent predictors of anaemia among women of reproductive age.

Results

Older age (adjusted OR [AOR]=0.75; 95% CI 0.64 to 0.96), no education (AOR=1.37; 95% CI 1.102 to 1.72), lowest wealth quantile (AOR=1.29; 95% CI 1.014 to 1.60), currently pregnant (AOR=1.28; 95% CI 1.10 to 1.51, currently breast feeding (AOR=1.09; 95% CI 1.025 to 1.28), high gravidity (AOR=1.39; 95% CI 1.13 to 1.69) and HIV positive (AOR=2.11; 95% CI 1.59 to 2.79) are individual factors associated with the occurrence of anaemia. Likewise, living in a rural area (AOR=1.29; 95% CI 1.02 to 1.63) and availability of unimproved latrine facilities (AOR=1.18; 95% CI 1.01 to 1.39) are community-level factors associated with higher odds of anaemia. The spatial analysis indicated that statistically high hotspots of anaemia were observed in the eastern (Somali, Dire Dawa and Harari regions) and north-eastern (Afar) parts of the country.

Conclusion

The prevalence rate of anaemia among women of reproductive age varied across the country. Significant hotspots/high prevalence of anaemia was observed in the eastern and north-eastern parts of Ethiopia. Anaemia prevention strategies need to be targeted on rural residents, women with limited to no education, women who are breast feeding, areas with poor latrine facilities and women who are HIV positive.
Neutropenic diets to prevent cancer infections: updated systematic review and meta-analysis
Authors: Sonbol Mohamad Bassam , Jain Tania , Firwana Belal , Hilal Talal , Deleon Thomas , Murad Angela , Murad M Hassan , Khera Nandita
Published: April 2019

Introduction

Multiple studies have questioned the benefit of neutropenic diets in decreasing infections in patients with cancer, but recent surveys showed that such diets are still prescribed. In this study, we sought to evaluate the effectiveness of neutropenic diet in decreasing infection and mortality in neutropenic patients with cancer with neutropenia. This review is an update of a previously published systematic review.

Materials and methods

We searched different databases to identify comparative studies that investigated the effect of neutropenic diet compared with regular diet in neutropenic adults and children with cancer. We conducted random‐effects meta‐analyses using the Der‐Simonian and Laird method to pool treatment effects from included studies. Outcomes of interest were mortality, bacteremia/fungemia, major infections, quality of life, and the composite outcome for neutropenic fever and/or infection.

Results

We included six studies (five randomised) with 1116 patients, with 772 (69.1%) having underwent haematopoietic cell transplant. There was no statistically significant difference between neutropenic diet and regular diet in the rates of major infections (relative risk [RR] 1.16; 95% CI 0.94 to 1.42) or bacteremia/fungemia (RR 0.96; 95% CI 0.60 to 1.53). In haematopoietic cell transplant patients, neutropenic diet was associated with a slightly higher risk of infections (RR 1.25; 95% CI 1.02 to 1.54). No difference in mortality was seen between neutropenic diet and regular diet (RR 1.08, 95% CI 0.78 to 1.50).

Conclusion

There is currently no evidence to support the use of neutropenic diet or other food restrictions in neutropenic patients with cancer. Patients and clinicians should continue to follow the safe food-handling guidelines as recommended by the U.S. Food and Drug Administration.
Reiki therapy for pain, anxiety and quality of life
Authors: Billot Maxime , Daycard Maeva , Wood Chantal , Tchalla Achille
Published: April 2019

The use of complementary and alternative therapies is growing year after year, and Reiki therapy takes a place of choice. Reiki therapy, classed as a biofield energy therapy, raises the question of validity when applied to patients, especially in palliative care. The purpose of this review is to highlight the effects of Reiki therapy on pain, anxiety/depression and quality of life of patients, specifically in palliative care. The current article indicates that Reiki therapy is useful for relieving pain, decreasing anxiety/depression and improving quality of life in several conditions. Due to the small number of studies in palliative care, we were unable to clearly identify the benefits of Reiki therapy, but preliminary results tend to show some positive effects of Reiki therapy for the end-of-life population. These results should encourage teams working in palliative care to conduct more studies to determine the benefits of Reiki therapy on pain, anxiety/depression and quality of life in palliative care.
PP12 New ‘nature of call’ telephone screening tool, employed prior to nhs pathways triage, can accurately identify those later treated for out of hospital cardiac arrest: analysis of sensitivity and specificity using routine ambulance service data
Authors: Green Jonathan , Ewings Sean , Wortham Richard , Walsh Bronagh
Published: April 2019

Background

A new pre-triage emergency medical call screening tool, Nature of Call (NoC), has been introduced into UK ambulance services which employ the NHS Pathways (NHSP) triage system. Its current function is to provide a rapid sieve, differentiating between patients who may need treatment for Out-of-Hospital Cardiac Arrest (OHCA), and therefore require immediate ambulance dispatch, and all other calls, for which ambulance dispatch is withheld whilst further triage is undertaken.

Objective

To evaluate the accuracy of NoC in identifying patients with potentially treatable OHCA or peri-arrest conditions.

Methods

Study of diagnostic accuracy. The sample was a retrospective cohort of consecutive calls to a UK ambulance service, taken over a four-month period. Sensitivity and specificity were determined, comparing allocated priority dispositions with an OHCA Treatment Registry. Context was supplied by the evaluation of subsequent categorisation by NHSP. The accuracy of the combined NoC and NHSP allocations was also investigated.

Results

A total of 1 87 419 emergency calls were received. Of these, 71 373 were allocated both NoC and NHSP priority dispositions and were associated with electronic Patient Clinical Records. 590 (0.8%) of these patients received treatment for OHCA. NoC, sensitivity=77.6% (95% CI 74.1 to 80.8); specificity=86.9% (95% CI 86.6 to 87.1). NHSP, sensitivity=79.2% (95% CI 75.7 to 82.2); specificity=93.4% (93.2 to 93.6). NoC and NHSP combined, sensitivity=84.1% (95% CI 80.9 to 86.8); specificity=95.0% (95% CI 94.8 to 95.3).

Conclusions

NoC and subsequent NHSP call categorisation each achieved relatively high sensitivity for the identification of treated OHCA, predicting similar groups of registry patients (although 6% were identified by NoC alone). Overall accuracy was enhanced when NoC and subsequent NHSP Results were combined. The unidentified group of treated OHCA patients (16%) present a challenge to the current dispatch system which relies on the early recognition of patients who may require treatment for OHCA.
PP13 The NHS pathways (NHSP) medical call triage system and new ‘nature of call’ telephone screening tool, employed prior to NHSP, can accurately identify high acuity patients: analysis of sensitivity and specificity using routine ambulance service data
Authors: Green Jonathan , Ewings Sean , Wortham Richard , Walsh Bronagh
Published: April 2019

Background

The NHS Pathways (NHSP) medical call triage system is employed by UK ambulance services. One function is to identify a broad category of ‘high-acuity calls’, distinguishing them from those that do not require an emergency response. A new pre-triage screening tool, Nature of Call (NoC), designed to augment NHSP could be employed as a rapid initial sieve of broad acuity.

Objectives

To identify the accuracy of NHSP (and NoC) in recognising patients who require an emergency ambulance response (and therefore those who may not).

Methods

Diagnostic accuracy. The sample is a retrospective cohort of consecutive calls, over a 4 month period, to a UK ambulance service. Sensitivity and specificity were determined, comparing allocated NoC and NHS Pathways priority dispositions with a composite reference standard comprised of administered medications, procedures, observations and clinical impressions associated with high-acuity, as recorded on ambulance electronic Patient Clinical Records.

Results

A total of 1 87 408 emergency calls were received. Of these, 71 373 were allocated both NoC and NHSP priority dispositions and were associated with electronic Patient Clinical Records. 40 997 (57%) of these patients met the high-acuity reference criteria. NHSP, sensitivity=98.1% (95% CI 98.0 to 98.2); specificity=5.9% (95% CI 5.6 to 6.1). NoC, sensitivity=84.0% (95% CI 83.7 to 84.4); specificity=26.5% (95% CI 26.0 to 27.0).

Conclusions

NHSP is effective in identifying high-acuity patients (as is NoC). Sensitivity analysis therefore supports the this function of NHSP and NoC/NHSP to inform initial ambulance dispatch decisions, particularly if NoC categorisation is reviewed in the light of subsequent NHSP triage. However, both systems appear to achieve high sensitivity by also allocating most low-acuity calls to high-acuity categories. This significantly restricts operational application. Only one quarter of low-acuity calls are allocated the lowest priority category by NoC and one-in-seventeen by NHSP, severely restricting the group likely to be considered for alternative care pathways.
PP15 Non-technical skills in the delivery of ambulance service telephone advice
Authors: O’Hara Rachel , Bishop-Edwards Lindsey , Knowles Emma , O’Cathain Alicia
Published: April 2019

Background

Around 10% of calls to ambulance services in England are resolved over the phone (referred to as telephone advice or hear and treat). These calls are generally dealt with by clinicians following initial call-handler assessment. A systematic review concluded that telephone advice is a safe alternative for patients categorised as low priority but recommended the need to understand the skills required. Our research explores the non-technical skills (cognitive, social and personal) required.

Methods

Non-participant observation of telephone advice in three ambulance services involved 40 hours of observation per service, (total n=27 clinicians and 20 call-handlers) and semi-structured interviews with clinicians (n=7), call-handlers (n=7) and managers (n=3). A framework approach and NVIVO qualitative data analysis software were used to analyse the data.

Findings

Situation awareness was a necessary skill in gathering information by telephone. Strategies included visualisation, attending to tone of voice and listening to Background noise. Decision making skill was needed to select an appropriate course of action. For clinicians this involved reference to prior experience and risk judgement that the available information supported a safe decision. Call-handlers were more reliant on computerised triage systems. Communication skill required rephrasing technical questions, providing reassurance and assertiveness in managing expectations. Call-handlers had less discretion to rephrase computerised scripts. Personal resources were required to manage role demands that included dealing with high call volumes, task conflict and difficult conversations with callers expecting an ambulance response.

Conclusions

The findings have implications for the recruitment, training and ongoing development of call-handlers and clinicians involved in the delivery of telephone advice. There is scope for further research to provide a more detailed understanding of non-technical skills in the delivery of telephone advice to ensure the consistent delivery of appropriate and safe care that is acceptable to patients.
PP16 Modelling of patient outcomes after emergency treatment for out-of-hospital cardiac arrest by paramedics and community first responders
Authors: D Smith Murray , Norman John , Niroshan Siriwardena A , Spaight Robert
Published: April 2019

Background

Patient outcomes for out-of-hospital-cardiac-arrest (OHCA) should include shorter term response resulting from care delivered by first aiders (CFR) and emergency services as well as any longer term response achieved following handover into hospital care. We construct statistical models of: Return of Spontaneous Circulation while under emergency care (ROSC), and Discharge Alive from hospital (DA).

Methods

Data on 15,103 OHCA patients aged 4+weeks from East Midlands Ambulance Service NHS Trust were gathered across a 3 year period April 2014 – March 2017. Both outcomes were represented by binary variables (yes=1, no=0). Duration variables: waiting time (WT; time from 999 to emergency service arrival at the patient’s side), total treatment time (TOT; time from emergency service arrival to patient handover at hospital), time to ROSC (TtoR; time from emergency service arrival to first ROSC achieved). Statistical analyses were to be conducted on complete records (2825 patients) and involve fitting of a bivariate probit model to the joint outcome (ROSC, DA) and a probit model to the conditional outcome (DA|ROSC=1).

Results

CFR attendance had no statistically significant influence on either patient outcome.

Patient outcomes worsened as wait time (WT) increased, but was insignificant versus no effect.

Total treatment time (TOT) was significant; with positive influence on ROSC occurrence the longer that time period (estimate >0, p=0.036), but worsening the chance of longer term survival DA (estimate <0, p<0.001).

Time to ROSC (TtoR) was the key driver in the DA|ROSC=1 model (estimate <0, p<0.001), evidencing the better the chances of longer term survival DA the sooner ROSC is achieved.

Conclusions

Our Results show that OHCA patient outcomes depend crucially on the quality of clinical care provided by the emergency services. Next steps include the need to gather granular data evidencing the pre-hospital care that is administered to patients by paramedics and community first responders.