bluuebunny/crossref_metadata_2025 huggingface dataset:
Can clinical case discussions foster clinical reasoning skills in undergraduate medical education? A randomised controlled trial
Authors: Weidenbusch Marc , Lenzer Benedikt , Sailer Maximilian , Strobel Christian , Kunisch Raphael , Kiesewetter Jan , Fischer Martin R , Zottmann Jan M
Published: September 2019

Objective

Fostering clinical reasoning is a mainstay of medical education. Based on the clinicopathological conferences, we propose a case-based peer teaching approach called clinical case discussions (CCDs) to promote the respective skills in medical students. This study compares the effectiveness of different CCD formats with varying degrees of social interaction in fostering clinical reasoning.

Design, setting, participants

A single-centre randomised controlled trial with a parallel design was conducted at a German university. Study participants (N=106) were stratified and tested regarding their clinical reasoning skills right after CCD participation and 2 weeks later.

Intervention

Participants worked within a live discussion group (Live-CCD), a group watching recordings of the live discussions (Video-CCD) or a group working with printed cases (Paper-Cases). The presentation of case information followed an admission-discussion-summary sequence.

Primary and secondary outcome measures

Clinical reasoning skills were measured with a knowledge application test addressing the students’ conceptual, strategic and conditional knowledge. Additionally, subjective learning outcomes were assessed.

Results

With respect to learning outcomes, the Live-CCD group displayed the best results, followed by Video-CCD and Paper-Cases, F(2,87)=27.07, p<0.001, partial η2=0.384. No difference was found between Live-CCD and Video-CCD groups in the delayed post-test; however, both outperformed the Paper-Cases group, F(2,87)=30.91, p<0.001, partial η2=0.415. Regarding subjective learning outcomes, the Live-CCD received significantly better ratings than the other formats, F(2,85)=13.16, p<0.001, partial η2=0.236.

Conclusions

This study demonstrates that the CCD approach is an effective and sustainable clinical reasoning teaching resource for medical students. Subjective learning outcomes underline the importance of learner (inter)activity in the acquisition of clinical reasoning skills in the context of case-based learning. Higher efficacy of more interactive formats can be attributed to positive effects of collaborative learning. Future research should investigate how the Live-CCD format can further be improved and how video-based CCDs can be enhanced through instructional support.
The association between the neighbourhood social environment and obesity in Brazil: a cross-sectional analysis of the ELSA-Brasil study
Authors: Chaparro M Pia , Pina Maria Fátima , de Oliveira Cardoso Letícia , Santos Simone M , Barreto Sandhi M , Giatti Gonçalves Luana , Alvim de Matos Sheila M , Mendes da Fonseca Maria de Jesus , Chor Dora , Griep Rosane Haerter
Published: September 2019

Objective

To investigate the association between the neighbourhood social environment, including social cohesion, perceived neighbourhood safety, perceived neighbourhood violence, and obesity in Brazil.

Design

Cross-sectional study.

Setting

6 state capitals in Brazil (Salvador, Vitoria, Belo Horizonte, Porto Alegre, Sao Paulo and Rio de Janeiro)

Participants

Current or former employees of five federal universities and one research centre in each of the six Brazilian state capitals who were participants of the baseline wave (2008–2010) of the Brazilian Longitudinal Study of Adult Health (n=11 456; 56% women; 56% White, 28% Brown, and 16% Black).

Primary outcome measure

Obesity, based on measured weight and height, and defined as having a body mass index ≥30 kg/m2.

Results

No associations were found between the neighbourhood social environment and obesity among men. In multilevel logistic regression models adjusted for age, education, skin colour, state of residence, and individual-level social cohesion and perceived violence scores, respectively, women living in the least socially cohesive neighbourhoods and in those perceived as most violent had higher odds of obesity compared with their counterparts (OR=1.25, 95% CI=1.02–1.53; OR=1.28, 95% CI=1.04–1.56, respectively). When stratified by neighbourhood socioeconomic status (SES)—defined based on number of people per household, proportion of children 0–4 years, median income and per cent of white residents at the neighbourhood level—results for social cohesion and for violence remained only for women residing in high SES and low SES neighbourhoods, respectively.

Conclusions

In this civil-servant sample in six large cities in Brazil, the neighbourhood social environment was associated with obesity among women, but not men. Neighbourhood-level interventions to increase social cohesion and reduce violence may help in the prevention of obesity among women in Brazil.
The impact of general practitioners’ gender on process indicators in Hungarian primary healthcare: a nation-wide cross-sectional study
Authors: Kovács Nóra , Varga Orsolya , Nagy Attila , Pálinkás Anita , Sipos Valéria , Kőrösi László , Ádány Róza , Sándor János
Published: September 2019

Objectives

The objectives of our study were (1) to investigate the association between gender of the general practitioner (GP) and the quality of primary care in Hungary with respect to process indicators for GP performance and (2) to assess the size of the gender impact.

Study design

A nation-wide cross-sectional study was performed in 2016.

Setting and participants

The study covered all general medical practices in Hungary (n=4575) responsible for the provision of primary healthcare (PHC) for adults. All GPs in their private practices are solo practitioners.

Main outcome measures

Multilevel logistic regression models were used to analyse the association between GP gender and process indicators of PHC, and attributable proportion (AP) was calculated.

Results

48% of the GPs (n=2213) were women in the study. The crude rates of care provided by female GPs were significantly higher for seven out of eight evaluated indicators than those provided by male GPs. Adjusted for practice, physician and patient factors, GP gender was associated with the haemoglobin A1c (HbA1c) measurement: OR=1.18, 95% CI (1.14 to 1.23); serum creatinine measurement: OR=1.14, 95% CI (1.12 to 1.17); lipid measurement: OR=1.14, 95% CI (1.11 to 1.16); eye examination: OR=1.06, 95% CI (1.03 to 1.08); mammography screening: OR=1.05, 95% CI (1.03 to 1.08); management of patients with chronic obstructive pulmonary disease: OR=1.05, 95% CI (1.01 to 1.09) and the composite indicator: OR=1.08, 95% CI (1.07 to 1.1), which summarises the number of care events and size of target populations of each indicator. The AP at the specific indicators varied from 0.97% (95% CI 0.49% to 1.44%) of influenza immunisation to 8.04% (95% CI 7.4% to 8.67%) of eye examinations.

Conclusion

Female GP gender was an independent predictor of receiving higher quality of care. The actual size of the gender effect on the quality of services seemed to be notable. Factors behind the gender effect should receive more attention in quality improvement particularly in countries where the primary care is organised around solo practices.
Tobacco pack display at hospitality venues after the introduction of standardised tobacco packaging in New Zealand: a field observation study
Authors: Nee-Nee Johanna , Sutherland Kirsty , Holland Rebecca , Wilson Miriam , Ackland Samuel , Bocock Claudia , Cartmell Abbie , Earp Jack , Grove Christina , Hewson Charlotte , Jefferies Will , Keefe Lucy , Lockyer Jamie , Patel Saloni , Quintans Miguel , Robbie Michael , Teape Lauren , Yang Jess , Wilson Nick , Hoek Janet , Thomson George
Published: September 2019

Objectives

In March 2018, New Zealand (NZ) introduced standardised tobacco packaging that also featured new pictorial warnings, with implementation completed by early June 2018. We evaluated how the new packaging affected tobacco pack displays in outdoor areas of hospitality venues.

Design

Before-and-after descriptive field observation study.

Setting

Central city area of the capital city of NZ (Wellington).

Participants

Observations of people smoking and tobacco packs were made at 56 hospitality venues with outdoor tables (2422 separate venue observations), after the introduction of standardised tobacco packaging. Comparisons were made with a prior study in the same setting, from a time when tobacco packaging still featured brand imagery.

Results

A total of 8191 patrons, 1113 active smokers and 889 packs and pouches (522 of known orientation) were observed over 2422 venue observations. There were 0.80 visible packs per active smoker in 2018, compared with 1.26 in 2014 (risk ratio (RR)=0.64, 95% CI 0.60 to 0.67, p<0.0001). The new packs in 2018 were also less likely to be displayed face-up, compared with packs in 2014, which had brand imagery on the front face (RR=0.77, 95% CI 0.72 to 0.83, p<0.0001). Pack and pouch display (RR=3.09 in 2014 and 3.10 in 2018) and active smoking (RR=3.16 in 2014 compared with 3.32 in 2018) were higher at venues without children present, compared with venues with children present (this finding was consistent over time).

Conclusions

The reduction in the number of visible packs per active smoker, along with the reduction in face-up positioning of packs, suggests that smokers found the new standardised packs less attractive. Countries introducing standardised packaging should consider evaluating social display of tobacco packaging.
Public awareness of and responses to media coverage of invitation errors in the Breast Screening Programme in England: a cross-sectional population survey
Authors: Ghanouni Alex , von Wagner Christian , Waller Jo
Published: September 2019

Objectives

In May 2018, the British Health Secretary announced the ‘serious failure’ that 450 000 women had missed out on invitations to breast screening in England, leading to extensive media coverage. This study measured public awareness of the story and tested for associated factors (eg, educational level and trust in the National Health Service (NHS)).

Design

A computer-assisted face-to-face survey in June 2018.

Setting

Participants completed the survey in their homes.

Participants

Males and females aged 16 years or older in England.

Primary and secondary outcome measures

Awareness of aspects of the media coverage and reported statistics. Other data included demographics (eg, ethnicity), awareness of unrelated contemporaneous news stories, trust in participants’ general practitioners (GPs) and the NHS, and (among women) worry about breast cancer and future breast screening intentions.

Results

Descriptive statistics showed that 67% of 1894 participants reported being aware of the media coverage. Regression analyses showed that those who were aware of other news stories, were white British and had a higher level of education or social grade were more likely to be aware. In contrast, only 36% correctly identified at least one of two headline statistics. This study did not find evidence that awareness was negatively associated with trust in participants’ GPs or the NHS, breast cancer worry or future breast cancer screening intentions.

Conclusions

Awareness of the breast screening news story was high but recall of reported statistics was much lower: the public may have retained only the gist of quantitative information. Associations between story awareness and attitudes or behaviour were not apparent.
Are perioperative interventions effective in preventing chronic pain after primary total knee replacement? A systematic review
Authors: Beswick Andrew David , Dennis Jane , Gooberman-Hill Rachael , Blom Ashley William , Wylde Vikki
Published: September 2019

Objectives

For many people with advanced osteoarthritis, total knee replacement (TKR) is an effective treatment for relieving pain and improving function. Features of perioperative care may be associated with the adverse event of chronic pain 6 months or longer after surgery; effects may be direct, for example, through nerve damage or surgical complications, or indirect through adverse events. This systematic review aims to evaluate whether non-surgical perioperative interventions prevent long-term pain after TKR.

Methods

We conducted a systematic review of perioperative interventions for adults with osteoarthritis receiving primary TKR evaluated in a randomised controlled trial (RCT). We searchedThe Cochrane Library, MEDLINE, Embase, PsycINFO and CINAHL until February 2018. After screening, two reviewers evaluated articles. Studies at low risk of bias according to the Cochrane tool were included.

Interventions

Perioperative non-surgical interventions; control receiving no intervention or alternative treatment.

Primary and secondary outcome measures

Pain or score with pain component assessed at 6 months or longer postoperative.

Results

44 RCTs at low risk of bias assessed long-term pain. Intervention heterogeneity precluded meta-analysis and definitive statements on effectiveness. Good-quality research provided generally weak evidence for small reductions in long-term pain with local infiltration analgesia (three studies), ketamine infusion (one study), pregabalin (one study) and supported early discharge (one study) compared with no intervention. For electric muscle stimulation (two studies), anabolic steroids (one study) and walking training (one study) there was a suggestion of more clinically important benefit. No concerns relating to long-term adverse events were reported. For a range of treatments there was no evidence linking them with unfavourable pain outcomes.

Conclusions

To prevent chronic pain after TKR, several perioperative interventions show benefits and merit further research. Good-quality studies assessing long-term pain after perioperative interventions are feasible and necessary to ensure that patients with osteoarthritis achieve good long-term outcomes after TKR.
Analysis of English general practice level data linking medication levels, service activity and demography to levels of glycaemic control being achieved in type 2 diabetes to improve clinical practice and patient outcomes
Authors: Heald Adrian , Davies Mark , Stedman Mike , Livingston Mark , Lunt Mark , Fryer Anthony , Gadsby Roger
Published: September 2019

Objective

Evaluate relative clinical effectiveness of treatment options for type 2 diabetes mellitus (T2DM) using a statistical model of real-world evidence within UK general practitioner practices (GPP), to quantify the opportunities for diabetes care performance improvement.

Method

From the National Diabetes Audit in 2015–2016 and 2016–2017, GPP target glycaemic control (TGC—%HbA1c ≤58 mmol/mol) and higher glycaemic risk (HGR —%HbA1c results >86 mmol/mol) outcomes were linked using multivariate linear regression to prescribing, demographics and practice service indicators. This was carried out both cross-sectionally (XS) (within year) and longitudinally (Lo) (across years) on 35 indicators. Standardised β coefficients were used to show relative level of impact of each factor. Improvement opportunity was calculated as impact on TGC & HGR numbers.

Results

Values from 6525 GPP with 2.7 million T2DM individuals were included. The cross-sectional model accounted for up to 28% TGC variance and 35% HGR variance, and the longitudinal model accounted for up to 9% TGC and 17% HGR variance. Practice service indicators including % achieving routine checks/blood pressure/cholesterol control targets were positively correlated, while demographic indicators including % younger age/social deprivation/white ethnicity were negatively correlated. The β values for selected molecules are shown as (increased TGC; decreased HGR), canagliflozin (XS 0.07;0.145/Lo 0.04;0.07), metformin (XS 0.12;0.04/Lo –;–), sitagliptin (XS 0.06;0.02/Lo 0.10;0.06), empagliflozin (XS–;0.07/Lo 0.09;0.07), dapagliflozin (XS –;0.04/Lo –;0.4), sulphonylurea (XS −0.18;−0.12/Lo–;–) and insulin (XS−0.14;0.02/ Lo−0.09;–). Moving all GPP prescribing and interventions to the equivalent of the top performing decile of GPP could result in total patients in TGC increasing from 1.90 million to 2.14 million, and total HGR falling from 191 000 to 123 000.

Conclusions

GPP using more legacy therapies such as sulphonylurea/insulin demonstrate poorer outcomes, while those applying holistic patient management/use of newer molecules demonstrate improved glycaemic outcomes. If all GPP moved service levels/prescribing to those of the top decile, both TGC/HGR could be substantially improved.
Socioeconomic determinants of chronic health diseases among older Indian adults: a nationally representative cross-sectional multilevel study
Authors: Singh Prashant Kumar , Singh Lucky , Dubey Ritam , Singh Shalini , Mehrotra Ravi
Published: September 2019

Objective

Study uses multilevel modelling to examine the effect of individual, household and contextual characteristics on chronic diseases among older Indian adults.

Design

Nationally representative cross-sectional study.

Participants

Data from the nationally representative, India Human Development Survey conducted in 2011–2012 was used in this study. The survey asked information related to the diagnosed chronic illnesses such as cataract, tuberculosis, hypertension, heart disease and others. The sample size of this study comprised 39 493 individuals who belonged to the age group 50 years and above.

Measures

Self-reported diagnosed chronic illness.

Method

Considering the hierarchal structure of the data multilevel logistic regression analysis was applied to attain the study objective.

Results

Older adults aged 80 years and older were found with three times more chances (OR: 3.99, 95% CI 2.91 to 5.48) of suffering from a chronic ailment than 50–54 years old. Lifestyle risk factors such as alcohol and tobacco (smoked and smokeless) consumption were noted to be significantly associated with the presence of chronic illness whereas older adults who have never consumed smokeless tobacco stood 20% fewer chances (OR: 0.80, 95% CI 0.68 to 0.94) of having any chronic illness. Contextual level variables such as older adults residing in the rural areas were found with 17% fewer chances (OR: 0.83, 95% CI 0.70 to 0.97) of suffering from a chronic illness.

Conclusion

Even after controlling for various characteristics at the individual, household and contextual levels, significant variations in chronic illness remain unexplained at the community and state level, respectively. The findings of this study could effectively be utilised to consider more contextual variables to examine the chronic health status among the growing older population of India.
Pharmaceutical payments to certified oncology specialists in Japan in 2016: a retrospective observational cross-sectional analysis
Authors: Ozaki Akihiko , Saito Hiroaki , Onoue Yosuke , Sawano Toyoaki , Shimada Yuki , Somekawa Yurie , Tsuji Aritsune , Tanimoto Tetsuya
Published: September 2019

Objective

This study investigated payments made by pharmaceutical companies to oncology specialists in Japan, what the payments were for and whether the receipt of such payments contravened any conflict of interest (COI) regulations.

Design, setting and participants

Payment data to physicians, as reported by all pharmaceutical companies belonging to the Japan Pharmaceutical Manufacturers Association, were retrospectively extracted for 2016. Of the named individual recipients of payments, all certified oncologists were identified, using certification data from the Japanese Society of Medical Oncology (JSMO). The individual specialisations of each of the oncologists was also identified.

Outcome

Payments to individual cancer specialists and what they were for were identified. Factors associated with receipt of higher value payments and payment flows to specialties were determined. Companies selling oncology drugs with annual sales of ≥5 billion yen (£33.9 million, €40.2 million and $46.0 million) (high revenue-generating drugs) were identified.

Results

In total, 59 companies made at least one payment to oncologists. Of the 1080 oncology specialists identified, 763 (70.6%) received at least one payment, while 317 received no payment. Of the 763, some 142 (13.1%) receiving at least 1 million yen (£6,800, €8,000 and $9200) accounted for 71.5% of the total. After adjustment of covariates, working for university hospitals and cancer hospitals and male gender were key factors associated with larger monetary payments. Payments preferentially targeted on cancer specialties using high revenue-generating drugs. The JSMO has its own COI policy for its members, but the policy did not mention any specific guidelines for certified oncology specialists.

Conclusion

Financial relationships were identified and quantified between pharmaceutical companies and oncology specialists, but the extent and worth varied significantly. Given the frequency and amounts of money involved in such linkages, it would be beneficial for specific COI regulations to be developed and policed for oncologists.
Cost-effectiveness of selective digestive decontamination (SDD) versus selective oropharyngeal decontamination (SOD) in intensive care units with low levels of antimicrobial resistance: an individual patient data meta-analysis
Authors: van Hout Denise , Plantinga Nienke L , Bruijning-Verhagen Patricia C , Oostdijk Evelien A N , de Smet Anne Marie G A , de Wit G Ardine , Bonten Marc J M , van Werkhoven Cornelis H
Published: September 2019

Objective

To determine the cost-effectiveness of selective digestive decontamination (SDD) as compared to selective oropharyngeal decontamination (SOD) in intensive care units (ICUs) with low levels of antimicrobial resistance.

Design

Post-hoc analysis of a previously performed individual patient data meta-analysis of two cluster-randomised cross-over trials.

Setting

24 ICUs in the Netherlands.

Participants

12 952 ICU patients who were treated with ≥1 dose of SDD (n=6720) or SOD (n=6232).

Interventions

SDD versus SOD.

Primary and secondary outcome measures

The incremental cost-effectiveness ratio (ICER; ie, costs to prevent one in-hospital death) was calculated by comparing differences in direct healthcare costs and in-hospital mortality of patients treated with SDD versus SOD. A willingness-to-pay curve was plotted to reflect the probability of cost-effectiveness of SDD for a range of different values of maximum costs per prevented in-hospital death.

Results

The ICER resulting from the fixed-effect meta-analysis, adjusted for clustering and differences in baseline characteristics, showed that SDD significantly reduced in-hospital mortality (adjusted absolute risk reduction 0.0195, 95% CI 0.0050 to 0.0338) with no difference in costs (adjusted cost difference €62 in favour of SDD, 95% CI –€1079 to €935). Thus, SDD yielded significantly lower in-hospital mortality and comparable costs as compared with SOD. At a willingness-to-pay value of €33 633 per one prevented in-hospital death, SDD had a probability of 90.0% to be cost-effective as compared with SOD.

Conclusion

In Dutch ICUs, SDD has a very high probability of cost-effectiveness as compared to SOD. These data support the implementation of SDD in settings with low levels of antimicrobial resistance.
Predicting future self-harm or suicide in adolescents: a systematic review of risk assessment scales/tools
Authors: Harris Isobel Marion , Beese Sophie , Moore David
Published: September 2019

Objective

This systematic review aimed to evaluate the ability of risk tools to predict the future episodes of suicide/self-harm in adolescents.

Design

Systematic review.

Data sources

MEDLINE, EMBASE, CINAHL and PsycINFO were searched from inception to 3 March 2018.

Eligibility criteria for selecting studies

Cohort studies, case–control studies and randomised controlled trials of adolescents aged 10–25 who had undergone risk assessment in a clinical setting following an episode of self-harm were included.

Data extraction and synthesis

Two independent reviewers extracted data and assessed risk of bias. Data were grouped by tool and narrative synthesis undertaken, with studies appraised using a checklist combining the QUIPS (Quality In Prognosis Studies) and QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies) tools.

Results

Of the 17 137 articles initially identified, 11 studies evaluating 10 separate tools were included. The studies varied in setting, population and outcome measure. The majority of the studies were rated as having an unclear risk of bias, and meta-analysis was not possible due to high variability between studies.

The ability of the tools to correctly identify those adolescents going on to make a self-harm/suicide attempt ranged from 27% (95% CI 10.7% to 50.2%) to 95.8% (95% CI 78.9% to 99.9%). A variety of metrics were provided for 1–10 points increases in various tools, for example, odds and HRs.

Conclusions

This systematic review is the first to explore the use of assessment tools in adolescents. The predictive ability of these tools varies greatly. No single tool is suitable for predicting a higher risk of suicide or self-harm in adolescent populations.

PROSPERO registration number

CRD42017058686
Effectiveness of pharmacological treatments in Duchenne muscular dystrophy: a protocol for a systematic review and meta-analysis
Authors: Pascual Morena Carlos , Martinez-Vizcaino Vicente , Álvarez-Bueno Celia , Fernández Rodríguez Ruben , Jiménez López Estela , Torres-Costoso Ana Isabel , Cavero-Redondo Iván
Published: September 2019

Introduction

In recent years, important advances have been made in the treatment of Duchenne muscular dystrophy (DMD). This protocol proposes a methodology for carrying out a systematic review and meta-analysis that aims to: (1) improve the evidence of the benefits of different pharmacological treatments in boys with DMD, and (2) compare the benefit of treatments specifically aimed at delaying the progression of disease in the functional outcomes.

Methods and analysis

This protocol is guided by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) and by the Cochrane Collaboration Handbook. A thorough selection of the literature will be done through the MEDLINE, EMBASE and Web of Science databases. The search will be conducted in English and Spanish. The Risk of Bias 2.0 tool from the Cochrane Collaboration will be used to assess the risk of bias. A narrative synthesis of the data will be performed. Meta-analysis will be conducted for effect of treatment on the 6 min walking distance (6MWD), North Star Ambulatory Assessment and Timed Functional Tests. Subgroup analyses will be performed by age or baseline values of the 6MWD, and overall bias.

Ethics and dissemination

The approval of an ethical committee is not required. All the included trials will comply with the current ethical standards and the Declaration of Helsinki. The results of this proposed systematic review and meta-analysis will provide a general overview and evidence concerning the effectiveness of pharmacological treatments in Duchenne muscular dystrophy. Findings will be disseminated to academic audiences through peer-reviewed publications, as well as to clinical audiences, patients’ associations and policy makers, and may influence guideline developers in order to improve outcomes for these patients.

PROSPERO registration number

CRD42018102207
Treatment success rate among adult pulmonary tuberculosis patients in sub-Saharan Africa: a systematic review and meta-analysis
Authors: Izudi Jonathan , Semakula Daniel , Sennono Richard , Tamwesigire Imelda K , Bajunirwe Francis
Published: September 2019

Objectives

To summarise treatment success rate (TSR) among adult bacteriologically confirmed pulmonary tuberculosis (BC-PTB) patients in sub-Saharan Africa (SSA).

Design

We searched MEDLINE, EMBASE, Google Scholar and Web of Science electronic databases for eligible studies published in the decade between 1 July 2008 and 30 June 2018. Two independent reviewers extracted data and disagreements were resolved by consensus with a third reviewer. We used random-effects model to pool TSR in Stata V.15, and presented results in a forest plot with 95% CIs and predictive intervals. We assessed heterogeneity with Cochrane’s (Q) test and quantified with I-squared values. We checked publication bias with funnel plots and Egger’s test. We performed subgroup, meta-regression, sensitivity and cumulative meta-analyses.

Setting

SSA.

Participants

Adults 15 years and older, new and retreatment BC-PTB patients.

Outcomes

TSR measured as the proportion of smear-positive TB cases registered under directly observed therapy in a given year that successfully completed treatment, either with bacteriologic evidence of success (cured) or without (treatment completed).

Results

31 studies (2 cross-sectional, 1 case–control, 17 retrospective cohort, 6 prospective cohort and 5 randomised controlled trials) involving 18 194 participants were meta-analysed. 28 of the studies had good quality data. Egger’s test indicated no publication bias, rather small study effect. The pooled TSR was 76.2% (95% CI 72.5% to 79.8%; 95% prediction interval, 50.0% to 90.0%, I2statistics=96.9%). No single study influenced the meta-analytical results or conclusions. Between 2008 and 2018, a gradual but steady decline in TSR occurred in SSA but without statistically significant time trend variation (p=0.444). The optimum TSR of 90% was not achieved.

Conclusion

Over the past decade, TSR was heterogeneous and suboptimal in SSA, suggesting context and country-specific strategies are needed to end the TB epidemic.

PROSPERO registration number

CRD42018099151.
Exploring healthcare providers’ perspectives of the paediatric discharge process in Uganda: a qualitative exploratory study
Authors: Nemetchek Brooklyn , Khowaja Asif , Kavuma Anthony , Kabajaasi Olive , Olirus Owilli Alex , Ansermino J Mark , Fowler-Kerry Susan , Jacob Shevin T , Kenya-Mugisha Nathan , Kabakyenga Jerome , Wiens Matthew O
Published: September 2019

Introduction

The burden of childhood mortality continues to be born largely by low-income and middle-income countries. The critical postdischarge period has been largely neglected despite evidence that mortality rates during this period can exceed inpatient mortality rates. However, there is a paucity of data on the paediatric discharge process from the perspective of the healthcare provider. Provider perspectives may be important in the development of an improved understanding of the barriers and facilitators to improving the transition from hospital to home.

Objectives

To explore healthcare providers’ and facility administrators’ perspectives of the paediatric discharge process with respect to: (1) current procedures, (2) barriers and challenges, (3) ideas for change, (4) facilitators for change and (5) the importance of discharge planning.

Design

A qualitative exploratory approach using focus groups (14) and in-depth interviews (7).

Setting

This study was conducted at seven hospitals providing paediatric care in Uganda.

Results

Current discharge procedures are largely based on hospital-specific protocols or clinician opinion, as opposed to national guidelines. Some key barriers to an improved discharge process included caregiver resources and education, critical communication gaps, traditional practices, and a lack of human and physical resources. Teamwork and motivation to see improved paediatric transitions to home were identified as facilitators to implementing the ideas for change proposed by participants. The need for a standardised national policy guiding paediatric discharges, implemented through education at many levels and coupled with appropriate community referral and follow-up, was broadly perceived as essential to improving outcomes for children.

Conclusions

Although significant challenges and gaps were identified within the current health system, participants’ ideas and the identified facilitators provide a significant basis from which change may occur. This work can facilitate the development of sustainable and effective interventions to improve postdischarge outcomes in Uganda and other similar settings.
Trends in educational and wealth inequalities in adult tobacco use in Nepal 2001–2016: secondary data analyses of four Demographic and Health Surveys
Authors: Sreeramareddy Chandrashekhar T , Harper Sam
Published: September 2019

Objective

To measure trends in socioeconomic inequalities tobacco use in Nepal.

Setting

Adults interviewed during house-to-house surveys.

Participants

Women (15–45 years) and men (15–49 years) surveyed in four Nepal Demographic and Health Surveys done in 2001, 2006, 2011 and 2016.

Outcome measure

Current tobacco use (in any form).

Results

The prevalence of tobacco use for men declined from 66% in 2001 to 55% in 2016, and declined from 29% to 8.4% among women. Across both education and wealth quintiles for both men and women, the prevalence of tobacco use generally declines with increasing education or wealth. We found persistently larger absolute inequalities by education than by wealth among men. Among women we also found larger educational than wealth-related gradients, but both declined over time. For men, the Slope Index of Inequality (SII) for education was larger than for wealth (44% vs 26% in 2001) and changed very little over time. For women, the SII for both education and wealth were similar in magnitude to men, but decreased substantially between 2001 and 2016 (from 44% to 16% for education; from 37% to 16% for wealth). Women had a larger relative index of inequality than men for both education (6.5 vs 2.0 in 2001) and wealth (4.8 vs 1.5 in 2001), and relative inequality increased between 2001 and 2016 for women (from 6.5 to 16.0 for education; from 4.8 to 12.0 for wealth).

Conclusion

Increasing relative inequalities indicates suboptimal reduction in tobacco use among the vulnerable groups suggesting that they should be targeted to improve tobacco control.
The use of the environmental scan in health services delivery research: a scoping review protocol
Authors: Charlton Patricia , Doucet Shelley , Azar Rima , Nagel Daniel A , Boulos Leah , Luke Alison , Mears Kim , Kelly Katherine J , Montelpare William J
Published: September 2019

Introduction

The environmental scan has been described as an important tool to inform decision-making on policy, planning and programme development in the healthcare sector. Despite the wide adoption of environmental scans, there is no consensus on a working definition within the health services delivery context and methodological guidance on the design and implementation of this approach is lacking in the literature. The objectives of this study are to map the extent, range and nature of evidence that describe the definitions, characteristics, conceptualisations, theoretical underpinnings, study limitations and other features of the environmental scan in the health services delivery literature and to propose a working definition specific to this context.

Methods and analysis

This protocol describes a scoping review based on the methodology outlined by Khalil and colleagues. A comprehensive search strategy was developed by experienced health science librarians in consultation with the research team. A Peer Review of Electronic Search Strategies (PRESS) was completed. Two reviewers will independently screen titles, abstracts and full-text articles and select studies meeting the inclusion criteria from seven electronic databases: Academic Search Premier, Canadian Business & Current Affairs (CBCA), CINAHL, ERIC, Embase, MEDLINE and PsycINFO. The grey literature and reference lists of included articles will also be searched. The data will be analysed and presented in tabular format, and will include a descriptive numerical summary as well as a qualitative thematic analysis.

Ethics and dissemination

This protocol provides an audit trail for a scoping review that will advance understanding about the environmental scan and its application in the health services delivery context. The review will propose a working definition and will inform future research to explore the development of a conceptual framework in this context. Findings will be disseminated through a peer-reviewed journal and conference presentations. The scoping review does not require ethics approval.
Associations of maternal diet with infant adiposity at birth, 6 months and 12 months
Authors: Gonzalez-Nahm Sarah , Hoyo Cathrine , Østbye Truls , Neelon Brian , Allen Carter , Benjamin-Neelon Sara E
Published: September 2019

Objectives

To assess associations between maternal prenatal diet quality and infant adiposity.

Design

The design was a prospective birth cohort.

Setting

We used data from the Nurture study, a cohort of women and their infants residing in the southeastern USA.

Participants and exposure assessment

Between 2013 and 2015, we enrolled 860 women between 20 and 36 weeks’ gestation. After reconsenting at delivery and excluding women with implausible calorie intakes, we measured dietary intake using the Block food frequency questionnaire, and assessed diet quality using a modified Alternate Healthy Eating Index 2010 (AHEI-2010), which assessed intake of 10 food categories, including fruits, vegetables, whole grains, nuts/legumes, fats, meats, beverages and sodium (excluding alcohol).

Outcomes

We assessed birth weight for gestational age z-score, small and large for gestational age, low birth weight and macrosomia. Outcomes at 6 and 12 months were weight-for-length z-score, sum of subscapular and triceps skinfold thickness (SS+TR) and subscapular-to-triceps skinfold ratio (SS:TR).

Results

Among mothers, 70.2% were black and 20.9% were white; less than half (45.2%) reported having a high school diploma or less. Among infants, 8.7% were low birth weight and 8.6% were small for gestational age. Unadjusted estimates showed that a higher AHEI-2010 score, was associated with a higher birth weight for gestational z-score (β=0.01; 95% CI 0.002 to 0.02; p=0.02) and a greater likelihood of macrosomia (OR=1.04; 95% CI 1.004 to 1.09; p=0.03). After adjustment, maternal diet quality was not associated with infant adiposity at birth, 6 or 12 months.

Conclusions

Although poor maternal diet quality during pregnancy was not associated with infant adiposity in our study, maternal diet during pregnancy may still be an important and modifiable factor of public health importance.
The perioperative administration of dexamethasone and infection (PADDI) trial protocol: rationale and design of a pragmatic multicentre non-inferiority study
Authors: Corcoran Tomás B , Myles Paul S , Forbes Andrew B , O'Loughlin Ed , Leslie Kate , Story David , Short Timothy G , Chan Matthew TV , Coutts Pauline , Sidhu Jaspreet , Cheng Allen C , Bach Leon A , Ho Kwok M
Published: September 2019

Introduction

The intraoperative administration of dexamethasone for prophylaxis against postoperative nausea and vomiting is a common and recommended practice. The safety of the administration of this immunosuppressive agent at a time of significant immunological disruption has not been rigorously evaluated in terms of infective complications.

Methods/analysis

This is a pragmatic, multicentre, randomised, controlled, non-inferiority trial. A total of 8880 patients undergoing elective major surgery will be enrolled. Participants will be randomly allocated to receive either dexamethasone 8 mg or placebo intravenously following the induction of anaesthesia in a 1:1 ratio, stratified by centre and diabetes status. Patient enrolment into the trial is ongoing. The primary outcome is surgical site infection at 30 days following surgery, defined according to the Centre for Disease Control criteria.

Ethics/dissemination

The PADDI trial has been approved by the ethics committees of over 45 participating sites in Australia, New Zealand, Hong Kong, South Africa and the Netherlands. The trial has been endorsed by the Australia and New Zealand College of Anaesthetists Clinical Trials Network and the Australian Society for Infectious Diseases Clinical Research Network. Participant recruitment began in March 2016 and is expected to be complete in mid-2019. Publication of the results of the PADDI trial is anticipated to occur in early 2020.

Trial registration number

ACTRN12614001226695.
A qualitative inquiry into implementing an electronic health record system (SmartCare) for prevention of mother-to-child transmission data in Zambia: a retrospective study
Authors: Gumede-Moyo Sehlulekile , Todd Jim , Bond Virginia , Mee Paul , Filteau Suzanne
Published: September 2019

Objective

This study aimed to investigate the challenges in implementing a Zambian electronic health records (EHR) system labelled ‘SmartCare’ from diverse stakeholder perspectives in order to improve prevention of mother-to-child transmission (PMTCT) data collection so that SmartCare can be used for clinic performance strengthening and programme monitoring.

Design

This is a qualitative retrospective study.

Setting and participants

SmartCare is a Zambian Ministry of Health (MoH)-led project funded by the US Centre for Disease Control and Prevention. Data were collected using in-depth interviews, observations and focus group discussions (FGDs) between September and November 2016. Seventeen in-depth interviews were held with a range of key informants from the MoH and local and international organisations implementing SmartCare. Four data entry observations and three FGDs with 22 pregnant and lactating women seeking PMTCT services were conducted. Data were analysed using a thematic content approach.

Results

The SmartCare system has evolved from various patient tracking systems into a multifunctional system. There is a burden of information required so that sometimes not all is collected and entered into the database, resulting in poor data quality. Funding challenges impede data collection due to manpower constraints and shortages of supplies. Challenges associated with data collection depend on whether a paper-based or computer-based system is used. There is no uniformity in the data quality verification and submission strategies employed by various IPs. There is little feedback from the EHR system at health facility level, which has led to disengagement as stakeholders do not see the importance of the system.

Conclusion

SmartCare has structural challenges which can be traced from its development. Funding gaps have resulted in staffing and data collection disparities within IPs. The lack of feedback from the system has also led to complacency at the operational level, which has resulted in poor data quality in later years.
Characterisation of concurrent use of prescription opioids and benzodiazepine/Z-drugs in Alberta, Canada: a population-based study
Authors: Sharma Vishal , Weir Daniala , Samanani Salim , Simpson Scot H , Gilani Fizza , Jess Ed , Eurich Dean T
Published: September 2019

Objective

The objective of this study is to characterise concurrent use of benzodiazepine receptor modulators and opioids among prescription opioid users in Alberta in 2017.

Design

A population based retrospective study.

Setting

Alberta, Canada, in the year 2017.

Participants

All individuals in Alberta, Canada, with at least one dispensation record from a community pharmacy for an opioid in the year 2017.

Exposure

Concurrent use of a benzodiazepine receptor modulator and opioid, defined as overlap of supply for both drugs for at least 1 day.

Main outcome measures

Prevalence of concurrency was estimated among subgroups of patient characteristics that were considered clinically relevant or associated with inappropriate medication use.

Results

Among the 547 709 Albertans who were dispensed opioid prescriptions in 2017, 132 156 (24%) also received prescriptions for benzodiazepine receptor modulators. There were 96 581 (17.6%) prescription opioid users who concurrently used benzodiazepine receptor modulators with an average of 98 days (SD=114, 95% CI 97 to 99) of total cumulative concurrency and a median of 37 days (IQR 10 to 171). The average longest duration of consecutive days of concurrency was 45 (SD=60, 95% CI 44.6 to 45.4) with a median of 24 days (IQR 8 to 59). Concurrency was more prevalent in females, patients using an average daily oral morphine equivalent >90 mg, opioid dependence therapy patients, chronic opioid users, patients utilising a high number of unique providers, lower median household incomes and those older than 65 (p value<0.001 for all comparisons).

Conclusions

Concurrent prescribing of opioids and benzodiazepine receptor modulators is common in Alberta despite the ongoing guidance of many clinical resources. Older patients, those taking higher doses of opioids, and for longer durations may be at particular risk of adverse outcomes and may be worthy of closer follow-up for assessment for dose tapering or discontinuations. As well, those with higher healthcare utilisation (seeking multiple providers) should also be closely monitored. Continued surveillance of concurrent use of these medications is warranted to ensure that safe drug use recommendations are being followed by health providers.
Quality of life in the limelight: a study protocol of a Swedish register-based cohort study on quality of life after an injury
Authors: Hasselberg Marie , Rissanen Ritva
Published: September 2019

Introduction

Currently, there are very few published studies on preinjury and postinjury assessments of quality of life (QoL) based on a prospective appraisal; specifically, knowledge of those who do not seek medical care following injury is lacking. To close these knowledge gaps, this study aims to identify the psychosocial consequences in terms of loss of QoL following injury in a Swedish population and to investigate the response shift in retrospective measures of self-reported QoL.

Methods and analysis

We will analyse preinjury and postinjury (including both minor and severe unintentional injuries as well as different injury mechanisms) assessments of QoL, including the phenomenon of response shift, using register-based data from the nationwide collaboration project LifeGene, which includes over 52 000 individuals living in Sweden. In addition to LifeGene data, a short online survey including a ‘ThenTest’ questionnaire, that is, comparison of previous QoL to current using EuroQoL five-dimensional questionnaire, was sent out to the participants of LifeGene. This study will provide a unique opportunity to study the changes in QoL by comparing preinjury and postinjury assessments using a prospective appraisal, both for populations who have sought medical care as well as those who have not due to their injury. Similarly, the study will also assess the response shift in retrospective measures of QoL. This information can guide the next generation of QoL measures and interventions for those suffering injuries and have an impact on how to interpret evaluations of interventions.

Ethics and dissemination

The study has been reviewed and approved by the Regional Ethical Review Board in Stockholm, Sweden (case number 2018/352-31). The results will be disseminated through peer-reviewed journals, conference presentations, print media and internet and via a report for the funding agency.