bluuebunny/crossref_metadata_2025 huggingface dataset:
Lack of effects of evidence-based, individualised counselling on medication use in insured patients with mild hypertension in China: a randomised controlled trial
Authors: Di Mengyang , Mao Chen , Yang Zuyao , Ding Hong , Liu Qu , Liu Shuiming , Guo Hongbo , Jiang Kunhua , Tang Jinling
Published: August 2019

Objective

To evaluate whether evidence-based, individualised (EBI) counselling regarding hypertension and the treatment would affect medication use in insured patients with mild hypertension in China.

Methods

We conducted a parallel-group, randomised controlled trial in two primary care centres in Shenzhen, a metropolitan city in China. Patients with mild primary hypertension, 10-year risk of cardiovascular diseases (CVDs) lower than 20% and no history of CVDs were recruited and randomly allocated to two groups. EBI plus general counselling was provided to the intervention group and general counselling alone to the control group. EBI counselling included information on the 10-year CVD risk and treatment benefit in terms of absolute risk reduction estimated for each individual and information on average side effects and costs of antihypertensive drugs. The outcomes included use of antihypertensive drugs and adherence to the treatment at 6-month follow-up, with the former being primary outcome.

Results

Two hundred and ten patients were recruited, with 103 and 107 allocated to the intervention and control groups, respectively. At baseline, 62.4% of the patients were taking antihypertensive drugs that were all covered by health insurance. At the end of 6-month follow-up, there was no statistically significant difference in the rate of medication use between the intervention group and the control group (65.0% vs 57.9%; OR=1.35, 95% CI: 0.77 to 2.36). The difference in adherence rate between the two groups was not statistically significant either (43.7% vs 40.2%; OR=1.15, 95% CI 0.67 to 2.00]). The results were robust in sensitivity analyses that used different cutoffs to define the two outcomes.

Conclusions

The EBI counselling by health educators other than the caring physicians had little impact on treatment choices and drug-taking behaviours in insured patients with mild primary hypertension in this study. It remains unclear whether EBI counselling would make a difference in uninsured patients, especially when conducted by the caring physicians.

Trial registration number

ChiCTR-TRC-14004169.
Tracking development assistance for reproductive, maternal, newborn, child and adolescent health in conflict-affected countries
Authors: Li Zhihui , Richter Linda , Lu Chunling
Published: August 2019

Background

Little is known about the patterns of development assistance (DA) for each component of reproductive, maternal, newborn, child and adolescent health (RMNCAH) in conflict-affected countries nor about the DA allocation in relation to the burden of disease.

Methods

We tracked DA to RMNCAH in general and to each of its four components: reproductive health (RH), maternal and newborn health (MNH), child health (CH) and adolescent health (AH), in 25 conflict-affected countries between 2003 and 2017. We compared DA and disability-adjusted life years (DALYs) for each component. Using keyword searching and funding allocation methods, we produced two sets of estimates: DA primarily targeting RMNCAH (lower bound) and DA both primarily and partially for RMNCAH or DA not explicitly targeting RMNCAH but benefiting it (upper bound).

Findings

Between 2003 and 2017, we identified 46 833 projects among the 25 countries that targeted RMNCAH. During the study period, DA to RMNCAH increased by seven-fold from $0.5 billion to $3.6 billion, with a slowdown since 2013. Cumulatively, RH received the largest proportion of DA to RMNCAH (50%) with 84% of its funding earmarked for HIV/AIDS, which contributed to less than 6% of the total RMNCAH-related DALYs. AH received 3% of the DA-RMNCAH but contributed 15% to the RMNCAH-related DALYs. Non-communicable diseases caused more than one-third of the DALYs among adolescents, but received only 3% of DA to AH. RMNCAH-inclusive estimates showed consistent results.

Conclusion

While there was a substantial increase in funding to RMNCAH in conflict-affected countries over the period of study, some health issues with high disease burden (eg, AH and non-communicable diseases) received a disproportionately small portion of aid for RMNCAH. We recommend that donors increase investment to RMNCAH in conflict-affected countries, particularly in areas where the burden of disease or the potential benefit of investment is likely to be high.
Comparison of different approaches to antibiotic restriction in food-producing animals: stratified results from a systematic review and meta-analysis
Authors: Tang Karen L , Caffrey Niamh P , Nóbrega Diego B , Cork Susan C , Ronksley Paul E , Barkema Herman W , Polachek Alicia J , Ganshorn Heather , Sharma Nishan , Kellner James D , Checkley Sylvia L , Ghali William A
Published: August 2019

Background

We have previously reported, in a systematic review of 181 studies, that restriction of antibiotic use in food-producing animals is associated with a reduction in antibiotic-resistant bacterial isolates. While informative, that report did not concretely specify whether different types of restriction are associated with differential effectiveness in reducing resistance. We undertook a sub-analysis of the systematic review to address this question.

Methods

We created a classification scheme of different approaches to antibiotic restriction: (1) complete restriction; (2) single antibiotic-class restriction; (3) single antibiotic restriction; (4) all non-therapeutic use restriction; (5) growth promoter and prophylaxis restriction; (6) growth promoter restriction and (7) other/undetermined. All studies in the original systematic review that were amenable to meta-analysis were included into this substudy and coded by intervention type. Meta-analyses were conducted using random effects models, stratified by intervention type.

Results

A total of 127 studies were included. The most frequently studied intervention type was complete restriction (n=51), followed by restriction of non-therapeutic (n=33) and growth promoter (n=19) indications. None examined growth promoter and prophylaxis restrictions together. Three and seven studies examined single antibiotic-class and single antibiotic restrictions, respectively; these two intervention types were not significantly associated with reductions in antibiotic resistance. Though complete restrictions were associated with a 15% reduction in antibiotic resistance, less prohibitive approaches also demonstrated reduction in antibiotic resistance of 9%–30%.

Conclusion

Broad interventions that restrict global antibiotic use appear to be more effective in reducing antibiotic resistance compared with restrictions that narrowly target one specific antibiotic or antibiotic class. Importantly, interventions that allow for therapeutic antibiotic use appear similarly effective compared with those that restrict all uses of antibiotics, suggesting that complete bans are not necessary. These findings directly inform the creation of specific policies to restrict antibiotic use in food-producing animals.
Predicting the risk of stroke among patients with type 2 diabetes: a systematic review and meta-analysis of C-statistics
Authors: Chowdhury Mohammad Ziaul Islam , Yeasmin Fahmida , Rabi Doreen M , Ronksley Paul E , Turin Tanvir C
Published: August 2019

Objective

Stroke is a major cause of disability and death worldwide. People with diabetes are at a twofold to fivefold increased risk for stroke compared with people without diabetes. This study systematically reviews the literature on available stroke prediction models specifically developed or validated in patients with diabetes and assesses their predictive performance through meta-analysis.

Design

Systematic review and meta-analysis.

Data sources

A detailed search was performed in MEDLINE, PubMed and EMBASE (from inception to 22 April 2019) to identify studies describing stroke prediction models.

Eligibility criteria

All studies that developed stroke prediction models in populations with diabetes were included.

Data extraction and synthesis

Two reviewers independently identified eligible articles and extracted data. Random effects meta-analysis was used to obtain a pooled C-statistic.

Results

Our search retrieved 26 202 relevant papers and finally yielded 38 stroke prediction models, of which 34 were specifically developed for patients with diabetes and 4 were developed in general populations but validated in patients with diabetes. Among the models developed in those with diabetes, 9 reported their outcome as stroke, 23 reported their outcome as composite cardiovascular disease (CVD) where stroke was a component of the outcome and 2 did not report stroke initially as their outcome but later were validated for stroke as the outcome in other studies. C-statistics varied from 0.60 to 0.92 with a median C-statistic of 0.71 (for stroke as the outcome) and 0.70 (for stroke as part of a composite CVD outcome). Seventeen models were externally validated in diabetes populations with a pooled C-statistic of 0.68.

Conclusions

Overall, the performance of these diabetes-specific stroke prediction models was not satisfactory. Research is needed to identify and incorporate new risk factors into the model to improve models’ predictive ability and further external validation of the existing models in diverse population to improve generalisability.
Do we need a core curriculum for medical students? A scoping review
Authors: Sharma Maulina , Murphy Ruth , Doody Gillian A
Published: August 2019

Objective

The General Medical Council (GMC) recommends medical schools to develop and implement curricula enabling students to achieve the required learning outcomes. UK medical schools follow the GMC’s Outcomes for graduates, which are generic. GMC plans to introduce a national Medical Licensing Assessment (MLA) for the medical graduates wanting to practise medicine in the UK in 2022. With no standardised or unified undergraduate (UG) curriculum in UK, various specialties have expressed concerns about not being represented in medical schools and developed specialty-specific core curricula. The aim of this review was to identify learned bodies who have developed a core curriculum for UK medical schools and highlight the drivers, gaps and future approaches to curricular development and implementation.

Methods

A literature search was conducted using online databases (EMBASE, MEDLINE, ERIC, HMIC, PubMed and CDSR), search engines and related websites (Google and Google Scholar, Department of Health, GMC and BMA) for relevant articles from 1996 to 5 March 2019 (~20 years). A methodological framework to map the key concepts of UG medical curriculum was followed. Any relevant body with a core curriculum for UK medical UGs was included.

Results

A total of 1283 articles were analysed with 31 articles included in the qualitative synthesis, comprising 26 specialties (clinical n=18, foundation subjects n=4 and professionalism related n=4). WHO, European and national (eg, Royal Colleges of UK) specialty bodies provided specific core learning outcomes for the medical graduates. Patient safety, disease burden, needs of society and inadequate preparedness of medical graduates were drivers for the development of these curricula.

Conclusions

This is the first comprehensive review of literature on UG core curricula recommending minimum standards on knowledge and skills, in alignment with GMC’s Outcomes for graduates for all the UK medical students. Adopting and assessing unified standards would help reduce variability across UK medical schools for both generic and specialty-specific competencies.
Use of varenicline and nicotine replacement therapy in people with and without general practitioner-recorded dementia: retrospective cohort study of routine electronic medical records
Authors: Itani Taha , Martin Richard , Rai Dheeraj , Jones Tim , Taylor Gemma , Thomas Kyla , Munafo Marcus , Davies Neil , Taylor Amy
Published: August 2019

Objectives

Our primary objective was to estimate smoking prevalence and prescribing rates of varenicline and nicotine replacement therapy (NRT) in people with and without general practitioner (GP)-recorded dementia. Our secondary objective was to assess and compare quit rates of smokers with versus without GP-recorded dementia who were prescribed varenicline or NRT for smoking cessation.

Design

A retrospective cohort study based on the analysis of electronic medical records within the Clinical Practice Research Datalink (2007–2015).

Setting

683 general practices in England.

Participants

People with and without GP-recorded dementia, aged 18 years and have a code indicating that they are a current smoker.

Intervention

Index prescription of varenicline or NRT (from 1 September 2006).

Outcome measures

The primary outcomes were smoking prevalence and prescribing rates of varenicline and NRT (2007–2015). The secondary outcome was smoking cessation at 2 years.

Results

Age and sex-standardised prevalence of smoking was slightly higher in people with GP-recorded dementia than in those without. There were 235 314 people aged 18 years and above prescribed NRT or varenicline. Among smokers with GP-recorded dementia (N=447), 409 were prescribed NRT and 38 varenicline. Smokers with GP-recorded dementia were 74% less likely (95% CI 64% to 82%) to be prescribed varenicline than NRT, compared with smokers without GP-recorded dementia. Compared with people without GP-recorded dementia, people with GP-recorded dementia had consistently lower prescribing rates of varenicline from 2007 to 2015. Two years after prescription, there was no clear evidence for a difference in the likelihood of smoking cessation after prescription of these medications between individuals with and without dementia (OR 1.0, 95% CI 0.8 to 1.2).

Conclusions

Between 2007 and 2015, people with GP-recorded dementia were less likely to be prescribed varenicline than those without dementia. Quit rates following prescription of either NRT or varenicline were similar in those with and without dementia.
What change in body mass index is associated with improvement in percentage body fat in childhood obesity? A meta-regression
Authors: Birch Laura , Perry Rachel , Hunt Linda P , Matson Rhys , Chong Amanda , Beynon Rhona , Shield Julian PH
Published: August 2019

Objective

Using meta-regression this paper sets out the minimum change in body mass index-SD score (BMI-SDS) required to improve adiposity as percentage body fat for children and adolescents with obesity.

Design

Meta-regression.

Setting

Studies were identified as part of a large-scale systematic review of the following electronic databases: AMED, Embase, MEDLINE via OVID, Web of Science and CENTRAL via Cochrane library.

Participants

Individuals aged 4–19 years with a diagnosis of obesity according to defined BMI thresholds.

Interventions

Studies of lifestyle treatment interventions that included dietary, physical activity and/or behavioural components with the objective of reducing obesity were included. Interventions of <2 weeks duration and those that involved surgical and/or pharmacological components (eg, bariatric surgery, drug therapy) were excluded.

Primary and secondary outcome measures

To be included in the review, studies had to report baseline and post-intervention BMI-SDS or change measurements (primary outcome measures) plus one or more of the following markers of metabolic health (secondary outcome measures): adiposity measures other than BMI; blood pressure; glucose; inflammation; insulin sensitivity/resistance; lipid profile; liver function. This paper focuses on adiposity measures only. Further papers in this series will report on other outcome measures.

Results

This paper explores the potential impact of BMI-SDS reduction in terms of change in percentage body fat. Thirty-nine studies reporting change in mean percentage body fat were analysed. Meta-regression demonstrated that reduction of at least 0.6 in mean BMI-SDS ensured a mean reduction of percentage body fat mass, in the sense that the associated 95% prediction interval for change in mean percentage body fat was wholly negative.

Conclusions

Interventions demonstrating reductions of 0.6 BMI-SDS might be termed successful in reducing adiposity, a key purpose of weight management interventions.

Trial registration number

CRD42016025317.
Prevalence and risk factors of depression in patients with lung cancer: protocol for a systematic review and meta-analysis
Authors: Yan Xiao-ru , Chen Xun , Zhang Peitong
Published: August 2019

Introduction

Patients with lung cancer often experience heavy psychological distress, especially depression, which results in poorer quality of life, shorter survival time and greater mortality. Our aim is to summarise data on the prevalence and risk factors of depression in patients with lung cancer.

Methods and analysis

We will search PubMed, EMBASE, MEDLINE, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang and Chinese Biomedicine Literature Database (SinoMed) for studies on the prevalence and risk factors of depression in patients with lung cancer, which should be published from 1 January 1975 to 25 November 2018 in English/Chinese. Two reviewers will independently screen studies, extract data and assess the risk of bias. We will use RevMan V.5.0 and STATA V.12.0 software for statistical analysis. The I² test will be used to identify the extent of heterogeneity. Publication bias will be assessed by generating a funnel plot and performing the Begg and Egger test. The quality of the systematic review will be evaluated using the AMSTAR (‘A Measurement Tool to Assess Systematic Reviews’) criteria and ‘The Grading of Recommendations Assessment, Development and Evaluation’.

Ethics and dissemination

Since this is a review involving analysis of publicly available data, ethical approval is not required. The final results of this study will be published in a peer-reviewed journal.

PROSPERO registration number

CRD42018118167.
The global epidemiology of viral-induced acute liver failure: a systematic review protocol
Authors: Patterson Jenna , Hussey Hannah Sophia , Abdullahi Leila Hussein , Silal Sheetal , Goddard Liz , Setshedi Mashiko , Spearman Wendy , Hussey Gregory D , Kagina Benjamin , Muloiwa Rudzani
Published: August 2019

Introduction

The burden of viral-induced acute liver failure (ALF) around the world still remains unclear, with little to no data collected regarding the disease incidence in general and synthesised data on the relative contribution of different viruses to the aetiology of ALF is missing in the field. The aim of this review is to estimate the burden (prevalence, incidence, mortality, hospitalisation) of ALF following infectionHAV, HBV, HCV, HDV, HEV, EBV), HSV1, HSV2, VZV, parvo-virus B19, HPIVs, YFV, HVV-6, CMV, CA16 and/or HAdVs. Establishing the common aetiologies of viral-induced ALF, which vary geographically, is important so that: (1) treatment can be initiated quickly, (2) contraindications to liver transplant can be identified, (3) prognoses can be deterined more accurately, and most importantly, (4) vaccination against viral ALF aetiologies can be prioritised especially in under-resourced regions with public health risks associated with the relevant attributable diseases.

Methods and analysis

EBSCOhost, PubMed, ScienceDirect, Scopus and Web of Science databases will be searched for relevant literature published and grey literature from 2009 up to 2019. Published cross-sectional and cohort studies will be eligible for inclusion in this review. Qualifying studies will be formally assessed for quality and risk of bias using a standardised scoring tool. Following standardised data extraction, meta-analyses will be carried out using STATA. Depending on characteristics of included studies, subgroup analyses and meta-regression analyses will be performed. This review will be reported according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.

Ethics and dissemination

No ethics approval is required as the systematic review will use only published data already in the public domain. Findings will be disseminated through publication in a peer-reviewed journal.

PROSPERO registration number

CRD42018110309
Cervical cancer screening uptake and correlates among HIV-infected women: a cross-sectional survey in Côte d’Ivoire, West Africa
Authors: Tchounga Boris , Boni Simon Pierre , Koffi Jean Jacques , Horo Apollinaire G , Tanon Aristophane , Messou Eugène , Koulé Serge-Olivier , Adoubi Innocent , Ekouevi Didier K , Jaquet Antoine
Published: August 2019

Objectives

Despite the increasing number of interventions aiming to integrate cervical cancer screening into HIV clinics in sub-Saharan Africa, Women living with HIV (WLHIV) still have a high risk of developing cervical cancer. The aim of this study was to estimate the coverage of cervical cancer screening and associated factors among WLHIV in Abidjan, Côte d’Ivoire.

Design

Cross-sectional survey conducted from May to August 2017.

Settings

Outpatient setting in the four highest volume urban HIV clinics of government’s or non-governmental organisation’s sector in Côte d’Ivoire.

Participants

All WLHIV, aged 25–55 years, followed since at least 1 year, selected through a systematic sampling procedure.

Intervention

A standardised questionnaire administered to each participant by trained healthcare workers.

Outcome

Cervical cancer screening uptake.

Results

A total of 1991 WLHIV were included in the study, aged in median 42 years (IQR 37–47), and a median CD4 count (last known) of 563 (378-773) cells/mm3. Among the participants, 1913 (96.1%) had ever heard about cervical cancer, 1444 (72.5%) had been offered cervical cancer screening, mainly in the HIV clinic for 1284 (88.9%), and 1188 reported a personal history of cervical cancer screening for an overall coverage of 59.7% (95% CI 57.6 to 62.0). In multivariable analysis, university level (adjusted OR (aOR) 2.1; 95% CI 1.4 to 3.1, p<0.001), being informed on cervical cancer at the HIV clinic (aOR 1.5; 95% CI 1.1 to 2.0, p=0.017), receiving information self-perceived as ‘clear and understood’ on cervical cancer (aOR 1.7; 95% CI 1.4 to 2.2, p<0.001), identifying HIV as a risk factor for cervical cancer (aOR 1.4; 95% CI 1.1 to 1.8, p=0.002) and being proposed cervical cancer screening in the HIV clinic (aOR 10.1; 95% CI 7.6 to 13.5, p<0.001), were associated with cervical cancer screening uptake.

Conclusion

Initiatives to support cervical cancer screening in HIV care programmes resulted in effective access to more than half of the WLHIV in Abidjan. Efforts are still needed to provide universal access to cervical cancer screening, especially among socioeconomically disadvantaged WLHIV.
Quality of essential newborn care and neonatal resuscitation at health facilities in Afghanistan: a cross-sectional assessment
Authors: Atiqzai Faridullah , Manalai Partamin , Amin Sher Shah , Edmond Karen M , Naziri Malalai , Soroush Mohammad Samim , Sultana Sharmina , Yousufi Khaksar , van den Akker Thomas , Stekelenburg Jelle , Tappis Hannah
Published: August 2019

Objective

To assess readiness and quality of essential newborn care and neonatal resuscitation practices in public health facilities in Afghanistan.

Design

Cross-sectional assessment.

Setting

226 public health facilities in Afghanistan, including 77 public health facilities with at least five births per day (high-volume facilities) and 149 of 1736 public health facilities with fewer than five births per day (low-volume facilities).

Participants

Managers of 226 public health facilities, 734 skilled birth attendants (SBAs) working at these facilities, and 643 women and their newborns observed during childbirth at 77 high-volume health facilities.

Outcome measures

Availability of knowledgeable SBAs, availability of supplies and compliance with global guidelines for essential newborn care and neonatal resuscitation practices.

Results

At high-volume facilities, 569/636 (87.9%) of babies were dried immediately after birth, 313/636 (49.2%) were placed in skin-to-skin contact with their mother and 581/636 (89.7%) had their umbilical cord cut with a sterile blade or scissors. A total of 87 newborn resuscitation attempts were observed. Twenty-four of the 87 (27.5%) began to breath or cry after simply clearing the airway or on stimulation. In the remaining 63 (72.5%) cases, a healthcare worker began resuscitation with a bag and mask; however, only 54 (62%) used a correct size of mask and three babies died as their resuscitation with bag and mask was unsuccessful.

Conclusions

The study indicates room for improvement of the quality of neonatal resuscitation practices at public health facilities in Afghanistan, requiring only strengthening of the current best practices in newborn care. Certain basic and effective aspects of essential newborn care that can be improved on with little additional resources were also missing, such as skin-to-skin contact of the babies with their mother. Improvement of compliance with the standard newborn care practices must be ensured to reduce preventable newborn mortality and morbidity in Afghanistan.
Perfusion parameters and target values during extracorporeal cardiopulmonary resuscitation: a scoping review protocol
Authors: Saemann Lars , Schmucker Christine , Rösner Lisa , Beyersdorf Friedhelm , Benk Christoph
Published: August 2019

Introduction

Extracorporeal cardiopulmonary resuscitation (eCPR) is increasingly applied in out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) patients. Treatment results are promising, but the efficacy and safety of the procedure are still unclear. Currently, there are no recommended target perfusion parameters during eCPR, the lack of which could result in inadequate (re)perfusion. We aim to perform a scoping review to explore the current literature addressing target perfusion parameters, target values, corresponding survival rates and neurologic outcomes in OHCA and IHCA patients treated with eCPR.

Methods and analysis

To identify relevant research, we will conduct searches in the electronic databases MEDLINE, EMBASE, Social Science Citation Index, Social Science Citation Index Expanded and the Cochrane library. We will also check references of relevant articles and perform a cited reference research (forward citation tracking).

Two independent reviewers will screen titles and abstracts, check full texts for eligibility and perform data extraction. We will resolve dissent by consensus, moderated by a third reviewer. We will include observational and controlled studies addressing target perfusion parameters and outcomes such as survival rates and neurologic findings in OHCA and IHCA patients treated with eCPR. Data extraction tables will be set up, including study and patients’ characteristics, aim of study, details on eCPR including target perfusion parameters and reported outcomes. We will summarise the data using tables and figures (ie, bubble plot) to present the research landscape and to describe potential clusters and/or gaps.

Ethics and dissemination

An ethical approval is not needed. We intend to publish the scoping review in a peer-reviewed journal and present results on a scientific meeting.
A cross-sectional study of burnout and its associations with learning environment and learner factors among psychiatry residents within a National Psychiatry Residency Programme
Authors: Chew Qian Hui , Ang Lye Poh , Tan Lay Ling , Chan Herng Nieng , Ong Seh Hong , Cheng Ambrose , Lai Yew Min , Tan Ming Yee , Tor Phern Chern , Gwee Kok Peng , Sim Kang
Published: August 2019

Background

Multiple studies have reported high burnout rates among residents, including psychiatry. There is a paucity of studies examining the relationship between burnout and learning context, stress levels, resilience, stigma in healthcare providers and coping methods concurrently within the same cohort.

Objective

We examined the rate of burnout among our psychiatry residents in a cross-sectional study and hypothesised that burnout is associated with poorer perception of learning environment, greater perceived stress, stigma levels, lower resilience and specific coping strategies during training.

Methods

Ninety-three out of 104 psychiatry residents (89.4%) within our National Psychiatry Residency Programme participated in the study from June 2016 to June 2018. Relevant scales were administered to assess the perception of learning environment, burnout, stress, resilience, stigma levels and coping methods, respectively. We performed comparisons of the above measures between groups (burnout vs no burnout) and within-group correlations for these same measures.

Results

Overall, 54.8% of the sample met criteria for burnout. Residents with burnout had poorer perception of the learning environment, greater stress levels (both p<0.001), were less willing to disclose/seek help and employed greater active-avoidance coping strategies. Within the burnout group, greater perceived stress was correlated with poorer perception of learning environment (rs=−0.549) and greater use of active-avoidance coping (rs=0.450) versus additional use of problem-focussed coping within the non-burnout group.

Conclusions

Burnout was related to both environment and learner factors. These findings viewed within the transactional, sequential and imbalance models of burnout suggest the need to address stressors, beef up coping, provide continual support and develop resilience among our learners.
Questionnaire about the risk of growth suppression of inhaled corticosteroids
Authors: Wolthers Ole D
Published: August 2019

Background

Inhaled corticosteroids are associated with a risk of growth suppression in children. The aim of the present study was to assess what children with asthma, lay people and paediatricians feel about the risk of growth suppression by inhaled corticosteroids.

Methods

A questionnaire was completed by seven populations consisting of 9–19 years old children and adolescents with asthma; 9–19 year olds with another chronic illness; healthy 9–19 year olds; parents to children with chronic conditions; parents to healthy schoolchildren; young adults; and paediatricians.

Results

A total of 1216 individuals completed the questionnaire. A total of 867 individuals (74.6%) would not worry about a risk of 1-year growth suppression in the range of 0.5–2 cm (range: 233 (63.3%) in parents to patients in a secondary referral centre to 59 (86.8%) in the group of paediatricians (χ2 53.3, df 12, p<0.001; γ −223, error 0.042, p<0.001). A total of 745 individuals (64.3%) said that a loss in final height of 0.5–2 cm would not worry them (range: 34 (54.0%) in paediatricians to 119 (76.3%) in parents to healthy children (χ2 49.5, df 12, p<0.001; γ −0.073, error 0.039, p=0.06).

Conclusions

Most children with asthma, lay people and paediatricians do not worry about the risk of growth suppression of inhaled corticosteroids in the range up to 2 cm. Paediatricians worry less about the risk of 1-year growth suppression but more about final height suppression than children with asthma and other groups of children and adults. Paediatricians need to address the different concerns of some of their patients on this issue.
Associations between demographic characteristics and unmet supportive care needs in adults with cystic fibrosis
Authors: Obregon Laura Liliana , Jeong Kwonho , Hoydich Zachariah P , Yabes Jonathan , Pilewski Joseph , Richless Connie , Moreines Laura T , Dellon Elisabeth P , Goss Christopher H , Arnold Robert M , Kavalieratos Dio
Published: August 2019

Context

Patients living with cystic fibrosis (CF) report impaired quality of life. Little is known about unmet supportive care needs among adults living with CF and how they are associated with demographic characteristics.

Objectives

The primary objective of this study was to identify associations between demographic variables and unmet supportive care needs regarding anxiety, sadness, pain and uncertainty about the future of living with CF.

Methods

We recruited 165 adults with CF from a single academic medical centre to complete a brief demographic survey and the Supportive Care Needs Survey (SCNS-34), a validated self-reported needs assessment that measures the prevalence of and preferences for support for 34 needs that commonly occur in patients with serious illness.

Results

Approximately half of the participant sample was male, with a median age of 29 years, varying income levels and a range of lung disease severity. We found statistically significant associations between insufficient income and increased odds of reporting need for support regarding anxiety (OR: 6.48; 95% CI 2.08 to 20.2), sadness (OR: 6.15; 95% CI 2.04 to 18.5), pain (OR: 7.06; 95% CI 2.22 to 22.4) and worries surrounding uncertainty about the future (OR: 3.43; 95% CI 1.18 to 9.99).

Conclusion

Adults with CF report significant unmet needs for support in several physical and emotional domains. Many of these domains were associated with demographic characteristics, most notably, income. Our findings underscore the importance of developing treatment approaches that are sensitive to patient demographics when addressing unmet supportive care needs among adults with CF.
SomaticSF3B1mutations in myelodysplastic syndrome with ring sideroblasts and chronic lymphocytic leukaemia
Authors: Foy Allister , McMullin Mary Frances
Published: August 2019

SF3B1 is the largest subunit of the Spliceosome Factor 3b (SF3B) complex and part of the U2 small nuclear ribosomal protein. It functions as an important part of spliceosomal assembly, converting precursor messenger RNA (mRNA) to mRNA ready for ribosomal translation. Mutations ofSF3B1are commonly seen in myelodysplastic syndromes with ring sideroblasts (MDS-RS)and MDS/myeloproliferative neoplasm (MPN-RS-T). These mutations are typically heterozygous missense substitutions, of which, 55% involve K700E. MDS-RS and MDS/MPN-RS-T usually carry a more favourable prognosis than other subtypes of MDS.SF3B1itself does not influence survival in these conditions, but does correlate with increased thrombotic risk. MutatedSF3B1is present in 9%–15% of chronic lymphocytic leukaemia cases and on its own correlates with improved responsiveness to ibrutinib, but is associated with additional adverse genetic abnormalities includingTP53andATMmutations, which traditionally confer adverse outcomes.
Differential disruption of autoinhibition and defect in assembly of cytoskeleton during cell division decide the fate of humanDIAPH1-related cytoskeletopathy
Authors: Kim Bong Jik , Ueyama Takehiko , Miyoshi Takushi , Lee Seungmin , Han Jin Hee , Park Hye-Rim , Kim Ah Reum , Oh Jayoung , Kim Min Young , Kang Yong Seok , Oh Doo Yi , Yun Jiwon , Hwang Sang Mee , Kim Nayoung K D , Park Woong-Yang , Kitajiri Shin-ichiro , Choi Byung Yoon
Published: August 2019

Background

Diaphanous-related formin 1 (DIA1), which assembles the unbranched actin microfilament and microtubule cytoskeleton, is encoded byDIAPH1. Constitutive activation by the disruption of autoinhibitory interactions between the N-terminal diaphanous inhibitory domain (DID) and C-terminal diaphanous autoregulatory domain (DAD) dysregulates DIA1, resulting in both hearing loss and blood cell abnormalities.

Methods and results

Here, we report the first constitutively active mutant in the DID (p.A265S) of humans with only hearing loss and not blood cell abnormality through whole exome sequencing. The previously reported DAD mutants and our DID mutant (p.A265S) shared the finding of diminished autoinhibitory interaction, abnormally upregulated actin polymerisation activity and increased localisations at the plasma membrane. However, the obvious defect in the DIA1-driven assembly of cytoskeleton ‘during cell division’ was only from the DAD mutants, not from p.A265S, which did not show any blood cell abnormality. We also evaluated the five DID mutants in the hydrophobic pocket since four of these five additional mutants were predicted to critically disrupt interaction between the DID and DAD. These additional pathogenic DID mutants revealed varying degrees of defect in the DIA1-driven cytoskeleton assembly, including nearly normal phenotype during cell division as well as obvious impaired autoinhibition, again coinciding with our key observation in DIA1 mutant (p.A265S) in the DID.

Conclusion

Here, we report the first mutant in the DID of humans with only hearing loss. The differential cell biological phenotypes of DIA1 during cell division appear to be potential determinants of the clinical severity ofDIAPH1-related cytoskeletopathy in humans.
Questionable benefits and unavoidable personal beliefs: defending conscientious objection for abortion
Authors: Blackshaw Bruce Philip , Rodger Daniel
Published: August 2019

Conscientious objection in healthcare has come under heavy criticism on two grounds recently, particularly regarding abortion provision. First, critics claim conscientious objection involves a refusal to provide a legal and beneficial procedure requested by a patient, denying them access to healthcare. Second, they argue the exercise of conscientious objection is based on unverifiable personal beliefs. These characteristics, it is claimed, disqualify conscientious objection in healthcare. Here, we defend conscientious objection in the context of abortion provision. We show that abortion has a dubitable claim to be medically beneficial, is rarely clinically indicated, and that conscientious objections should be accepted in these circumstances. We also show that reliance on personal beliefs is difficult to avoid if any form of objection is to be permitted, even if it is based on criteria such as the principles and values of the profession or the scope of professional practice.
Some difficulties involved in locating the truth behind conscientious objection in medicine
Authors: Clarke Steve
Published: August 2019

Inspired by Smith, Ben-Moshe suggests that we should only accommodate conscientious objections (COs) in medicine based on moral beliefs that are true, or which closely approximate to the truth. He suggests that we can identify moral truths by consulting our consciences when our consciences adopt the standpoint of an impartial spectator. He also suggests some (surprisingly modest) changes to our current practices in regard to the management of CO in medicine that would be needed were his proposal to be adopted. Here, I argue that both Smith and Ben-Moshe underestimate the difficulties involved in adopting the standpoint of an impartial spectator. In particular, both authors fail to recognise the extent to which cognitive bias and ideological commitments prevent many of us from identifying the standpoint of an impartial spectator and also prevent us from realising that we are failing to be impartial. I also consider some different changes to current practices that would be needed if we were to take on Ben-Moshe’s approach to CO in medicine while also recognising the difficulties involved in adopting the standpoint of an impartial spectator.
Blind exchange with mini-pinning technique for distal occlusion thrombectomy
Authors: Haussen Diogo C , Al-Bayati Alhamza R , Eby Brendan , Ravindran Krishnan , Rodrigues Gabriel Martins , Frankel Michael R , Nogueira Raul G
Published: August 2019

Introduction

Technical improvements to enhance distal occlusion thrombectomy are desirable. We describe the blind catheter exchange technique and report the pinning technique with small devices (‘mini-pinning’) for distal occlusions.

Methods

A retrospective review of a prospective database from January 2015 to August 2018 was performed for cases of distal occlusion in which the ‘blind exchange/mini-pinning’ (BEMP) techniques were used. The technique involves the deployment of a 3 mm Trevo retriever followed by microcatheter removal and blind advancement of a 3MAX aspiration catheter over the bare retriever delivery wire (‘blind exchange’) until clot contact under aspiration. The retriever is subsequently partially recaptured in order to ‘cork’ the thrombus (‘mini-pinning’) and the system pulled as a unit. Patients with distal occlusions treated with BEMP and standard techniques (either 3 mm Trevo or 3MAX) were compared.

Results

Twenty-five vessels were treated in 22 patients. The majority of patients had isolated distal occlusions predominantly in the distal middle cerebral artery (MCA) segments, half of which involved the superior division. The comparison between BEMP (n=25 vessels) and standard techniques (n=144 vessels) revealed balanced groups. One of the highlighted differences was the more distal MCA occlusions among those who underwent BEMP (M3 occlusions 52% vs 22%; p=0.001). Otherwise, the vessel, segments, divisions and luminal diameter were comparable. There was a higher rate of first-pass modified Thrombolysis in Cerebral Infarction 2b–3 (80% vs 56%; p=0.03) and a trend towards higher rates of first-pass full reperfusion (60% vs 40%; p=0.07) with BEMP compared with standard techniques. Final reperfusion and clinical outcomes were comparable.

Conclusion

BEMP appears to be a safe and effective technique for the treatment of distal occlusions. Additional studies are warranted.
A descriptive study of venous sinus pressures and gradients in patients with idiopathic intracranial hypertension
Authors: Fargen Kyle M , Garner Rebecca M , Kittel Carol , Wolfe Stacey Q
Published: August 2019

Objective

To determine the relationship between normal physiologic and pathologic venous sinus pressures in patients with idiopathic intracranial hypertension (IIH), which is poorly understood.

Methods

Retrospective analysis was performed to identify patients with medically refractory IIH who were evaluated by angiography and retrograde venography with venous manometry. Patients were further subdivided into groups based on anatomic factors.

Results

104 patients met inclusion criteria for the study. In the absence of non-invasive venographic screening, 58% of patients in this series were found to have pressure gradients of ≥8 mm Hg; 93% were located near the transverse-sigmoid sinus junction. Opening pressure (OP) is strongly predictive of superior sagittal sinus (SSS) pressures (p<0.001) and also of the presence of a pressure gradient ≥8 mm Hg (p<0.001). Twenty-three percent of patients with an OP <25 had a pressure gradient ≥8 mm Hg compared with 77% of patients with an OP ≥35. Analysis of patients with OP ≤20 suggests that SSS pressures in patients without IIH should be less than 16–18 mm Hg with total cranial gradients <5 mm Hg. Across all patients, a pressure decrement of approximately 1 mm Hg occurs with progressively more caudal transition across anatomic points of measurement.

Conclusions

This study describes intracranial and extracranial venous pressure measurements and gradients in different subgroups of patients with IIH. OP is highly predictive of intracranial venous pressures and significant venous pressure gradients.
Pulmonary thrombosis with spontaneous pneumothorax
Authors: Amorós Olga , Domínguez Elisabet , Santana Sergio , Vizcaino Reves Nuria , Puig Jordi
Published: August 2019

A 12‐year‐old, neutered male Rough Collie was referred because of a 5‐day history of lethargy and respiratory distress. A pneumothorax was detected on a right lateral radiography at the referring veterinary surgeon. Contrast‐enhanced CT of the thorax was performed and a severe bilateral pneumothorax with a collapse of the left cranial lung lobe was observed. The underlying cause of the pneumothorax could not be found at that point and an exploratory thoracotomy was performed. The left cranial lung lobe had several perforations and a lobectomy was achieved. A thrombus obliterating a medium calibre artery and associated severe surrounding pulmonary necrosis were detected histologically.
Heart Failure Risk Stratification and Efficacy of Sodium-Glucose Cotransporter-2 Inhibitors in Patients With Type 2 Diabetes Mellitus
Authors: Berg David D. , Wiviott Stephen D. , Scirica Benjamin M. , Gurmu Yared , Mosenzon Ofri , Murphy Sabina A. , Bhatt Deepak L. , Leiter Lawrence A. , McGuire Darren K. , Wilding John P.H. , Johanson Per , Johansson Peter A. , Langkilde Anna Maria , Raz Itamar , Braunwald Eugene , Sabatine Marc S.
Published: August 2019

Background:

Patients with type 2 diabetes mellitus (T2DM) are at increased risk of developing heart failure. Sodium-glucose cotransporter-2 inhibitors reduce the risk of hospitalization for heart failure (HHF) in patients with T2DM. We aimed to develop and validate a practical clinical risk score for HHF in patients with T2DM and assess whether this score can identify high-risk patients with T2DM who have the greatest reduction in risk for HHF with a sodium-glucose cotransporter-2 inhibitor.

Methods:

We developed a clinical risk score for HHF in 8212 patients with T2DM in the placebo arm of SAVOR-TIMI 53 (Saxagliptin Assessment of Vascular Outcomes Recorded in Patients With Diabetes Mellitus–Thrombolysis in Myocardial Infarction 53). Candidate variables were assessed using multivariable Cox regression, and independent clinical risk indicators achieving statistical significance of
P
<0.001 were included in the risk score. We externally validated the score in 8578 patients with T2DM in the placebo arm of DECLARE-TIMI 58 (Dapagliflozin Effect on Cardiovascular Events–Thrombolysis in Myocardial Infarction 58). The relative and absolute risk reductions in HHF with the sodium-glucose cotransporter-2 inhibitor dapagliflozin were assessed by baseline HHF risk.

Results:

Five clinical variables were independent risk predictors of HHF: prior heart failure, history of atrial fibrillation, coronary artery disease, estimated glomerular filtration rate, and urine albumin-to-creatinine ratio. A simple integer-based score (0–7 points) using these predictors identified a >20-fold gradient of HHF risk (
P
for trend <0.001) in both the derivation and validation cohorts, with C indices of 0.81 and 0.78, respectively. Although relative risk reductions with dapagliflozin were similar for patients across the risk scores (25%–34%), absolute risk reductions were greater in those at higher baseline risk (1-sided
P
for trend=0.04), with high-risk (2 points) and very-high-risk (≥3 points) patients having 1.5% and 2.7% absolute reductions in Kaplan-Meier estimates of HHF risk at 4 years, respectively.

Conclusions:

Risk stratification using a novel clinical risk score for HHF in patients with T2DM identifies patients at higher risk for HHF who derive greater absolute benefit from sodium-glucose cotransporter-2 inhibition.

Clinical Trial Registration:

URL:
https://www.clinicaltrials.gov
. Unique identifiers: NCT01107886 and NCT01730534.