bluuebunny/crossref_metadata_2025_split huggingface dataset:
The magnitude and determinants of violence against healthcare workers in Pakistan
Authors: Shaikh Shiraz , Baig Lubna Ansari , Hashmi Ibrahim , Khan Mirwais , Jamali Seemin , Khan Muhammad Naseem , Saleemi Munir Akhtar , Zulfiqar Komal , Ehsan Sumera , Yasir Iram , Haq Zia ul , Mazharullah Lubna , Zaib Samina 
Published: April 2020

ObjectivesTo determine the magnitude and determinants of violence against healthcare workers (HCWs) and to identify the predominant types and causes of violence experienced by them.MethodologyA cross-sectional survey based on structured questionnaire adopted from previous surveys and qualitative data was conducted in 4 large cities and 12 districts in 3 provinces of Pakistan. The survey covered 8579 from all cadres of HCWs, including doctors, nurses, technicians, support staff, ambulance workers, vaccinators, lady health visitors, midwives and lady health workers (LHWs). The predictors of overall violence experienced, physical violence experienced and verbal violence experienced were separately analysed for tertiary care hospitals, secondary care hospitals, primary care hospitals and field-level HCWs. Logistic regression was used to compute adjusted ORs with 95% CIs for the association of different factors with the violence experienced.ResultsMore than one-third (38.4%) reported having experienced any form of violence in the last 6 months. Verbal violence was the most commonly experienced form (33.9%), followed by physical violence (6.6%). The main reasons for physical violence were death of patients (17.6%), serious condition of patients (16.6%) and delay in care (13.4%). Among the different types of field HCWs, emergency vehicle operators were significantly more likely to experience verbal violence compared with LHWs (adjusted OR=1.97; 95% CI 1.31 to 2.94; p=0.001). Among hospital HCWs, those working in private hospitals were significantly less likely to experience physical violence (adjusted OR=0.52; 95% CI 0.38 to 0.71; p=0.001) and verbal violence (adjusted OR=0.57; 95% CI 0.48 to 0.68; p=0.001).ConclusionViolence against HCWs exists in various forms among all cadres and at different levels of care. The gaps in capacity, resources and policies are evident. Specific strategies need to be adopted for different types of HCWs to protect them against violence.*The study was conducted under the framework of ICRC’s Healthcare in Danger Initiative for protection of healthcare against Violence
Time for nutrition in medical education
Authors: Macaninch Elaine , Buckner Luke , Amin Preya , Broadley Iain , Crocombe Dominic , Herath Duleni , Jaffee Ally , Carter Harrison , Golubic Rajna , Rajput-Ray Minha , Martyn Kathy , Ray Sumantra 
Published: April 2020

AimTo synthesise a selection of UK medical students’ and doctors’ views surrounding nutrition in medical education and practice.MethodsInformation was gathered from surveys of medical students and doctors identified between 2015 and 2018 and an evaluation of nutrition teaching in a single UK medical school. Comparative analysis of the findings was undertaken to answer three questions: the perceived importance of nutrition in medical education and practice, adequacy of nutrition training, and confidence in current nutrition knowledge and skills.ResultsWe pooled five heterogeneous sources of information, representing 853 participants. Most agreed on the importance of nutrition in health (>90%) and in a doctor’s role in nutritional care (>95%). However, there was less desire for more nutrition education in doctors (85%) and in medical students (68%). Most felt their nutrition training was inadequate, with >70% reporting less than 2 hours. There was a preference for face-to-face rather than online training. At one medical school, nutrition was included in only one module, but this increased to eight modules following an increased nutrition focus. When medical students were asked about confidence in their nutrition knowledge and on advising patients, there was an even split between agree and disagree (p=0.869 and p=0.167, respectively), yet few were confident in the UK dietary guidelines. Only 26% of doctors were confident in their nutrition knowledge and 74% gave nutritional advice less than once a month, citing lack of knowledge (75%), time (64%) and confidence (62%) as the main barriers. There was some recognition of the importance of a collaborative approach, yet 28% of doctors preferred to get specialist advice rather than address nutrition themselves.ConclusionThere is a desire and a need for more nutrition within medical education, as well as a need for greater clarity of a doctor’s role in nutritional care and when to refer for specialist advice. Despite potential selection bias and limitations in the sampling frame, this synthesis provides a multifaceted snapshot via a large number of insights from different levels of training through medical students to doctors from which further research can be developed.
Recognition of anxiety disorders in children: a cross-sectional vignette-based survey among general practitioners
Authors: Aydin Semiha , Crone Mathilde R , Siebelink Bart M , Vermeiren Robert R J M , Numans Mattijs E , Westenberg P Michiel 
Published: April 2020

ObjectiveTo quantify general practitioners’ (GPs) sensitivity to anxiety disorders (ADs) when confronted with the range of symptoms common to children with ADs. Also, to explore GPs’ conscious preferences and implicit tendencies for referral of children with ADs to mental healthcare.Design and settingIn a cross-sectional vignette-based survey, all attendees of a Dutch continuing medical education conference for primary care physicians were presented with subtitled audio fragments of five vignettes that we constructed to mimic symptom presentation of children with ADs in general practice. We asked attendees to select per vignette the most plausible diagnoses and most adequate referral option, and for their general referral preferences when they suspect each of the most common mental health problems.ParticipantsA sample of 229 GPs, resulting in a total of 1128 vignette evaluations.Main outcome measureGPs’ selection rate of ADs in the five vignettes compared with a benchmark provided by mental health professionals (MHPs).ResultsOverall, recognition of ADs was less likely in GPs compared with MHPs (OR=0.26, 95% CI 0.15 to 0.46). GPs varied in their recognition of anxiety, with 44.1% not once selecting anxiety as the probable presenting problem. When asked explicitly, 63.9% of the GPs reported that they would refer a child to mental healthcare when they suspect probable ADs. By contrast, only 12.0% of the GPs who recognised anxiety in the vignettes actually selected that referral option.ConclusionA significant fraction of GPs did not notice the depicted symptoms as anxiety. Despite the widespread prevalence of ADs, GPs seem to overlook anxiety already in their early diagnostic opinion. Improving GPs’ familiarity with initial symptom presentation, ADs’ base-rate, relevance and impact yields potential for timely recognition.
Impact of smoking status on the efficacy of inhaled corticosteroids in chronic obstructive pulmonary disease: a systematic review
Authors: Sonnex Kimberley , Alleemudder Hanna , Knaggs Roger 
Published: April 2020

ObjectivesInhaled corticosteroids (ICS) reduce exacerbation rates and the decline in lung function in people with chronic obstructive pulmonary disease (COPD). There is evidence that smoking causes ‘steroid resistance’ and thus reduces the effect of ICS. This systematic review aimed to investigate the effect of smoking on efficacy of ICS in COPD in terms of lung function and exacerbation rates.DesignSystematic review.Data sourcesAn electronic database search of PubMed, Ovid MEDLINE, Ovid Embase and Cochrane Library (January 2000 to January 2020).Eligibility criteriaFully published randomised controlled trials (RCTs), in the English language, evaluating the use of ICS in COPD adults that stratified the participants by smoking status. Trials that included participants with asthma, lung cancer and pneumonia were excluded. The primary outcome measures were changes in lung function and yearly exacerbation rates.Data extraction and synthesisTwo independent reviewers extracted data and assessed risk of bias using the Cochrane Collaboration’s tool.ResultsSeven studies were identified. Four trials (17 892 participants) recorded change in forced expiratory volume in one second (FEV1) from baseline to up to 30 months after starting treatment. Heavier smokers (>36 pack years) using ICS had a greater decline in FEV1that ranged from −22 mL to −75 mL in comparison to lighter smokers. Smokers using ICS had mixed results in FEV1change: −8 mL to +77 mL in comparison to ex-smokers. Four trials (21 270 participants) recorded difference in COPD exacerbation rates at 52 weeks. The rate ratios favoured more exacerbations in ICS users who were current or heavier smokers than those who were ex-smokers or lighter smokers (0.81 to 0.99 vs 0.92 to 1.29).ConclusionsIn COPD, heavier or current smokers do not gain the same benefit from ICS use on lung function and exacerbation rates as lighter or ex-smokers do, however effects may not be clinically important.PROSPERO registration numberCRD42019121833
Implementing receiver-driven handoffs to the emergency department to reduce miscommunication
Authors: Huth Kathleen , Stack Anne M , Hatoun Jonathan , Chi Grace , Blake Robert , Shields Robert , Melvin Patrice , West Daniel C , Spector Nancy D , Starmer Amy J 
Published: April 2020

BackgroundMiscommunications during care transfers are a leading cause of medical errors. Recent consensus-based recommendations to standardise information transfer from outpatient clinics to the emergency department (ED) have not been formally evaluated. We sought to determine whether a receiver-driven structured handoff intervention is associated with 1) increased inclusion of standardised elements; 2) reduced miscommunications and 3) increased perceived quality, safety and efficiency.MethodsWe conducted a prospective intervention study in a paediatric ED and affiliated clinics in 2016–2018. We developed a bundled handoff intervention included a standard template, receiver training, awareness campaign and iterative feedback. We assessed a random sample of audio-recorded handoffs and associated medical records to measure rates of inclusion of standardised elements and rate of miscommunications. We surveyed key stakeholders pre-intervention and post-intervention to assess perceptions of quality, safety and efficiency of the handoff process.ResultsAcross 162 handoffs, implementation of a receiver-driven intervention was associated with significantly increased inclusion of important elements, including illness severity (46% vs 77%), tasks completed (64% vs 83%), expectations (61% vs 76%), pending tests (0% vs 64%), contingency plans (0% vs 54%), detailed callback request (7% vs 81%) and synthesis (2% vs 73%). Miscommunications decreased from 48% to 26%, a relative reduction of 23% (95% CI −39% to −7%). Perceptions of quality (35% vs 59%), safety (43% vs 73%) and efficiency (17% vs 72%) improved significantly post-intervention.ConclusionsImplementation of a receiver-driven intervention to standardise clinic-to-ED handoffs was associated with improved communication quality. These findings suggest that expanded implementation of similar programmes may significantly improve the care of patients transferred to the paediatric ED.
Influence of bedspacing on outcomes of hospitalised medicine service patients: a retrospective cohort study
Authors: Kohn Rachel , Harhay Michael O , Bayes Brian , Song Hummy , Halpern Scott D , Kerlin Meeta Prasad , Greysen S Ryan 
Published: April 2020

BackgroundSpecialty wards cohort hospitalised patients to improve outcomes and lower costs. When demand exceeds capacity, patients overflow and are “bedspaced” to alternate wards. Some studies have demonstrated that bedspacing among medicine service patients is associated with adverse patient-centred outcomes, however, results have been inconsistent and have primarily been performed within national health systems. The objective of this study was to assess the association of bedspacing with patient-centred outcomes among United States patients admitted to general medicine services.MethodsWe performed a retrospective cohort study of internal medicine, family medicine and geriatric service patients who were bedspaced vs cohorted for the entirety of their hospital stay within three large, urban United States hospitals (quaternary referral centre, tertiary referral centre and community hospital, with different patient demographics and case-mixes) in 2014 and 2015. We performed quantile regression to determine differences in length of stay (LOS) between bedspaced vs cohorted patients and logistic regression for in-hospital mortality and discharge to home.ResultsAmong 18 802 patients in 33 wards, 6119 (33%) patients were bedspaced. Bedspaced patients had significantly longer LOS compared with cohorted patients at the 25th(0.1 days, 95% CI: 0.05 to 0.2, p=0.001), 50th(0.2 days, 95% CI: 0.1 to 0.3, p=0.003) and 75th(0.3 days, 95% CI: 0.2 to 0.5, p<0.001) percentiles; and no statistically significant differences in odds of mortality (OR=0.9, 95% CI: 0.6 to 1.3, p=0.5) or discharge to home (OR=0.9, 95% CI: 0.9 to 1.0, p=0.06) in adjusted analyses.ConclusionBedspacing is associated with adverse patient-centred outcomes. Future work is needed to confirm these findings, understand mechanisms contributing to adverse outcomes and identify factors that mitigate these adverse effects in order to provide high-value, patient-centred care to hospitalised patients.
Intraindividual variation of the transversus abdominis plane block: an exploratory study in healthy volunteers
Authors: Juhl Christian Svendsen , Rothe Christian , Støving Kion , Aasvang Eske K , Rosenstock Charlotte V , Lange Kai Henrik Wiborg , Lundstrøm Lars Hyldborg 
Published: April 2020

IntroductionThe transversus abdominis plane block is widely used in postoperative pain management after abdominal surgery. However, large interindividual variation in the cutaneous distribution area of the block has been demonstrated. The purpose of the present study was to explore the reproducibility of the block by determining the intraindividual variation when repeating the block on two separate days.MethodsUltrasound-guided posterior transversus abdominis plane blocks were performed in 16 healthy volunteers and repeated after at least 2 days. Cutaneous sensory block areas and distributions, thresholds for mechanical stimulation, abdominal muscle thicknesses at rest and during maximal contraction, waist circumferences and block duration times were measured on both days. Outcome measurements from the 2 days were compared using a one-sample t-test and intraclass correlation coefficients were calculated for each parameter. Agreement was evaluated visually using Bland-Altman plots.ResultsNone of the mean values of the outcome measurements differed significantly between the 2 days. Intraclass correlation coefficient was 0.75 (moderate-to-good reliability) for lateral abdominal muscle thickness during maximal contraction, but ranges from −0.07 to 0.67 were found for all other outcome measurements (poor-to-moderate reliability).ConclusionWe found a moderate-to-good reproducibility for lateral abdominal muscle thickness during maximal voluntary contraction, but a moderate-to-poor reproducibility for all other block characteristics. However, the cutaneous distribution of the block was still located primarily inferior to a horizontal line through the umbilicus and lateral relative to a vertical line through the anterior superior iliac spine.
Illicit tobacco trade is ‘booming’: UK newspaper coverage of data funded by transnational tobacco companies
Authors: Evans-Reeves Karen , Hatchard Jenny , Rowell Andy , Gilmore Anna B 
Published: April 2020

BackgroundTransnational tobacco companies (TTCs) have heavily publicised their argument that standardised tobacco packaging will increase the illicit tobacco trade. Leaked Philip Morris International (PMI) documents suggest that the company may have intended to use third parties to promulgate this argument in the UK.MethodsWe examined articles in UK newspapers (1 April 2013 to 31 March 2015) from LexisNexis for presence and nature of tobacco industry data. We also examined documents released by Freedom of Information requests made to Scottish Councils for evidence of how PMI operationalised its third-party strategy.FindingsTwo-thirds of newspaper articles (63%, 99/157) mentioned a PMI consultant; 36% of which did not disclose this industry funding. Most articles mentioned counterfeit tobacco, illicit whites or both (72%, 113/157), while few (4%, 7/157) specifically mentioned tobacco industry illicit tobacco and none explained that the latter can include tobacco-company involvement. Freedom of Information documents revealed that the PMI consultant sought to build relationships with Trading Standards officers, conducted undercover test purchases (UTPs) in illicit tobacco ‘hotspots’ and may have promoted unrepresentative findings in the media. While the data set featured PMI data predominantly, other TTCs also engaged in third-party techniques to promulgate messages on illicit tobacco.InterpretationPMI engaged a third party, seemingly with the aim of securing media coverage on illicit tobacco positing that standardised packaging would worsen the problem. The predominant focus of articles which featured industry-funded data and information was on counterfeit tobacco despite official data showing tobacco-industry illicit tobacco as the most prevalent. Other jurisdictions considering the policy should anticipate that third parties will promote the illicit-trade argument.
Compliance with San Francisco’s flavoured tobacco sales prohibition
Authors: Vyas Priyanka , Ling Pamela , Gordon Bob , Callewaert Jennifer , Dang Alvin , Smith Derek , Chan Brittany , Glantz Stanton 
Published: April 2020

BackgroundIn June 2018, San Francisco voters upheld the first comprehensive prohibition on sales of flavoured tobacco products (all products including menthol, everywhere in the city with no exceptions).MethodsThis paper used data collected by the San Francisco Department of Public Health as part of its implementation and enforcement of San Francisco’s city-wide ban on the sale of flavoured tobacco products. Every licensed tobacco retailer was visited and inspected. The San Francisco Department of Public Health and volunteers conducted an educational campaign from September 2018 to December 2018, including emailing all licensed tobacco retailers about the law, mailing a fact sheet poster, conducting four listening sessions and visiting permitted tobacco retailers to educate them about the law and solicit questions.ResultsCompliance inspections started in December 2018, which found that compliance was 17%. Compliance increased in January 2019 and averaged 80% between January 2019 and December 2019. After the phase-in period, all retailers were visited as part of routine inspections. This effort resulted in 80% compliance.ConclusionIncluding retailer education prior to enforcement can result in compliance with a comprehensive ban on the sale of menthol and other flavoured tobacco products.
Do people know that cigarette filters are mainly composed of synthetic material? A representative survey of the German population (the DEBRA study)
Authors: Kotz Daniel , Kastaun Sabrina 
Published: April 2020

IntroductionMost cigarettes are smoked with filters made of synthetic plastic, which are not fully biodegradable. Littering used cigarette filters (butts) represents a substantial environmental hazard. It is unclear if people, in particular smokers, know that filters consist of synthetic plastic.MethodsWe used data collected in August/September 2019 from a representative household survey of the German population aged 14 years and over (wave 20 of the German Study on Tobacco Use; DEBRA). Respondents were asked: ‘The majority of smokers use cigarettes with a filter. What do you think these filters are composed of? (1) Mainly of natural material; (2) Mainly of synthetic material; (3) I don’t know what cigarette filters are composed of.’ Response option 2 indicated correct knowledge.ResultsA total of 2066 people were interviewed, including 625 current smokers. The weighted response rate to option 2 (‘mainly of synthetic material’) was 34.8% (95%CI 32.7 to 36.9) in the total sample and 42.7% (95%CI=38.7 to 46.8) in the subgroup of current smokers. In the latter subgroup, smokers with low compared with those with high educational level were less likely to know that filters are mainly composed of synthetic material (OR=0.62, 95%CI=0.39 to 0.99).ConclusionsThe majority of smokers in Germany does not know that cigarette filters are mainly composed of synthetic material. Our findings suggest a need for promoting awareness as well as knowledge of environmental health hazards of cigarette filters to the general population, and specifically to current smokers.Trial registration numberDRKS00011322 and DRKS00017157.
The Rise of Xi Jinping and China’s New Era: Implications for the United States and Taiwan
Authors: THOMPSON DREW 
Published: April 2020

Xi Jinping’s rise to power has heralded a new foreign policy that is more assertive and uncompromising toward China’s neighbors, the United States, and the rest of the world. This change presents challenges for the United States and Taiwan in particular which must be addressed with a sense of urgency due to Xi Jinping’s ambitious objectives and his firm grip on the levers of power which increase the likelihood that the Communist Party and government of China will seek to achieve them without delay. This paper reviews changes to Chinese foreign policy in the Xi Jinping era and argues how the modernization of the People’s Liberation Army (PLA) over time has increased the threat to Taiwan, with concurrent risks for the United States. Taiwan and the US can address the challenge presented by China by strengthening their relationship to adapt to the new era under Xi Jinping’s leadership. According to CIA (2018), China’s economy now stands at approximately US$12 trillion, second only to the United States (CIA [2018]. World fact book). Unlike in 1978, China’s economy today is dependent on access to globally sourced raw materials, and access to overseas consumer markets for its industrial and consumer goods. This dependency on overseas markets has increased China’s global presence and interests, driving the need to protect them. The Chinese Government’s now ample resources have been allocated to both hard and soft power means toward this purpose. The PLA has greatly benefitted from economic development and the expansion of the Chinese economy, transforming from a backward institution focused on private-sector moneymaking into the sharpest tool of China’s power and influence. Since Xi Jinping came to power in 2012, China’s foreign policy and strategy have undergone a dramatic shift away from Deng Xiaoping’s focus on increasing domestic productivity and avoiding potentially costly overseas entanglements. The confluence of accumulated national wealth, diplomatic, economic, and military power, and the will to use those levers of power, has dramatic implications for the United States and China’s neighbors. A more assertive China, confident in its wealth, power, and international status, is increasingly unafraid of overt competition with its neighbors and the United States, unwilling to back down or compromise in the face of disputes. This dynamic has resulted in a new paradigm in the Indo-Pacific region that is unlike previous challenges of the past 40 years. The shift in China’s foreign policy and the PLA’s modernization threaten to challenge the credibility of US security assurances and alliances in the region, making the cultivation and strengthening of the US–Taiwan relationship, and the network of US bilateral alliances in the region an urgent imperative.