Cross-sectional/observational study.

This study was carried out in five cities of eastern Nepal (Dharan, Itahari, Biratnagar, Damak and Birtamode). Both restaurant-based and street-based FSWs were recruited in the study.

Women who had been involved in commercial sex activity in the past 6 months and gave informed consent were included in the study.

A score of more than or equal to 16 on the Centre for Epidemiological Studies Depression (CESD) scale was considered as depression.

Face-to-face interviews were conducted with respondents who were sought through a snowball sampling technique. Information regarding their depression status, HIV high-risk behaviour and violence was recorded. The estimated sample size was 210.

We interviewed 210 FSWs (both restaurant-based and street-based). The prevalence of depression among respondents was 82.4%. FSWs who had experienced violence were five times more likely to be depressed than those who were not victims of violence. The odds of depression were six times higher among respondents who were involved in any HIV risk behaviour compared with those who were not involved.

The present study reports a high prevalence of depression, HIV risk behaviours and violence among FSWs of eastern Nepal. The mental health of FSWs should also be regarded as an important aspect of HIV prevention efforts which can help to promote the overall health of this population.

Ecological analysis of routine data using random effects logistic regression.

All 151 primary care trusts (PCTs) in England 2010–2011.

PCT level data on breastfeeding: initiation, any and exclusive breastfeeding at 6–8 weeks.

There was considerable variation in breastfeeding across PCTs (breastfeeding initiation mean 72%, range 39–93%; any breastfeeding at 6–8 weeks mean 45%, range 19–83%; exclusive breastfeeding at 6–8 weeks mean 32%, range 14–58%), with London PCTs reporting markedly higher rates. Maternal age was strongly associated with area-based breastfeeding, with a 4–6% increase in odds of breastfeeding associated with a unit increase in the percentage of older mothers. Outside London, the proportion of the local population from a Black and Minority Ethnic (BME) background, compared with those from a White British background, was associated with higher breastfeeding (1–3% increase in odds per unit increase in the proportion from a BME background). Area-based deprivation was associated with reduced odds of breastfeeding (21–32% reduced odds comparing most deprived quintile to least deprived quintile). Weaker associations were observed between sociodemographic factors and breastfeeding in London PCTs. Very few PCTs reported breastfeeding figures substantially above or below the national average, having adjusted for variations in sociodemographic factors.

Our results show striking associations between sociodemographic factors and breastfeeding at the area level, with much of the variation in breastfeeding rates explained by the sociodemographic profile. The sociodemographic context of breastfeeding is clearly important at the area level as well as the individual level. Our findings can be used to inform decision-making relating to local priorities and service provision.

Cost and utilisation data were collected retrospectively from April 2010 to March 2011 to avoid seasonal variability.

For this study, we chose five hospitals of different types: a 57-bed charitable hospital, a 200-bed private hospital, a 400-bed district hospital, a 655-bed private teaching hospital and a 778-bed tertiary care teaching hospital based on their willingness to cooperate and data accessibility. The hospitals were from four states in India. The private, charitable and tertiary care hospitals serve urban populations, the district hospital serves a semiurban area and the private teaching hospital serves a rural population.

Costs of conducting lower section caesarean section ranged from rupees 2469 to 41 087; hysterectomy rupees 4124 to 57 622 and appendectomy rupees 2421 to 3616 (US$1=rupees 52). We computed the costs of conducting lap and open cholecystectomy (rupees 27 732 and 44 142, respectively); hernia repair (rupees 13 204); external fixation (rupees 8406); intestinal obstruction (rupees 6406); amputation (rupees 5158); coronary artery bypass graft (rupees 177 141); craniotomy (rupees 75 982) and functional endoscopic sinus surgery (rupees 53 398).

Estimated costs are roughly comparable with rates of reimbursement provided by the Rashtriya Swasthya Bima Yojana (RSBY)—India's government-financed health insurance scheme that covers 32.4 million poor families. Results from this type of study can be used to set and revise the reimbursement rates.

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

PensionDanmark; one of Denmark's largest pension funds.

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

The incidence of MS.

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

Our results indicate some occupational risk factors in MS, and this should be investigated further.

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

Primary and Tertiary Care.

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

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

The marked variation in the frequency of testing for vitamin D deficiency indicates that large sums of potentially unnecessary funds are being expended. The rate of 25(OH)D testing increased exponentially at an unsustainable rate. Consequences of such findings are widespread in terms of cost and effectiveness. Further research is required to determine the drivers and cost benefit of such expenditure. Our data indicate that adoption of specific guidelines may improve efficiency and effectiveness of 25(OH)D testing.

A prospective observational study.

11 UK primary care practices.

Patients (n=1290) with an abnormal eight-panel LFT (but no previously diagnosed liver disease).

Patients were investigated by recording clinical features, and repeating LFTs, specific tests for individual liver diseases, and abdominal ultrasound scan. Patients were characterised as having: hepatocellular disease; biliary disease; tumours of the hepato-biliary system and none of the above. The relationship between LFT results and disease categories was evaluated by stepwise regression and logistic discrimination, with adjustment for demographic and clinical factors. True and False Positives generated by all possible LFT combinations were compared with a view towards optimising the choice of analytes in the routine LFT panel.

Regression methods showed that alanine aminotransferase (ALT) was associated with hepatocellular disease (32 patients), while alkaline phosphatase (ALP) was associated with biliary disease (12 patients) and tumours of the hepatobiliary system (9 patients). A restricted panel of ALT and ALP was an efficient choice of analytes, comparing favourably with the complete panel of eight analytes, provided that 48 False Positives can be tolerated to obtain one additional True Positive. Repeating a complete panel in response to an abnormal reading is not the optimal strategy.

The LFT panel can be restricted to ALT and ALP when the purpose of testing is to exclude liver disease in primary care.

Case–control study.

The analysis was conducted as a case–control analysis, using data from a series of studies of direct causes of severe maternal morbidity undertaken through the UK Obstetric Surveillance System (UKOSS), with data collected throughout all consultant-let obstetric units in the UK.

The analysis included 1144 cases and 2256 comparison women (controls). UKOSS studies from which data on case women were obtained included amniotic fluid embolism, acute fatty liver of pregnancy, eclampsia, peripartum hysterectomy, therapies for peripartum haemorrhage and uterine rupture.

Odds of severe maternal morbidity by socioeconomic group, independent of ethnicity, maternal age, smoking, pre-existing medical condition, body mass index (BMI), multiple pregnancy and past pregnancy complications. Occupation was used to classify different socioeconomic groups.

Odds of morbidity related to ethnic group, maternal age, smoking, pre-existing medical condition, BMI, multiple pregnancy and past pregnancy complications.

Across the socioeconomic groups, compared with the ‘managerial/professional’ group, adjusted ORs were 1.17 (95% CI 0.94 to 1.45) for the ‘intermediate group’, 1.16 (95% CI 0.93 to 1.45) for ‘routine/manual’, 1.22 (95% CI 0.92 to 1.61) for ‘unemployed’ women and 1.51 (95% CI 1.18 to 1.94) for women with missing socioeconomic information. Women of non-white ethnicity, older maternal age (≥35 years), BMI ≥25 kg/m² and those with pre-existing medical condition/s, multiple pregnancy or past pregnancy complications were shown to have a significantly increased odds of severe maternal morbidity.

This study suggests that socioeconomic position may be independently associated with an increased risk of severe maternal morbidity, although the observed association was not statistically significant. Further research is warranted to confirm this and investigate why this association might exist in a country where healthcare is universal and free at the point of access.

Retrospective and descriptive study of all swabs obtained from all MSM attendees at an STI unit, from 2007 to 2011. Retrospective ethical approval was granted by the Ethical Regional Committee of Clinical Investigation of the Principality of Asturias.

The STI clinic in Oviedo, Spain, offers screening and free-of-charge treatment to about 3646 patients per year.

303 symptomatic and asymptomatic consecutive and unselected MSM patients (mean age 36.7 and range 21–55 years) were evaluated for anorectal chlamydial infection.

C trachomatis DNA extraction and detection in all rectal and in 36 urethral swabs. Characterisation of C trachomatis genotypes through sequencing of ompA gene amplicons and further phylogenetic tree analysis.

We found 40 (13. 2%) positive rectal samples. The distribution of genotypes was E (37. 5%) followed by G (25%), D (12. 5%), J (10%) and L2b (5%).25 (62.5%, 95% CI 46.2 to 78.7) of the chlamydia-infected MSM showed clinical manifestations while 15 (37.5%, 95% CI 21.25 to 53.75) reported no symptoms. Concurrent infection with other STIs was documented in 27 (67.5%, 95% CI 51.7 to 83.2) patients. The most frequently reported clinical symptom was anal ulcer (7 cases, 17.5%; 95% CI 4.47 to 30.52). E genotype was mostly detected in asymptomatic patients. There were non-E genotypes detected in 21 (84%, 95% CI 63.9 to 95.5) of 25 symptomatic patients (p<0.001).

The first two confirmed cases of lymphogranuloma venereum (LGV) in MSM in Asturias are reported, probably indicating the increase of this infection. The Spanish C trachomatis laboratory-based surveillance system may underlie an underestimated number of chlamydial infections. Whenever mild and atypical symptoms exist, laboratory evaluation would contribute to the early implementation of appropriate therapy and prevent LGV dissemination.

Systematic review and meta-analysis.

MEDLINE and Scopus were searched for placebo-controlled trials on vitamin C and EIB. The primary measures of vitamin C effect used in this study were: (1) the arithmetic difference and (2) the relative effect in the postexercise forced expiratory volume in 1 s (FEV₁) decline between the vitamin C and placebo periods. The relative effect of vitamin C administration on FEV₁ was analysed by using linear modelling for two studies that reported full or partial individual-level data. The arithmetic differences and the relative effects were pooled by the inverse variance method. A secondary measure of the vitamin C effect was the difference in the proportion of participants suffering from EIB on the vitamin C and placebo days.

3 placebo-controlled trials that studied the effect of vitamin C on EIB were identified. In all, they had 40 participants. The pooled effect estimate indicated a reduction of 8.4 percentage points (95% CI 4.6 to 12) in the postexercise FEV₁ decline when vitamin C was administered before exercise. The pooled relative effect estimate indicated a 48% reduction (95% CI 33% to 64%) in the postexercise FEV₁ decline when vitamin C was administered before exercise. One study needed imputations to include it in the meta-analyses, but it also reported that vitamin C decreased the proportion of participants who suffered from EIB by 50 percentage points (95% CI 23 to 68); this comparison did not need data imputations.

Given the safety and low cost of vitamin C, and the positive findings for vitamin C administration in the three EIB studies, it seems reasonable for physically active people to test vitamin C when they have respiratory symptoms such as cough associated with exercise. Further research on the effects of vitamin C on EIB is warranted.

Validation study of cases of AMI identified from general practitioner records and hospital discharge diagnoses using free text and codes from the International Classification of Primary Care (ICPC), International Classification of Diseases 9th revision-clinical modification (ICD9-CM) and ICD-10th revision (ICD-10).

Population-based databases comprising routinely collected data from primary care in Italy and the Netherlands and from secondary care in Denmark from 1996 to 2009.

A total of 4 034 232 individuals with 22 428 883 person-years of follow-up contributed to the data, from which 42 774 potential AMI cases were identified. A random sample of 800 cases was subsequently obtained for validation.

PPVs were calculated overall and for each code/free text. ‘Best-case scenario’ and ‘worst-case scenario’ PPVs were calculated, the latter taking into account non-retrievable/non-assessable cases. We further assessed the effects of AMI misclassification on estimates of risk during drug exposure.

Records of 748 cases (93.5% of sample) were retrieved. ICD-10 codes had a ‘best-case scenario’ PPV of 100% while ICD9-CM codes had a PPV of 96.6% (95% CI 93.2% to 99.9%). ICPC codes had a ‘best-case scenario’ PPV of 75% (95% CI 67.4% to 82.6%) and free text had PPV ranging from 20% to 60%. Corresponding PPVs in the ‘worst-case scenario’ all decreased. Use of codes with lower PPV generally resulted in small changes in AMI risk during drug exposure, but codes with higher PPV resulted in attenuation of risk for positive associations.

ICD9-CM and ICD-10 codes have good PPV in identifying AMI from EHRs; strategies are necessary to further optimise utility of ICPC codes and free-text search. Use of specific AMI disease codes in estimation of risk during drug exposure may lead to small but significant changes and at the expense of decreased precision.

Cross-sectional study.

Population-based in Mid-Ohio Valley, West Virginia following contamination by a chemical plant.

The C8 Health Project collected data and measured the serum level of perfluoroalkyl acids (PFAAs) of 21 024 adults aged 50+ years.

Self-reported memory impairment as defined by the question ‘have experienced short-term memory loss?’

A total of 4057 participants self-reported short-term memory impairment. Inverse associations between PFOS and PFOA and memory impairment were highly statistically significant with fully adjusted OR=0.93 (95% CI 0.90 to 0.96) for doubling PFOS and OR=0.96 (95% CI 0.94 to 0.98) for doubling PFOA concentrations. Comparable inverse associations with PFNA and PFHxS were of borderline statistical significance. Inverse associations of PFAAs with memory impairment were weaker or non-existent in patients with diabetes than overall in patients without diabetes.

An inverse association between PFAA serum levels and self-reported memory impairment has been observed in this large population-based, cross-sectional study that is stronger and more statistically significant for PFOA and PFOS. The associations can be potentially explained by a preventive anti-inflammatory effect exerted by a peroxisome proliferator-activated receptor agonist effect of these PFAAs, but confounding or even reverse causation cannot be excluded as an alternative explanation.

Questionnaires were administered to 94 BSA and 185 BW recently diagnosed patients with cancer at baseline and at 3 and 9 months. In total, 53.8% of the BSA samples were born in the Indian subcontinent, 33% in Africa and 12.9% in the UK. Three screening tools for depression were used to counter concerns about ethnic bias and validity in linguistic translation. The Hospital Anxiety and Depression Scale (HADS-D), Patient Health Questionnaire-9 (both validated in Gujarati), Emotion Thermometers (including the Distress Thermometer (DT), Mini-MAC and the newly developed Cancer Insight and Denial questionnaire (CIDQ) were completed.

Leicestershire Cancer Centre, UK.

94 BSA and 185 BW recently diagnosed patients with cancer.

BSA self-reported significantly higher rates of depressive symptoms compared with BW patients longitudinally (HADS-D ≥8: baseline: BSA 35.1% vs BW 16.8%, p=0.001; 3 months BSA 45.6% vs BW 20.8%, p=0.001; 9 months BSA 40.6% vs BW 15.3%, p=0.004). BSA patients used potentially maladaptive coping strategies more frequently than BW patients at baseline (hopelessness/helplessness p=0.005, fatalism p=0.0005, avoidance p=0.005; the CIDQ denial statement ‘I do not really believe I have cancer’ p=0.0005). BSA patients experienced more physical symptoms (DT checklist), which correlated with ethnic differences in depressive symptoms especially at 3 months.

Health professionals need to be aware of a greater probability of depressive symptomatology (including somatic symptoms) and how this may present clinically in the first 9 months after diagnosis if this ethnic disparity in mental well-being is to be addressed.

A cross-sectional study was conducted from January 2010 to February 2010.

This study was carried out in Lashio city, Northern Shan State, Myanmar.

In total, 158 male IDUs and 210 male NIDUs were recruited using a respondent-driven sampling method.

Proportion of both drug users who were ever tested for HIV and factors associated with HIV testing.

Approximately 77% of IDUs and 46% of NIDUs were ever tested for HIV. The multivariate analysis revealed that having ever received drug treatment was positively associated with HIV testing among both IDUs (adjusted OR (AOR) 13.07; 95% CI 3.38 to 50.53) and NIDUs (AOR 3.58; 95% CI 1.38 to 9.24). IDUs who were married (AOR 0.24; 95% CI 0.06 to 0.94) and who injected at least twice daily (AOR 0.30; 95% CI 0.09 to 0.97) were less likely to undergo HIV testing. Among NIDUs, those who belonged to Shan (AOR 0.30; 95% CI 0.11 to 0.84) or Kachin (AOR 0.30; 95% CI 0.10 to 0.87) ethnicities were less likely to test for HIV.

IDUs and NIDUs who have received drug treatment are more likely to test for HIV. Integrating HIV testing into drug treatment programmes alongside general expansion of HIV testing services may be effective in increasing HIV testing uptake among both IDUs and NIDUs in the Northern Shan State of Myanmar.

Observational, prospective study.

84 secondary care centres in 22 countries.

456 adults (≥18 years) with poststroke upper limb spasticity treated with one cycle of BoNT-A.

Muscle selection, BoNT-A preparation, injection technique and timing of follow-up were conducted according to routine practice for each centre. Primary outcome: achievement of the patient's primary goal for treatment using goal-attainment scaling (GAS). Measurements of spasticity, standardised outcome measures and global benefits were also recorded.

The median number of injected muscles was 5 (range 1–15) and the most frequently injected muscles were the long finger flexors, followed by biceps and brachioradialis. The median (range) follow-up time was 14 (2.6 to 32.3) weeks. The common primary treatment goals were passive function (132 (28.9%)), active function (104 (22.8%)), pain (61 (13.4%)), impairment (105 (23%)), involuntary movement (41 (9%)) and mobility (10 (2.2%)). Overall, 363 (79.6%) (95% CI 75.6% to 83.2%) patients achieved (or overachieved) their primary goal and 355 (75.4%) (95% CI 71.2% to 79.2%) achieved their secondary goal. Mean (SD) change from baseline in GAS T-scores was 17.6 (11.0) (95% CI 16.4 to 18.8; p<0.001). GAS T-scores were strongly correlated with global benefit and other standard measures (correlations of 0.38 and 0.63, respectively; p<0.001).

BoNT-A demonstrated a clinically significant effect on goal attainment for the real-life management of upper-limb spasticity following stroke. The study confirms the feasibility of a common international data set to collect systematic prospective data, and of using GAS to capture person-centred outcomes relating to passive and active functions and to pain.

ClinicalTrials.gov identifier: NCT01020500

Cross-sectional study.

Allier, one of the major areas of polyvinyl chloride production in France.

We screened 761 (97% men) retired workers exposed to chemical toxics. Exposure to chemicals other than VCM excluded potential participants.

These participants underwent a medical examination including a capillaroscopy, symptoms of Raynaud and comorbidities, as well as a survey to determine exposure time, direct or indirect contact, type of occupation, smoking status and time after exposure. A double blind analysis of capillaroscopic images was carried out. A control group was matched in age, sex, type of occupation.

179/761 retired workers were only exposed to VCM at their work, with 21 meeting the inclusion criteria and included. Exposure time was 29.8±1.9 years and time after exposure was 15.9±2.4 years. Retired workers previously exposed to VCM had significantly higher capillaroscopic modifications than the 35 controls: enlarged capillaries (19% vs 0%, p<0.001), dystrophy (28.6% vs 0%, p=0.0012) and augmented length (33% vs 0%, p<0.001). Time exposure was linked (p<0.001) with enlarged capillaries (R²=0.63), dystrophy (R²=0.51) and capillary length (R²=0.36). They also had higher symptoms of Raynaud (19% vs 0%, p=0.007) without correlation with capillaroscopic modifications.

Although VCM exposure was already known to affect microcirculation, our study demonstrates residual long-term abnormalities following an average of 15 years’ retirement, with a time-related exposure response. Symptoms of Raynaud, although statistically associated with exposure, were not related to capillaroscopic modifications; its origin remains to be determined.

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

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

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

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

Although only a very small percentage of paid malpractice claims in the USA are judged in court, a number of characteristics differ between settled and judged claims. Such differences may influence perceptions of malpractice risk and future reform efforts.

A systematic review of layperson perspectives of SA was conducted across MEDLINE, PsycInfo, CINAHL, EMBASE and ISI Web of Knowledge.

Peer-reviewed studies conducting qualitative investigations of lay perspectives of SA were included. Included studies were coded and analysed using NVivo V.9 to examine underlying themes of SA.

The search strategy identified 7285 articles; 26 articles met the inclusion criteria. Laypersons identified psychosocial components, notably engagement (eg, social engagement), and personal resources (eg, attitude) as integral components of SA more often than ‘physiological’ components, such as longevity or physical functioning. These results also highlight the profound under-representation of non-Western countries and the cultural homogeneity of research participants.

The current study reveals the importance laypersons place on incorporating psychosocial components into multidimensional models of SA, as well as highlighting the need for increased research with under-represented populations.

This study prospectively evaluated the 12-month incidence of exercise-related injuries to community-dwelling older adults (n=167 respondents; 63 men, 104 women; mean age 69±5 year).

A questionnaire developed for use in older adults was administered to document self-reported injuries. Linear regression analysis was conducted to identify covariates related to injury outcomes.

23 people (14%) reported injuries. 41% of injuries were to the lower extremities, where the most common type was overuse muscle strains (32%, n=7). Overexertion was the most common cause of injury (n=9) and walking accounted for half of the activities during which injury occurred. 70% of injuries required medical treatment. 44% were not able to continue exercising after injury and return-to-activity time varied from 1 to 182 days. Sex, age and exercise volume were not significantly associated with injury occurrence.

These results showed similar, or lower, exercise-related injury rates as compared with previous reports on younger and middle-aged adults; however, the definition of, and criteria for, ‘injury’ reporting varies in the literature. This study indicates that older adults taking up exercise are not at increased risk of injury versus younger age groups.

Retrospective cohort.

Urban academic hospital.

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

None.

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

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

SP pneumonia generally remains associated with substantial mortality while azithromycin treatment is associated with significantly higher survival rates. The impact of azithromycin is independent of multiple potential confounders.

WelTel Retain is an open, parallel group RCT that will be conducted at the Kibera Community Health Centre in Nairobi, Kenya. Over a 1-year period, we aim to recruit 686 individuals newly diagnosed with HIV who will be randomly allocated to an intervention or control arm (standard care) at a 1:1 ratio. Intervention arm participants will receive the weekly WelTel SMS ‘check-in’ to which they will be instructed to respond within 48 h. An HIV clinician will follow-up and triage any problems that are identified. Participants will be followed for 1 year, with a primary endpoint of retention in care at 12 months. Secondary outcomes include retention in stage 1 HIV care (patients return to the clinic to receive their first CD4 results) and timely ART initiation. Cost-effectiveness will be analysed through decision-analytic modelling.

Ethical approval has been obtained from the University of British Columbia and the African Medical and Research Foundation. This trial will test the effectiveness and cost-effectiveness of the WelTel intervention to engage patients during the first year of HIV care. Trial results and economic evaluation will help inform policy and practice on the use of WelTel in the early stages of HIV care.

ClinicalTrials.gov NCT01630304.

Diagnostic accuracy study in a multicentre prospective cohort study.

Alzheimer Disease Neuroimaging Initiative participants with complete data on neuropsychological assessment, MRI of the brain and CSF analysis.

Patients with mild cognitive impairment (MCI; n=181) were included. Mean follow-up was 38.9 months (range 5.5–75.9).

Diagnostic accuracy of individual instruments and incremental value of entorhinal cortex volume on MRI and p-/Aβ ration in CSF after administration of Rey's Auditory Verbal Learning Memory Test are calculated and expressed as the ‘Net Reclassification Improvement’ (NRI), which is the change in the percentage of individuals that are correctly diagnosed as Alzheimer or non-Alzheimer case.

Tested in isolation, a short memory test, MRI and CSF all substantially contribute to the differentiation of those MCI patients who remain stable during follow-up from those who progress to develop Alzheimer's disease. The memory test, MRI and CSF improved the diagnostic classification by 21% (95% CI 15.1 to 26.9), 22.1% (95% CI 16.1 to 28.1) and 18.8% (95% CI 13.1 to 24.5), respectively. After administration of a short memory test, however, the NRI of MRI is +1.1% (95% CI 0.1 to 3.9) and of CSF is –2.2% (95% CI –5.6 to –0.6).

After administration of a brief test of memory, MRI or CSF do not substantially affect diagnostic accuracy for predicting progression to Alzheimer's disease in patients with MCI. The NRI is an intuitive and easy to interpret measure for evaluation of potential added value of new diagnostic instruments in daily clinical practice.

Cross-sectional study.

Local Association of Fibromyalgia (Granada, Spain).

The study comprised 94 women with diagnosed fibromyalgia who did not have other severe somatic or psychiatric disorders, or other diseases that prevent physical loading, able to ambulate and to communicate and capable and willing to provide informed consent.

Sedentary time and physical activity were measured by accelerometry and expressed as time spent in sedentary behaviours, average physical activity intensity (counts/minute) and amount of time (minutes/day) spent in moderate intensity and in moderate-to-vigorous-intensity physical activity (MVPA).

The proportion of women meeting the physical activity recommendations of 30 min/day of MVPA on 5 or more days a week was 60.6%. Women spent, on average, 71% of their waking time (approximately 10 h/day) in sedentary behaviours. Both sedentary behaviour and physical activity levels were similar across age groups, waist circumference and percentage body fat categories, years since clinical diagnosis, marital status, educational level and occupational status, regardless of the severity of the disease (all p>0.1). Time spent on moderate-intensity physical activity and MVPA was, however, lower in those with greater body mass index (BMI) (–6.6 min and –7 min, respectively, per BMI category increase, <25, 25–30, >30 kg/m²; p values for trend were 0.056 and 0.051, respectively). Women spent, on average, 10 min less on MVPA (p<0.001) and 22 min less on sedentary behaviours during weekends compared with weekdays (p=0.051).

These data provide an objective measure of the amount of time spent on sedentary activities and on physical activity in women with fibromyalgia.

We demonstrate, using somatically gene-targeted human cells that the ATG16L1 T300A variant confers protection from cellular invasion by Salmonella. In addition, we show that ATG16L1-deficient cells are resistant to bacterial invasion.

These results suggest that cellular expression of ATG16L1 facilitates bacterial invasion and that the CD-associated ATG16L1 T300A variant may confer protection from bacterial infection.

The Dutch Famine Birth Cohort consists of 2414 men and women born in Amsterdam as term singletons around the time of the Dutch famine. In a subsample of 150 cohort members, who now are about 68 years of age, we are currently measuring cognitive decline and the incidence of white matter hyperintensities and cerebral microbleeds (through MRI), incidence of fractures, grip strength and physical performance, visual acuity and incidence of cataract operations. In this same subgroup, we will assess telomere length, oxidative stress and inflammatory status as potential underlying mechanisms. Furthermore, in the entire cohort, we will assess mortality as well as hospital admissions for age-related diseases up to the age of 68 years.

The study was approved by the local medical ethics committee (Academic Medical Centre, University of Amsterdam) and is being carried out in agreement with the Declaration of Helsinki. All participants give written informed consent. Study findings will be widely disseminated to the scientific public as well as to the medical society and general public.

Systematic reviews of interventions for cystic fibrosis published on the Cochrane Library by the Cochrane Cystic Fibrosis and Genetic Disorders Group before 2010 were assessed for discrepancies in outcomes between review protocol and full review. ORB in eligible trials was also assessed for all efficacy review outcomes. Two authors independently classified each outcome using a nine-point classification system developed by the Outcome Reporting Bias In Trials study. These classifications were used to inform the assessment of the risk of bias for selective outcome reporting for each trial.

–46 Cochrane cystic fibrosis systematic reviews were included. The median number of primary outcomes, number of trials and participants per trial in the reviews were 3 (IQR 2, 3), 4 (IQR 2, 8) and 21 (IQR 14, 41), respectively. 18 reviews (39%, 18/46) had a discrepancy in outcomes between protocol and full review. 37 reviews were eligible to be included in the ORB assessment. When considering review primary outcomes and all review outcomes, ORB was suspected in at least one trial in 86% and 100%, respectively.

Assessment of ORB within a systematic review of a single primary outcome underestimates the risk of ORB in comparison to the assessment of multiple primary and secondary outcomes. ORB in trials is highly prevalent within systematic reviews of cystic fibrosis when assessed across all outcomes. This could be reduced by the development of a core outcome set for trials and systematic reviews in cystic fibrosis.

A cross-sectional study utilising an internet-based questionnaire sent to key figures responsible for leading on the planning and delivery of undergraduate medical teaching at all schools of medicine in the UK and Ireland.

All identified undergraduate schools of medicine in the UK and Ireland between August 2012 and December 2012.

Numerical data and free text feedback about relevant aspects of undergraduate teaching.

Of the 38 medical schools approached, 34 (28 in UK, 6 in Ireland) completed the questionnaire (89.47%). 4 (all in UK) chose not to complete it. 6/34 (17.65%) included some specific teaching on biological weapons and bioterrorism. 7/34 (20.59%) had staff with bioterrorism expertise (mainly in microbiological and syndromic aspects). 4/34 (11.76%) had plans to introduce some specific teaching on bioterrorism. Free text responses revealed that some felt that because key bodies (eg, UK's General Medical Council) did not request teaching on bioterrorism, then it should not be included, while others regarded this field of study as a postgraduate subject and not appropriate for undergraduates, or argued that the curriculum was too congested already. 4/34 (11.76%) included some specific teaching on chemical weapons, and 3/34 (8.82%) on weaponised radiation.

This study provides evidence that at the present time there is little teaching at the undergraduate level in the UK and Ireland on the subjects of biological weapons and bioterrorism, chemical weapons and weaponised radiation and signals that this situation is unlikely to change unless there were to be high-level policy guidance.

Retrospective cohort design using hospital discharge data for dementia patients, case matched on sex, age, comorbidity and surgical status on a 1 : 4 ratio to non-dementia patients.

Public hospital discharge data from the state of New South Wales, Australia for 2006/2007.

426 276 overnight hospital episodes for patients aged 50 and above (census sample).

Rates of preventable complications, with episode-level risk adjustment for 12 complications that are known to be sensitive to nursing care.

Controlling for age and comorbidities, surgical dementia patients had higher rates than non-dementia patients in seven of the 12 complications: urinary tract infections, pressure ulcers, delirium, pneumonia, physiological and metabolic derangement (all at p<0.0001), sepsis and failure to rescue (at p<0.05). Medical dementia patients also had higher rates of these complications than did non-dementia patients. The highest rates and highest relative risk for dementia patients compared with non-dementia patients, in both medical and surgical populations, were found in four common complications: urinary tract infections, pressure areas, pneumonia and delirium.

Compared with non-dementia patients, hospitalised dementia patients have higher rates of potentially preventable complications that might be responsive to nursing interventions.

Observational study using health data routinely collected for non-research purposes.

Department of Pain Management, Russells Hall Hospital, Dudley, UK.

Twenty consecutive male patients attending follow-up clinics for intrathecal opioid therapy had the gonadal axis evaluated by measuring their serum luteinising hormone, follicle stimulating hormone, total testosterone, sex hormone binding globulin and calculating the free testosterone level. Bone mineral density was measured by DEXA scanning in those patients diagnosed with hypogonadism.

Based on the calculated free testosterone concentrations, 17 (85%) patients had biochemical hypogonadism with 15 patients (75%) having free testosterone <180 pmol/L and 2 patients (10%) between 180 and 250 pmol/L. Bone mineral density was assessed in 14 of the 17 patients after the exclusion of 3 patients. Osteoporosis (defined as a T score ≤–2.5 SD) was detected in three patients (21.4%) and osteopaenia (defined as a T score between –1.0 and –2.5 SD) was observed in seven patients (50%). Five of the 14 patients (35.7%) were at or above the intervention threshold for hip fracture.

This study suggests an association between hypogonadism and low bone mass density in patients undertaking intrathecal opioid delivery for the management of chronic non-malignant pain. Surveillance of hypogonadism and the bone mineral density levels followed by appropriate treatment may be of paramount importance to reduce the risk of osteoporosis development and prevention of fractures in this group of patients.

Systematic mapping review of qualitative research undertaken with randomised controlled trials and published in peer-reviewed journals.

MEDLINE, PreMEDLINE, EMBASE, the Cochrane Library, Health Technology Assessment, PsycINFO, CINAHL, British Nursing Index, Social Sciences Citation Index and ASSIA.

Articles reporting qualitative research undertaken with trials published between 2008 and September 2010; health research, reported in English.

296 articles met the inclusion criteria. Articles focused on 22 aspects of the trial within five broad categories. Some articles focused on more than one aspect of the trial, totalling 356 examples. The qualitative research focused on the intervention being trialled (71%, 254/356); the design, process and conduct of the trial (15%, 54/356); the outcomes of the trial (1%, 5/356); the measures used in the trial (3%, 10/356); and the target condition for the trial (9%, 33/356). A minority of the qualitative research was undertaken at the pretrial stage (28%, 82/296). The value of the qualitative research to the trial itself was not always made explicit within the articles. The potential value included optimising the intervention and trial conduct, facilitating interpretation of the trial findings, helping trialists to be sensitive to the human beings involved in trials, and saving money by steering researchers towards interventions more likely to be effective in future trials.

A large amount of qualitative research undertaken with specific trials has been published, addressing a wide range of aspects of trials, with the potential to improve the endeavour of generating evidence of effectiveness of health interventions. Researchers can increase the impact of this work on trials by undertaking more of it at the pretrial stage and being explicit within their articles about the learning for trials and evidence-based practice.

Cross-sectional study.

The Cardiovascular Risk in Young Finns Multicenter Study. Participants Sedentary time (TV viewing, computer time, reading, music/radio listening and other relaxation) was assessed with a questionnaire for 1084 women and 909 men aged 30–45 years. Other study variables included occupational and leisure-time physical activity, sleep duration, socioeconomic status, smoking, alcohol consumption, energy intake, adherence to the recommended diet, multiple individual food items, age and genetic variants associated with body mass index (BMI). Primary outcome measures BMI in kg/m² and waist circumference (WC in cm).

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

Out of the different types of sedentary behaviour, TV viewing was most consistently associated with adiposity markers in adults. Partial dilution of these associations after adjustments for covariates suggests that the obesogenic effects of TV viewing are partly mediated by other lifestyle factors.

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

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

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

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

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

These findings suggest that, along with a generally poor availability of housing stock for individuals with SMI, access problems are compounded by a lack of attention to the unique needs and illness trajectories that attend gender.

COMPORT is a multicentre, open label, phase III randomised trial using a parallel two-arm design. 150 patients <40 years old fulfilling the ‘Bologna criteria’ will be randomised to corifollitropin α followed by hpHMG (group A) or recombinant FSH (group B) in a GnRH antagonist protocol for IVF/intracytoplasmic sperm injection (ICSI). The primary outcome is the ongoing pregnancy rate (defined as the presence of intrauterine gestational sac with an embryonic pole demonstrating cardiac activity at 9–10 weeks of gestation). Secondary outcomes are clinical and biochemical pregnancy rates and number of oocytes retrieved. Central randomisation will be performed using a computer-generated list and allocation concealment will be secured with the use of sealed-opaque envelopes. A sample size of 150 women is essential to detect a difference of 19.5% in ongoing pregnancy rates between group A (28%) and group B (8.5%) with a power of 85% and a level of significance at 0.05 using a two-sided Fisher's exact test.

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

Trial Registration: The study is registered at UMIN Clinical Trials Registry (UMIN000006839).

A cross-sectional, single-site study.

A fatigue clinic in the Netherlands.

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

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

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

The results highlight the need to routinely screen for Primary Sleep Disorders in clinical practice and tailor sleep interventions, based on phenotype, to patients presenting with CFS. The results are discussed in terms of matching patients’ self-reported sleep to these phenotypes in clinical practice.

Prospective cohort study.

University hospital.

259 patients with AFP.

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

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

Start of treatment and grading, but most importantly EMG evaluated for pathological spontaneous activity and the stapedius reflex test are powerful prognosticators for estimating the recovery time from AFP. These results need confirmation in larger datasets.

Cross-sectional and longitudinal data from a longitudinal population study.

Data from two cohorts participating in the first two waves of the nationally representative Longitudinal Study of Australian Children.

Baby cohort at ages 0–1 and 2–3 (n=5107, 4606) and Kindergarten cohort at ages 4–5 and 6–7 (n=4983, 4460).

Federal Government expenditure on healthcare attendances and prescription medication from birth to 8 years, calculated via linkage to Australian Medicare data, were compared according to parent report of child sleep problems at each of the surveys.

At both waves and in both cohorts, over 92% of children had both sleep and Medicare data. The average additional healthcare costs for children with sleep problems ranged from $141 (age 5) to $43 (age 7), falling to $98 (age 5) to $18 (age 7) per child per annum once family socioeconomic position, child gender, global health and special healthcare needs were taken into account. This equates to an estimated additional $27.5 million (95% CI $9.2 to $46.8 million) cost to the Australian federal government every year for all children aged between 0 and 7 years. In both cohorts, costs were higher for persistent than transient sleep problems.

Higher healthcare costs were sustained by infants and children with sleep problems. This supports ongoing economic evaluations of early prevention and intervention services for sleep problems considering impacts not only on the child and family but also on the healthcare system.

This was a descriptive before-and-after study. Participating patients completed the Edmonton Symptom Assessment System (ESAS) twice, upon hospital admission and prior to discharge. All patients underwent a structured interview assessing their opinion about the emergency admission. Medical data were obtained from the hospital records.

The study was performed in two Norwegian acute care secondary hospitals with urban catchment areas.

44 patients with cancer (men 27 and women 17; mean age 69.2, SD 9.2) representing 50 emergency admissions were included.

Median length of stay was 7 days (95% CI 7.4 to 11.4). Median survival was 50 days (95% CI 51 to 115). 90% were admitted from home, and 46% had been hospitalised less than 1 month earlier. Lung and gastrointestinal symptoms and pain were the most frequent reasons for admissions. Mean pain scores on ESAS were reduced by 50% from admission to discharge (p<0.01). Simple interventions such as hydration, bladder catheterisation and oxygen therapy were most frequent. Nearly one-third would have preferred treatment at another site, provided that the quality of care was similar. Home visits by the family doctor and specialised care teams were perceived by patients as important to prevent hospitalisation.

In most emergency admissions, relatively simple medical interventions are necessary. Specialised care teams with palliative care physicians, easier access to the family doctor and better lines of cooperation between hospitals and the primary care sector may make it possible to perform more of these procedures at home, thereby reducing the need for emergency admissions.

Prospective cohort study.

Multicentre outpatient clinics in the Netherlands.

We followed 397 patients with newly diagnosed transient ischaemic attack (TIA) or minor ischaemic stroke receiving anticoagulants or antiplatelet drugs. 58% were men. The mean age was 65.3 years. 395 (99%) patients were white Europeans. MRI including a T2*-weighted gradient echo was performed within 3 months after start of medication. 48 (12%) patients had one or more microbleeds. They were followed every 6 months by telephone for a mean of 3.8 years.

Primary outcome was a symptomatic ICH. Secondary outcome were all strokes, ischaemic stroke, myocardial infarct, death from all vascular causes, death from non-vascular causes and death from all causes.

Five patients (1%) suffered from a symptomatic ICH. One ICH occurred in a patient with microbleeds at baseline (adjusted HR 2.6, 95% CI 0.3 to 27). The incidence of all strokes during follow-up was higher in patients with than without microbleeds (adjusted HR 2.3, 95% CI 1.0 to 5.3), with a dose–response relationship. The incidences of ischaemic stroke, vascular death, non-vascular death and death of all causes were higher in patients with microbleeds, but not statistically significant.

In our cohort of patients using antithrombotic drugs after a TIA or minor ischaemic stroke, we found that microbleeds on MRI are associated with an increased risk of future stroke in general, but we did not find an increased risk of symptomatic ICH.

Retrospective cohort study.

Olmsted County, Minnesota.

All adult residents of Olmsted County, Minnesota, who underwent ERCP from 1997 to 2006.

Diagnostic and therapeutic ERCPs were assessed.

Patient and procedural characteristics and complications within 30 days; and rates of ERCP utilisation and unplanned admissions and risk factors for admissions.

In 10 years, 1072 ERCPs were performed on 827 individual patients. Average utilisation of ERCP was 83.1 ERCPs/100 000 persons/year, with an increase from 58 to 104.8 ERCPs/100 000 persons/year over time, driven by increases in therapeutic procedures. Within 30 days after 236 procedures, 62 admissions were definitely related to the index ERCP. The complication rate was 5.3%, including pancreatitis (26, 2.4%), infection/cholangitis (16, 1.5%), bleeding (15, 1.4%) and perforation (4, 0.37%). 30-day mortality was 2.4%, none of which was directly related to the ERCP or complications thereof. Risk factors identified through multivariate analysis to be associated with adverse events included: age <45 years (p=0.0498); body mass index ≥35 (p=0.0024); pancreatic duct cannulation (p=0.0026); outpatient procedure (p<0.0001); intraprocedure sphincterotomy bleeding (p<0.0001); difficulty grade (p=0.115) and patient's first ERCP (p=0.0394).

Retrospective study.

Population utilisation of ERCP rose during the study period, specifically in therapeutic procedures. Admissions within 30 days of ERCP are common but often unrelated. Complications of ERCP remain infrequent and deaths quite unusual.

Cross-sectional study conducted between January and December 2010 to survey graduates, using in-person, phone or online surveys using email and social networks. Logistic regression analysis was applied to determine ORs for association between predictors and outcomes.

Located rurally, Mbarara University of Science and Technology (MUST) is one of three government supported medical schools in Uganda.

Graduates who completed a health-related degree at MUST.

Location of health profession graduates (Uganda or abroad) and main field of current job (HIV-related non-governmental organisation (NGO) or others).

We interviewed 85.4% (n=796) of all MUST alumni since the university opened in 1989. 78% (n=618) were physicians and 12% (n=94) of graduates worked outside Uganda. Over 50% (n=383) of graduates worked for an HIV-related NGO whether in Uganda or abroad. Graduates receiving their degree after 2005, when large HIV programmes started, were less likely to leave the country, OR=0.24 (95% CI 0.1 to 0.59) but were more likely to work for an HIV-related NGO, OR=1.53 (95% CI 1.06 to 2.23).

A majority of health professionals surveyed work for an HIV-related NGO. The increase in resources and investment in HIV-treatment capacity is temporally associated with retention of medical providers in Uganda. Donor funds should be channelled to develop and retain healthcare workers in disciplines other than HIV and broaden the healthcare workforce to other areas.

Ecological time series study.

Data on suicide incidents, air pollen counts and meteorological status were retrieved from Danish registries.

13 700 suicide incidents over 1304 consecutive weeks were obtained from two large areas covering 2.86 million residents.

Risk of suicide associated with pollen concentration was assessed using a time series Poisson-generalised additive model.

We noted a significant association between suicide risk and air pollen counts. A change of pollen counts levels from 0 to ‘10–<30’ grains/m³ air was associated with a relative risk of 1.064, that is, a 6.4% increase in weekly number of suicides in the population, and from 0 to ‘30–100’ grains, a relative risk of 1.132. The observed association remained significant after controlling for effects of region, calendar time, temperature, cloud cover and humidity. Meanwhile, we observed a significant sex difference that suicide risk in men started to rise when there was a small increase of air pollen, while the risk in women started to rise until pollen grains reached a certain level. High levels of pollen had slightly stronger effect on risk of suicide in individuals with mood disorder than those without the disorder.

The observed association between suicide risk and air pollen counts supports the hypothesis that aeroallergens, acting as immune triggers, may precipitate suicide.

A cross-sectional study using a microsimulation model of the 2009 Australian population (Health&WealthMOD).

2009 Australian population.

9198 people aged between 45 and 64 years surveyed for the 2003 Survey of Disability, Ageing and Carers.

50% of the median equivalised income-unit-income poverty line.

It was found that individuals who had retired early due to other reasons were significantly less likely to be in income poverty than those retired due to ill health (OR 0.43 95% CI 0.33 to 0.51), and there was no significant difference in the likelihood of being in income poverty between these individuals and those unemployed. Being in the same family as someone who is retired due to illness also significantly increases an individual's chance of being in income poverty.

It can be seen that being retired due to illness impacts both the individual and their family.

A serial cross-sectional design will be combined with a two-point in time longitudinal design to measure the levels of stigma among healthcare students from each year of undergraduate and graduate courses in Malaysia and Australia. In the absence of suitable measures, we will carry out a sequential mixed methods design to develop such a tool. The questionnaire data will be analysed using mixed effects linear models to manage the repeated measures.

We have received ethical approval from the Monash MBBS executive committee as well as the Monash University Human Research Ethics Committee. We will keep the data in a locked filing cabinet in the Monash University (Sunway campus) premises for 5 years, after which the information will be shredded and disposed of in secure bins, and digital recordings will be erased in accordance with Monash University's regulations. Only the principal investigator and the researcher will have access to the filing cabinet. We aim to present and publish the results of this study in national and international conferences and peer-reviewed journals, respectively.

Population-based, retrospective cohort study.

Public and private hospitals in Western Australia.

Included were 93 802 public and 66 479 private singleton, term deliveries during 1998–2008, from which 32 757 public patients were matched with 32 757 private patients on the propensity score of maternal characteristics.

Neonatal outcomes were compared in the propensity score-matched cohorts using conditional logistic regression, adjusted for antenatal risk factors and mode of delivery. Outcomes included Apgar score <7 at 5 min, neonatal resuscitation (endotracheal intubation or external cardiac massage) and admission to a neonatal special care unit.

No significant differences in maternal characteristics were found between the propensity score-matched groups. Private patients were more likely than their matched public counterparts to undergo prelabour caesarean section (25.2% vs 18%, p<0.0001). Public patients had lower rates of neonatal unit admission (AOR 0.67, 95% CI 0.62 to 0.73) and neonatal resuscitation (AOR 0.73, 95% CI 0.56 to 0.95), but higher rates of low Apgar scores at 5 min (AOR 1.31, 95% CI 1.06 to 1.63) despite adjustment for antenatal factors. Additional adjustment for mode of delivery reduced the resuscitation risk (AOR 0.86, 95% CI 0.63 to 1.18) but did not significantly alter the other estimates.

Propensity score methods can be used to generate comparable groups of public and private patients. Despite the rates of low Apgar scores being higher in public patients, the rates of special care admission were lower. Whether these findings stem from differences in paediatric services or clinical factors is yet to be determined.

 A retrospective cohort study using aggregated data from a national perinatal registry.

All midwifery practices and hospitals in the Netherlands.

All pregnant women with a singleton pregnancy without congenital malformations and a gestational age of ≥20 weeks who delivered between January 2000 and December 2007.

Preterm delivery, cervical incompetence treated by cerclage, placenta praevia, placental abruption, retained placenta and postpartum haemorrhage.

A previous pregnancy termination was reported in 16 000 (1.2%) deliveries. The vast majority of these (90–95%) were performed by surgical methods. The incidence of all outcome measures was significantly higher in women with a history of pregnancy termination. Adjusted ORs (95% CI) for cervical incompetence treated by cerclage, preterm delivery, placental implantation or retention problems and postpartum haemorrhage were 4.6 (2.9 to 7.2), 1.11 (1.02 to 1.20), 1.42 (1.29 to 1.55) and 1.16 (1.08 to 1.25), respectively. Associated numbers needed to harm were 1000, 167, 111 and 111, respectively. For any listed adverse outcome, the number needed to harm was 63.

In this large nationwide cohort study, we found a positive association between surgical termination of pregnancy and subsequent preterm delivery, cervical incompetence treated by cerclage, placental implantation or retention problems and postpartum haemorrhage in a subsequent pregnancy. Absolute risks for these outcomes, however, remain small. Medicinal termination might be considered first whenever there is a choice between both methods.

Children aged 9–11 years were recruited from 24 primary schools that participated in the Steps to Active Kids (STAK) physical activity intervention study. Study inclusion criteria were low exercise self-efficacy, teacher-rated overweight or asthma. Children with high levels of physical activity were excluded. Measures included parent and teacher-rated behavioural and emotional well-being using the Strengths and Difficulties Questionnaire, physical and sedentary activity levels, BMI (body mass index) and exercise self-efficacy.

Of 424 participating children, 62% were girls and 39% were classified as overweight or obese. As compared with population norms, boys in this at-risk sample were more likely to receive an abnormal teacher-rated hyperactivity/inattention score (OR 1.48, 95% CI 1.01 to 2.17). Children with teacher-rated abnormal hyperactivity/inattention scores reported higher levels of sedentary activity (OR 1.13, 95% CI 1.02 to 1.17), but not physically active activity. The pattern of findings was similar for children with hyperactivity/inattention problems as rated by both parent and teacher (pervasive hyperactivity and impairment).

Although BMI was not directly related to hyperactivity/inattention, children with risk factors for adult obesity have more hyperactivity/inattention problems. In particular, hyperactivity/inattention is associated with higher levels of sedentary activity. Higher rates of pervasive hyperactivity and impairment were apparent in this at-risk group.

Cohort study with baseline data from the Swedish Conscription Register and outcome information from the random population-based Swedish Living Conditions Surveys.

Sweden, 1970–2005.

5489 men who at age 17–19 years tested their isometric muscle strength (hand grip, arm flexion and knee extension) during the compulsory conscription.

The men were surveyed regarding self-reported musculoskeletal pain; mean follow-up time of 17 (range 1–35) years. Our primary outcome was a self-report of musculoskeletal pain, and secondary outcomes were a report of ‘severe pain’, ‘pain in back/hips’, ‘pain in neck/shoulders’ or ‘pain in arms/legs’, respectively. We categorised muscle strength into three groups: low, average and high, using the 25th–75th percentile to define the reference category (average). We estimated relative risks using log binomial regression with adjustment for smoking, body mass index, education and physical activity.

In the adjusted model, men with low overall muscle strength had decreased risk of self-reported musculoskeletal pain (0.93, 95% CI 0.87 to 0.99). We observed no such association in men with high strength (0.99, 0.93 to 1.05). Furthermore, no statistically significant increase or decrease in risk was observed for any of the secondary outcomes.

In men, low overall isometric muscle strength in youth was not associated with an increased risk of future musculoskeletal pain. Contrarily, we observed a slightly decreased risk of self-reported musculoskeletal pain in adulthood. Our results do not support a model in which low muscle strength is a risk factor for future musculoskeletal pain.

Case control.

Secondary care, single centre.

34 pSS patients, 11 SLE patients and 13 healthy volunteers (all women) entered and completed the study.

Primary outcomes: TEG and MEA parameters between three subject groups. Secondary outcomes: The relationships between TEG/MEA and clinical/laboratory parameters analysed using bivariate correlation analysis with corrections for multiple testing.

All TEG and MEA parameters were similar for the three subject groups. After corrections for multiple testing, interleukin (IL)-1α and Macrophage inflammatory proteins (MIP)-1α remain correlated inversely with clot strength (r=–0.686, p=0.024 and r=–0.730, p=0.012, respectively) and overall coagulability (r=–0.640, p=0.048 and r=–0.648, p=0.048). Stepwise regression analysis revealed that several cytokines such as MIP-1α, IL-17a, IL-1α and Interferon (IFN)- may be key predictors of clot strength and overall coagulability in pSS.

Clot kinetics and platelet receptor function are normal in pSS. Several cytokines correlate with clot strength and overall coagulability in pSS.

A Swedish nationwide implementation survey, conducted in February 2013, assessed the level of clinical implementation of a 20 ml dose of oral solution of sulfamethoxazole and trimethoprim deposited in the PEG catheter immediately after insertion. All hospitals inserting at least five PEGs annually were identified from the Swedish Patient Registry. A clinician involved in the PEG insertions at each hospital participated in a structured telephone interview addressing their routine use of antibiotic prophylaxis.

All Swedish hospitals inserting PEGs (n=60).

Representatives of PEG insertions at each of the 60 eligible hospitals participated (100% participation).

Use of routine antibiotic prophylaxis for PEG.

A total of 32 (53%) of the 60 hospitals had adopted the new regimen. It was more frequently adopted in university hospitals (67%) than in community hospitals (41%). An annual total of 1813 (70%) of 2573 patients received the new regimen. Higher annual hospital volume was associated with a higher level of adoption of the new regimen (80% in the highest vs 31% in the lowest).

The clinical implementation of the new antibiotic prophylaxis regimen for PEG was high and rapid (70% of all patients within 3 years), particularly in large hospitals.

Qualitative study adopting a qualitative descriptive approach.

25 patients, 11 nurses and 9 doctors who were participating in an RCT of BP telemonitoring. A maximum variation sample of patients from within the trial based on age, sex and deprivation status of the practice was sought.

6 primary care practices in Scotland.

Data were collected via taped semistructured interviews. Initial thematic analysis was inductive. Multiple strategies were employed to ensure that the analysis was credible and trustworthy.

Prior to the trial, both patients and professionals were reluctant to increase the medication based on single BP measurements taken in the surgery. BP measurements based on multiple electronic readings were perceived as more accurate as a basis for action. Patients using telemonitoring became more engaged in the clinical management of their condition. Professionals reported that telemonitoring challenged existing roles and work practices and increased workload. Lack of integration of telemonitoring data with the electronic health record was perceived as a drawback.

BP telemonitoring in a usual care setting can provide a trusted basis for medication management and improved BP control. It increases patients’ engagement in the management of their condition, but supporting telemetry and greater patient engagement can increase professional workloads and demand changes in service organisation. Successful service design in practice would have to take account of how additional roles and responsibilities could be realigned with existing work and data management practices. The embedded qualitative study was included in the protocol for the HITS trial registered with ISRCTN no. 72614272.

Within trial post hoc economic evaluation of data from a pragmatic randomised controlled trial using an intention-to-treat approach.

20 socioeconomically diverse general practices in Lothian, Scotland.

401 primary care patients aged 29–95 with uncontrolled daytime ambulatory blood pressure (ABP) (≥135/85, but <210/135 mm Hg).

Participants were centrally randomised to 6 months of a telemonitoring service comprising of self-monitoring of BP transmitted to a secure website for review by the attending nurse/doctor and patient, with optional automated patient decision-support by text/email (n=200) or usual care (n-201). Randomisation was undertaken with minimisation for age, sex, family practice, use of three or more hypertension drugs and self-monitoring history.

Mean difference in total NHS costs between trial arms and blinded assessment of mean cost per 1 mm Hg systolic BP point reduced.

Home telemonitoring of BP costs significantly more than usual care (mean difference per patient £115.32 (95% CI £83.49 to £146.63; p<0.001)). Increased costs were due to telemonitoring service costs, patient training and additional general practitioner and nurse consultations. The mean cost of systolic BP reduction was £25.56/mm Hg (95% CI £16.06 to £46.89) per patient.

Over the 6-month trial period, supported telemonitoring was more effective at reducing BP than usual care but also more expensive. If clinical gains are maintained, these additional costs would be very likely to be compensated for by reductions in the cost of future cardiovascular events. Longer-term modelling of costs and outcomes is required to fully examine the cost-effectiveness implications.

International Standard Randomised Controlled Trials, number ISRCTN72614272.

Cross-sectional study.

Secondary schools in Hong Kong.

A total of 33 300 secondary 1 (US grade 7) to secondary 5 students (47.6% boys; mean age 14.6 years, SD 1.6) in 85 randomly selected schools.

An anonymous questionnaire was used to obtain information about medical consultation in the past 14 days, hospitalisation in the past 12 months, drinking alcohol, smoking, illicit drug use, physical activity, secondhand smoke exposure, feeling depressed, feeling anxious and sociodemographic characteristics. Drinking alcohol was categorised as non-drinking (reference), <1, 1–2 and 3–7 days/week. Logistic regression yielded adjusted ORs (AORs) of medical consultation and hospitalisation for drinking, adjusting for different potential confounders. Subgroup analysis was conducted among adolescents who did not report feeling anxious or depressed.

More than one-fourth (27.6%) of adolescents drank alcohol, 15.9% had medical consultation and 5.1% had been hospitalised. In the fully adjusted model, the AORs (95% CI) for medical consultation were 1.14 (1.06 to 1.23) for <1 day/week, 1.30 (1.13 to 1.50) for 1–2 days/week and 1.70 (1.41 to 2.06) for 3–7 days/week of drinking compared with non-drinking (p for trend <0.001). The corresponding AORs (95% CI) for hospitalisation were 1.14 (1.02 to 1.28), 1.68 (1.32 to 2.14) and 2.38 (1.90 to 2.98) (p for trend <0.001). Similar associations were observed among students who did not feel anxious or depressed.

Alcohol consumption was associated with medical services use in Chinese adolescents. More rigorous alcohol control policies and health promotion programmes are needed to reduce alcohol drinking and related harms in adolescents.

A national registry set up in Spain by Grupo Español de Cirugía Metástasis Pulmonares de Carcinoma Colo-Rectal (GECMP-CCR).

32 Spanish thoracic units.

All patients with one or more histologically proven lung metastasis removed by surgery between March 2008 and February 2010.

Pulmonary metastasectomy for one or more pulmonary nodules proven to be metastatic colorectal carcinoma.

The age and sex of the patients having this surgery were recorded with the number of metastases removed, the interval between the primary colorectal cancer operation and the pulmonary metastasectomy, and the carcinoembryonic antigen level. Also recorded were the practices with respect to mediastinal lymphadenopathy and coexisting liver metastases.

Data were available on 543 patients from 32 units (6–43/unit). They were aged 32–88 (mean 65) years, and 65% were men. In 55% of patients, there was a solitary metastasis. The median interval between the primary cancer resection and metastasectomy was 28 months and the serum carcinoembryonic antigen was low/normal in the majority. Liver metastatic disease was present in 29% of patients at some point prior to pulmonary metastasectomy. Mediastinal lymphadenectomy varied from 9% to 100% of patients.

The data represent a prospective comprehensive national data collection on pulmonary metastasectomy. The practice is more conservative than the impression gained when members of the European Society of Thoracic Surgeons were surveyed in 2006/2007 but is more inclusive than would be recommended on the basis of recent outcome analyses. Further analyses on the morbidity associated with this surgery and the correlation between imaging studies and pathological findings are being published separately by GECMP-CCR.

Cross-sectional MSWS-12 to EQ-5D cross-walking analysis.

NARCOMS registry spring 2010 biannual update and supplemental survey.

North American patients completing both the MSWS-12 and the EQ-5D randomly split into derivation and validation cohorts.

Ordinary least squares regression was performed within the derivation cohort, with participants’ EQ-5D as the dependent variable. Results of the MSWS-12 were input as independent variable(s) into six regression models. Model goodness-of-fit was subsequently assessed in the validation cohort using the mean absolute error (MAE), root mean square error (RMSE) and the adjusted R². The best performing model was refined in the entire cohort and utilised for additional analyses.

A total of 3505 NARCOMS participants were included. Their mean±SD EQ-5D and MSWS-12 scores were 0.74±0.18 and 50.8±33.5, respectively, and these assessments were found to be moderately correlated (r=–0.553, p<0.001). The model using all individual MSWS-12 item scores as independent variables was found to have the best fit (MAE=0.109±0.096, RMSE=0.145, adjusted R²=0.329). The percentage of EQ-5D estimates within 0.05 and 0.10 of the actual value were 30% and 61%, respectively. This mapping equation was more precise in patients with moderate mobility impairment (MAE=0.087±0.061 at patient-determined disease step (PDDS) of 3–6) and less precise in patients with no (MAE=0.141±0.128 at PDDS of 0–2) or severe mobility impairment (MAE=0.121±0.049 at PDDS ≥7).

The EQ-5D scores can be predicted using the MSWS-12 item scores with reasonable precision in North American patients with MS. Prediction estimates were more precise in patients with moderate mobility impairment.

Observational study.

The National Health and Medical Research Council (NHMRC) of Australia.

Researchers who submitted one or more NHMRC Project Grant proposals in March 2012.

Total researcher time spent preparing proposals; funding success as predicted by the time spent.

The NHMRC received 3727 proposals of which 3570 were reviewed and 731 (21%) were funded. Among our 285 participants who submitted 632 proposals, 21% were successful. Preparing a new proposal took an average of 38 working days of researcher time and a resubmitted proposal took 28 working days, an overall average of 34 days per proposal. An estimated 550 working years of researchers' time (95% CI 513 to 589) was spent preparing the 3727 proposals, which translates into annual salary costs of AU$66 million. More time spent preparing a proposal did not increase the chances of success for the lead researcher (prevalence ratio (PR) of success for 10 day increase=0.91, 95% credible interval 0.78 to 1.04) or other researchers (PR=0.89, 95% CI 0.67 to 1.17).

Considerable time is spent preparing NHMRC Project Grant proposals. As success rates are historically 20–25%, much of this time has no immediate benefit to either the researcher or society, and there are large opportunity costs in lost research output. The application process could be shortened so that only information relevant for peer review, not administration, is collected. This would have little impact on the quality of peer review and the time saved could be reinvested into research.

Comparative study.

20 post-MI (64.8±6.6, range 51–74 years) and 20 non-cardiac male controls (64.1±5.7, range 52–74 years) participated.

Participants performed MSWT with and without cones. Throughout, the participants expired air, and the heart rate (bpm) (HR) and ratings of perceived exertion (RPE) were measured. Participant protocol preference was recorded verbatim.

One-way analysis of variance found no significant difference in VO₂ peak (cones 20.4±5.1 vs no-cones 21.9±4.8 ml/kg/min, p=0.197) or distance ambulated (cones 631.8±132.9 m vs no-cones 662.4±164.1 m, p=0.371) between protocols or groups. Analysis comparing lines of regression showed a significant trajectory difference in VO₂ (ml/kg/min) (p<0.01) between protocols with higher HR (p<0.01) and respiratory exchange ratio (RER, p<0.001) values during cones. RPEs were higher for post-MIs versus controls during both protocols (p<0.05). Post-MIs taking β-blockers produce significantly lower HR values. The ² analysis found no significant difference in protocol preference (no-cones: all n=25, 63%; post-MIs n=13, 65%; and controls n=12, 60%).

Post-MIs found both protocols subjectively harder than controls with no significant difference in the VO₂ peak. However, both groups worked at a lesser percentage of their anaerobic threshold during no-cones protocol as indicated by lower RER values. Importantly, for the post-MIs, this would reduce their risk of functional impairment. Therefore, though more research is required, indicators at present are more favourable for the use of the no-cones with post-MIs.

Population-based cohort study.

Denmark and Sweden.

All live-born children born in Denmark between 1968 and 2007 (n=2 729 308) and in Sweden between 1973 and 2006 (n=3 395 166) were included in this study. Exposure was bereavement by the death of a close relative before 15 years of age. Follow-up started from birth and ended at the first of the following: date of a cancer diagnosis, death, emigration, day before their 15th birthday or end of follow-up (2007 in Denmark, 2006 in Sweden).

Rates and HRs for all childhood cancers and specific childhood cancers.

A total of 1 505 938 (24.5%) children experienced bereavement at some point during their childhood and 9823 were diagnosed with cancer before the age of 15 years. The exposed children had a small (10%) increased risk of childhood cancer (HR 1.10; 95% CI 1.04 to 1.17). For specific cancers, a significant association was seen only for central nervous system tumours (HR 1.14; 95% CI 1.02 to 1.28).

Our data suggest that psychological stress in early life is associated with a small increased risk of childhood cancer.

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

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

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

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

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

Low-protein diet was significantly associated with improvement of diabetic nephropathy. The adverse effects of low-protein diet were not apparent such as worsening of glycaemic control and malnutrition.

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

Ethical approval was obtained for the individual studies. The results of this paper will be disseminated as peer-reviewed publications, at conferences and as part of a doctoral thesis. This individual patient data meta-analysis may provide important insights into the effects of text messaging on ART adherence in different subpopulations, with important implications for programme implementation involving such interventions and future research.

Preintervention and postintervention observational study.

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

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

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

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

Interventions to improve HH compliance are challenging to implement and sustain with the need for ongoing reinforcement and education.

Cross-sectional survey study.

Sweden.

A postal survey was sent to 1006 women between January and March 2009, during which 624 women (62%) returned the questionnaire. 51 women who did not answer any of the violence items were excluded from the analyses, resulting in a final sample of 573 women.

Self-reported exposure to psychological, physical and sexual intimate partner violence.

Cronbach's α coefficients were 0.79 (psychological scale), 0.80 (physical scale), 0.72 (sexual scale) and 0.88 (total scale). A predetermined three-component solution largely replicated the explored three component conceptual model of the Violence Against Women instrument. The instrument was able to discriminate between groups known from previous studies to differ in exposure to physical and/or sexual violence, that is, respondents with poor versus good self-rated health and witnessed versus not witnessed physical violence at home when growing up. Past-year prevalence of physical (8.1%; 95% CI 5.9 to 10.3) and sexual (3%; 1.6 to 4.4) violence was similar to that reported in other Nordic studies; however, earlier-in-life prevalence was lower in the current study (14.3%; 95% CI 11.4 to 17.2 and 9.2%; 95% CI 6.8 to 11.6, respectively). Reported exposure rates were higher than those obtained from a concurrently administered instrument (NorVold Abuse Questionnaire).

The Violence Against Women instrument demonstrated good construct validity and internal reliability in an adult female population in Sweden. However, further studies examining these and other psychometric properties need to be conducted in other countries.

A series of semistructured, in-depth interviews with local health professionals and UMPIRE trial participants in India and the UK will be undertaken. The aim is to understand their views and experiences of the trial context and of day-to-day use of medications more generally. The grounded theory approach will be used to analyse data and help inform the processes of the UMPIRE trial.

The study has received ethical approval for all sites in the UK and India where trial participant interviews will be undertaken. The process evaluation will help inform and enhance the understanding of the UMPIRE trial results and its applicability to clinical practice as well as shaping policy regarding strategies for improving cardiovascular medication adherence.

Survey study involving a mailed questionnaire.

New Zealand hospital and community-based medical care settings.

The questionnaire was mailed to a random sample of 800 doctors in New Zealand who were vocationally registered with the Medical Council of New Zealand in disciplines involving caring for patients at the end of their lives.

Willingness to provide honest answers about various aspects of end-of-life care; assurances that might increase willingness to provide honest answers to questions about end-of-life practices.

Completed questionnaires were returned by 436 doctors. The majority of respondents (59.9–91.5%) indicated willingness to provide honest answers to such questions. However, more than a third of doctors were unwilling to give honest answers to certain questions regarding euthanasia. These results are comparable with the UK data. Complete anonymity was the assurance most likely to encourage honest answering, with most of the respondents preferring the use of anonymous written replies. Respondents were less reassured by survey endorsements from regulatory bodies. Themes in free comments included the deterrent effect of medicolegal consequences, fear of censure from society, peers and the media and concerns about the motivations and potential uses of such research.

Many New Zealand doctors were willing to give honest answers to questions about end-of-life practices, particularly if anonymity was guaranteed; others, however, expressed doubts or indicated that they would not be willing to provide honest answers to questions of this sort.

Observational pilot.

Liverpool, UK.

(1) 12 men and 5 women recruited to ER. (2) 7 specialist gym instructors.

Logistic feasibility and acceptability of ER and associated research, rate of recruitment, level of participation over 8 weeks and changes in health.

22 gym inductions were arranged (recruitment time: 5 weeks), 17 inductions were completed and 14 participants began exercising. Attendance at the gym fluctuated with people missing weeks then re-engaging; in week 8, seven participants were in contact with the project and five of these attended the gym. Illness and caring responsibilities affected participation. Participants and gym instructors found the intervention and associated research processes acceptable. In general, participants enjoyed exercising and felt fitter, but would have welcomed more support and the offer of a wider range of activities. Non-significant reductions in blood pressure and heart rate and improvements in metabolic equivalents (METs; a measure of fitness) and general well-being were observed for eight participants who completed baseline and follow-up assessments. The number of weeks of gym attendance was significantly associated with a positive change in METs.

It is feasible to recruit older drug users into a gym-based ER scheme, but multiple health and social challenges affect their ability to participate regularly. The observed changes in health measures, particularly the association between improvements in METs and attendance, suggest further investigation of ER for older drug users is worthwhile. Measures to improve the intervention and its evaluation include: better screening, refined inclusion/exclusion criteria, broader monitoring of physical activity levels, closer tailored support, more flexible exercise options and the use of incentives.

Pharmacokinetic intervention study.

Tertiary paediatric gastroenterology unit.

8 children (M:F; 4:4) entered the study. All completed: 5 South Asian British; 2 White British; 1 African British. Inclusion criteria: Children over 10 years with active Crohn's disease (C reactive protein >10 mg/l or erythrocyte sedimentation rate >25 mm/h) and height velocity <–2 SD score. Exclusion criteria: closed epiphyses; corticosteroids within 3 months; neoplasia or known hypersensitivity to recombinant human IGF-1 (rhIGF-1).

Subcutaneous rhIGF-1 (120 μg/kg) per dose over two admissions: the first as a single dose and the second as twice daily doses over 5 days.

Significant increase in circulating IGF-1.

Incidence of side effects of IGF-1. A mathematical model of circulating IGF-1 (A_c) was developed to include parameters of endogenous synthesis (K_syn); exogenous uptake (K_a) from the subcutaneous dose (A_s): and IGF-1 clearance: where dA_c/dt=K_syn – K_outxA_c+K_axA_s.

Subcutaneous IGF-1 increased concentrations, which were maintained on twice daily doses. In covariate analysis, disease activity reduced K_syn (p<0.001). Optimal dosing was derived from least squares regression fitted to a dataset of 384 Crohn's patients, with model parameters assigned by simulation.

By using age, weight and disease activity scaling in IGF-1 dosing, over 95% of children will have normalised IGF-1 concentrations below +2.5 SDs of the normal population mean, a level not associated with cancer risk.

Bed sharing was defined as sleeping with a baby in the parents’ bed; room sharing as baby sleeping in the parents’ room. Frequency of bed sharing during last sleep was compared between babies who died of SIDS and living control infants. Five large SIDS case–control datasets were combined. Missing data were imputed. Random effects logistic regression controlled for confounding factors.

Home sleeping arrangements of infants in 19 studies across the UK, Europe and Australasia.

1472 SIDS cases, and 4679 controls. Each study effectively included all cases, by standard criteria. Controls were randomly selected normal infants of similar age, time and place.

In the combined dataset, 22.2% of cases and 9.6% of controls were bed sharing, adjusted OR (AOR) for all ages 2.7; 95% CI (1.4 to 5.3). Bed sharing risk decreased with increasing infant age. When neither parent smoked, and the baby was less than 3 months, breastfed and had no other risk factors, the AOR for bed sharing versus room sharing was 5.1 (2.3 to 11.4) and estimated absolute risk for these room sharing infants was very low (0.08 (0.05 to 0.14)/1000 live-births). This increased to 0.23 (0.11 to 0.43)/1000 when bed sharing. Smoking and alcohol use greatly increased bed sharing risk.

Bed sharing for sleep when the parents do not smoke or take alcohol or drugs increases the risk of SIDS. Risks associated with bed sharing are greatly increased when combined with parental smoking, maternal alcohol consumption and/or drug use. A substantial reduction of SIDS rates could be achieved if parents avoided bed sharing.

Register-based study.

Primary care. Data were obtained from a primary care register, the General Practice Research Database, which contains anonymised records representing about 5% of the UK population.

All patients with a first-time diagnosis of AN, BN and EDNOS were identified.

Annual crude and age-standardised incidence rates were calculated.

A total of 9072 patients with a first-time diagnosis of an ED were identified. The age-standardised annual incidence rate of all diagnosed ED for ages 10–49 increased from 32.3 (95% CI 31.7 to 32.9) to 37.2 (95% CI 36.6 to 37.9) per 100 000 between 2000 and 2009. The incidence of AN and BN was stable; however, the incidence of EDNOS increased. The incidence of the diagnosed ED was highest for girls aged 15–19 and for boys aged 10–14.

The age-standardised incidence of ED increased in primary care between 2000 and 2009. New diagnoses of EDNOS increased, and EDNOS is the most common ED in primary care.

Descriptive study.

Specialist urology service at a single centre in metropolitan Victoria in Australia.

Between 2004 and 2011, 1471 patients underwent radical prostatectomy at our institution. In a large proportion of these cases, clinicopathological variables were recorded by manual data-entry. In 2011, we obtained electronic versions of the same printed pathology reports for our cohort. The data were electronically imported in parallel to any existing manual entry record enabling direct comparison between them.

Error rates of manually entered data compared with electronically imported data across clinicopathological fields.

421 patients had at least 10 comparable pathology fields between the electronic import and manual records and were selected for study. 320 patients had concordant data between manually entered and electronically populated fields in a median of 12 pathology fields (range 10–13), indicating an outright accuracy in manually entered pathology data in 76% of patients. Across all fields, the error rate was 2.8%, while individual field error ranges from 0.5% to 6.4%. Fields in text formats were significantly more error-prone than those with direct measurements or involving numerical figures (p<0.001). 971 cases were available for review of error within the source data, with figures of 0.1–0.9%.

While the overall rate of error was low in manually entered data, individual pathology fields were variably prone to error. High-quality pathology data can be obtained for both prospective and retrospective parts of our data repository and the electronic checking of source pathology data for error is feasible.

Randomised trial conducted with multiple follow-ups.

15 communities in Cape Town, South Africa.

720 drug-using women aged 18–33, randomised to an intervention (360) or one of two control arms (181 and 179) with 91.9% retained at follow-up.

The WHC brief peer-facilitated intervention consisted of four modules (two sessions), 2 h addressing knowledge and skills to reduce drug use, sex risk and violence; and included role-playing and rehearsal, an equal attention nutrition intervention, and an HCT-only control.

Biologically confirmed drug abstinence measured at 12-month follow-up, sober at last sex act, condom use with main and casual sex partners, and intimate partner violence.

At the 12-month endpoint, 26.9% (n=83/309) of the women in the WHC arm were abstinent from drugs, compared with 16.9% (n=27/160) in the Nutrition arm and 20% (n=31/155) in the HCT-only control arm. In the random effects model, this translated to an effect size on the log odds scale with an OR of 1.54 (95% CI 1.07 to 2.22) comparing the WHC arm with the combined control arms. Other 12-month comparison measures between arms were non-significant for sex risk and victimisation outcomes. At 6-month follow-up, women in the WHC arm (65.9%, 197/299) were more likely to be sober at the last sex act (OR1.32 (95% CI 1.02 to 1.84)) than women in the Nutrition arm (54.3%, n=82/152).

This is the first trial among drug-using women in South Africa showing that a brief intervention added to HCT results in greater abstinence from drug use at 12 months and a larger percentage of sexual activity not under the influence of substances.

NCT00729391 ClinicalTrials.gov

Archived cohort data (n=1254, age 54.5±11.7 year, BMI 29.8±6.6 kg/m²) from the National Survey of Midlife Development in the USA (MIDUS) Biomarkers Study were analysed for concentrations of inflammatory markers using general linear models. MMW was defined as no regular exercise, <500 MMW, 500–1000 MMW, >1000 MMW and BMI was defined as <25, 25–29.9, ≥30 kg/m². Analyses were adjusted for age, sex, smoking and relevant medication use.

Respondents reported to three centres to complete questionnaires and provide blood samples.

Participants were men and women currently enroled in the MIDUS Biomarker Project (n=1254, 93% non-Hispanic white, average age 54.5 years).

Concentration of serum IL-6, CRP, fibrinogen, IL-6sr, sE-selectin and sICAM.

Significant interactions were found between BMI and MMW for CRP and sICAM-1 (p<0.05). CRP in overweight individuals was similar to that in obese individuals when no PA was reported, but it was similar to normal weight when any level of regular PA was reported. sICAM-1 was differentially lower in obese individuals who reported >1000 MMW compared to obese individuals reporting less exercise.

The association of exercise with CRP and sICAM-1 differed by BMI, suggesting that regular exercise may buffer weight-associated elevations in CRP in overweight individuals while higher levels of exercise may be necessary to reduce sICAM-1 or CRP in obese individuals.

In this exploratory study, we used in-depth qualitative interviews with doctors to gain insight into their understanding of the term ‘individualised treatments’ and the methods that they use to achieve it.

16 general practitioners in 6 rural and 10 urban practices, 2 geriatricians and 2 clinical academics were recruited.

Primary and secondary care in South West of England.

Understanding of individualisation varied between doctors, and their initial descriptions of individualisation were not always consistent with subsequent examples of the patients they had treated. Understandings of, and methods used to achieve, individualised treatment were frequently discussed in relation to making drug treatment decisions. Few doctors spoke of using strategies to support patients to individualise their own treatments after the consultation.

Despite its widespread use, variation in doctors’ understanding of the term individualisation highlights the need for it to be defined. Efforts are needed to develop effective methods that would offer a structured approach to support patients to manage their treatments after consultations.

Secondary analysis of English national GP patient survey data (2009).

Primary Care, England, UK.

Data from year 3 of the GP patient survey: 5 660 217 questionnaires sent to patients aged 18 and over, registered with a GP in England for at least 6 months; overall response rate was 42% after adjustment for sampling design.

We used binary logistic regression analysis to investigate patients’ reported confidence and trust in the GP, analysing ratings of 7 interpersonal aspects of the consultation, controlling for patients’ sociodemographic characteristics. Further modelling examined moderating effects of age, gender and ethnicity on the relative importance of these 7 predictors.

Among 1.5 million respondents (adjusted response rate 42%), the sense of ‘being taken seriously’ had the strongest association with confidence and trust. The relative importance of the 7 interpersonal aspects of care was similar for men and women. Non-white patients accorded higher priority to being given enough time than did white patients. Involvement in decisions regarding their care was more strongly associated with reports of confidence and trust for older patients than for younger patients.

Associations between patients’ ratings of interpersonal aspects of care and their confidence and trust in their GP are influenced by patients’ demographic characteristics. Taking account of these findings could inform patient-centred service design and delivery and potentially enhance patients’ confidence and trust in their doctor.

Representative national cross-sectional survey.

Republic of Ireland.

4369 men and 5995 women aged 18 or more (Survey of Lifestyle, Attitudes and Nutrition (SLÁN) 2007).

SRH was measured using one single item. Three groups of factors were studied: material, psychosocial and behavioural factors. Statistical analyses were performed using logistic regression analysis and interaction testing, the sample design being taken into account. All results were adjusted for age and educational level and stratified on gender.

When each group of factors was studied separately, non-working status, no private health insurance, inability to afford enough food, no car, being non-married, low social participation, serious neighbourhood problems, low social support, smoking, no alcohol consumption, illicit drug use, low physical activity and obesity were associated with poor SRH. When studied together, some material and psychosocial factors were no longer significant. Four significant interaction terms were found, suggesting that some factors might have a stronger association with SRH among low-educated people.

Various types of factors were found to be associated with SRH, and most of these associations were similar according to educational level. Behavioural factors might be intermediate factors in the causal pathways from material and psychosocial factors to SRH. Prevention policies should integrate a large number of factors comprehensively to improve SRH.

This was a population-based data study.

New South Wales, Australia.

510 006 women giving birth to a singleton baby during the period 2000–2008.

Rates of severe perineal trauma between 2000 and 2008 and associated demographic, fetal, antenatal, labour and delivery events and factors.

There was an increase in the overall rate of severe perineal trauma from 2000 to 2008 from 1.4% to 1.9% (36% increase). Compared with women who were intact or had minor perineal trauma (first-degree tear, vaginal graze/tear), women who were primiparous (adjusted OR (AOR) 1.8 CI (1.65 to 1.95), were born in China or Vietnam (AOR 1.1 CI (1.09 to 1.23), gave birth in a private hospital (AOR 1.1 CI (1.03 to 1.20), had an instrumental birth (AOR 1.8 CI (1.65 to 1.95) and male baby (AOR 1.3 CI (1.27 to 1.34) all had a significantly higher risk of severe perineal trauma. Only giving birth to a male baby, adjusted for birth weight (AOR 1.5 CI (1.44 to 1.58), remained significant, when women with severe perineal trauma were compared with all other women not experiencing severe perineal trauma. This association increased over the study period.

To our knowledge, this is the first time that having a male baby has been found to exert such a strong independent risk for severe perineal trauma and the increasing significance of this in recent years needs further exploration.

A cross-sectional study examining sexual behaviours and syphilis infection.

4 STI clinics in the Pearl River Delta of South China.

1792 Chinese men and women attending STI clinics.

STI history, syphilis infection defined as positive non-treponemal and treponemal tests.

Among all clinic patients, 824 (46.3%) were first-born, 354 (19.9%) were middle-born and 602 (33.8%) were final-born. Middle-born individuals had a higher percentage of reported STI history (44.7% compared to 34.7%, p<0.001) and syphilis infection (9.7% compared to 4.9%, p=0.01) among men (n=1163) compared to other sibling positions in bivariate analyses, but not in the final multivariate model. The relationship between sibling position and syphilis was independent of income and education level. There was no trend observed between middle-born position and female sexual risk behaviours (n=626). Higher education was significantly associated with syphilis among women and men in respective multivariate models.

This study suggests that middle-born men in China may have an increased sexual risk compared to other sibling positions. As Chinese family and social structures change, a more thorough understanding of how demographic factors influence sexual risk behaviours is needed.

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

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

The project has been approved by the James Cook University Human Research Ethics Committee (approval number H4651).The results will be reported via peer reviewed publications, conference, seminar presentations and on-line media for national and international dissemination.

Data were derived from an acoustical before and after intervention study providing repeated measurements.

The study was performed at seven preschools in Mölndal, Sweden.

Children were recruited from these preschools and the final sample comprised 61 and 59 preschool children aged 4–5 years, with a response rate of 98% and 48% girls and 52% boys. Two children were excluded from analysis because they fell outside the age range.

The instrument was developed based on a qualitative study performed in Swedish preschools. Questions pertained to preschool children's perception of noise when at school, their bodily and emotional reactions to it, non-specific symptoms and the coping strategies used by them to diminish the detrimental effects of the noise.

Confirmative factor analysis yielded a three-factor model fitted to 10 items pertaining to angry reactions, symptoms and coping. The model fit was moderate to good (standardised root mean square residual=0.08, 0.12; adjusted goodness of fit=0.97/0.91) in the before and after conditions, respectively. The  scales showed moderate to good reliability in terms of internal consistency, with an α ranging between 0.52 and 0.67, and was stronger in the before condition. Concurrent validity was strongest for symptoms by comparing groups based on bodily reaction (general and sound specific).

Young children's emotional and bodily reactions to coping with noise can be reliably measured with this instrument. Like adults and older children, young children are able to distinguish between emotional reactions, bodily reactions, coping and unwell-being. Future research on larger groups of preschool children is needed to further refine the questions, in particular the questions pertaining to well-being.

A cross-sectional survey.

Malawi

The study used a sample of 6395 women aged 15–49 years from the 2010 Malawi Health and Demographic Surveys.

N/A

Individual HIV status: positive or not.

Findings from the Pearson ² and ² Automatic Interaction Detector analyses revealed that marital status is the most significant predictor of HIV. Women who are no longer in union and living in the highest wealth quintiles households constitute the most-at-risk group, whereas the less-at-risk group includes young women (15–24) never married or in union and living in rural areas.

In the light of these findings, this study recommends: (1) that the design and implementation of targeted interventions should consider the magnitude of HIV prevalence and demographic size of most-at-risk groups. Preventive interventions should prioritise couples and never married people aged 25–49 years and living in rural areas because this group accounts for 49% of the study population and 40% of women living with HIV in Malawi; (2) with reference to treatment and care, higher priority must be given to promoting HIV test, monitoring and evaluation of equity in access to treatment among women in union disruption and never married or women in union aged 30–49 years and living in urban areas; (3) community health workers, households-based campaign, reproductive-health services and reproductive-health courses at school could be used as canons to achieve universal prevention strategy, testing, counselling and treatment.

A cross-sectional study.

Data from the Survey of Lifestyle, Attitudes and Nutrition in Ireland, a nationally representative dataset using the Geodirectory (a listing of all residential addresses in Ireland compiled by the postal service) as the sampling frame.

A nationally representative sample of 10 364 adults aged 18+, carried out by face-to-face interview with clinical measurement applied to a number of outcomes to a representative subsample of 2174. After discarding the observations with missing values and errors, the eventual sample was 1874.

BMI based on measured and self-reported weight and height.

It is generally found that self-reported BMI understates true or measured BMI and accordingly revised obesity thresholds have been suggested.

Data from the 2007 Survey of Lifestyles, Attitudes and Nutrition in Ireland were used to analyse self-reported and measured BMI. The self-reported BMI threshold was adjusted to obtain the optimal signal for measured BMI using different criteria viz. efficiency (maximum number of correct classifications), maximisation of Youden's J, maximisation of OR, minimisation of cost of misclassification and constrained optimisation.

The optimal threshold differed substantially depending on the criterion adopted for choosing it, with thresholds of 29.1 (efficiency criterion), 27.5 (Youden's J) and 26.0 (FN rate of 5%). Standard criteria such as Youden's J index were shown to implicitly impose relative costs of false-negatives and false-positives which may not always correspond to the values of the analyst.

When adjusting self-reported BMI thresholds in order to obtain the optimal signal for ‘true’ obesity, analysts should explicitly choose the relative costs of false-positives and false-negatives.

A randomised controlled trial.

Nine Dutch hospitals.

Five years’ follow-up data from 231 of 283 patients (82%) were collected.

Early surgery or an intended 6 months of conservative treatment.

Scores from Roland disability questionnaire, visual analogue scale (VAS) for leg and back pain and a Likert self-rating scale of global perceived recovery were analysed.

There were no significant differences between groups on the 5 years’ primary outcome scores. Despite at least 6 months of conservative treatment 46% of the conservatively allocated patients were treated surgically because of severe leg pain and disability. Forty-nine (21%) patients had an unsatisfactory recovery at 5 years and the recovery pattern showed that there was a variable group of 66 patients (31%) with at least one unsatisfactory outcome at 1, 2 or 5 years of follow-up. Multivariate logistic regression showed that age (>40; OR 2.42 (95% CI 1.16 to 5.02)), severity of leg pain (VAS >70; OR 3.32 (95% CI 1.69 to 6.54)) and the Mc Gill affective score (score >3; OR 6.23 (95% CI 2.23 to 17.38)) were the only significant predictors for an unsatisfactory outcome at 5 years.

In the long term, 8% of the patients with sciatica never showed any recovery and in at least 23%, sciatica appears to result in ongoing complaints, which fluctuate over time, irrespective of treatment. Prolonged conservative care might give patients a fair chance for pain and disability to resolve without surgery, but with the risk to receive delayed surgery after prolonged suffering of sciatica. Age above 40 years, severe leg pain at baseline and a higher affective Mc Gill pain score were predictors for unsatisfactory recovery. Trial Registry ISRCT No 26872154.

We undertook a case series analysis by searching the National Coroners’ Information System using the most recent International Classification of Diseases-10 codes J45 and J46 and the keyword ‘asthma’ as the underlying cause of death.

Records for 283 cases aged 70 years and under were retrieved from each Australian state and territory. Coroner's findings, autopsy, toxicology and police reports were reviewed to determine: if the team agreed the death was due to asthma and whether the death was preventable or modifiable factors existed? Owing to the likelihood of comorbidities or alternative diagnoses contributing to deaths in those over 70 years of age, this group was excluded.

Examination of available data in those aged under 70 years identified risk factors associated with asthma death. These included physical barriers (rural and remote location, institutionalised care), psychosocial issues (social disengagement, mental illness, living alone, being unemployed), smoking, drug and alcohol dependence, allergies, respiratory tract infections, inadequate treatment and delay in seeking help.

Our study provides a current assessment of death from asthma across Australia. Further reductions in the rate of asthma deaths will require interventions targeted at the personal, practice and policy levels. Asthma-related health literacy needs to be improved especially among those with episodic asthma. Reforms are also needed to address inequity in healthcare delivery to ‘reach the unreached’. Our study points to the dangers associated with smoking, drug and alcohol use and the consequences of delay in seeking care among those with asthma.

Prospective nationwide cohort study.

The database of the Danish Colorectal Cancer Group (DCCG).

23 487 CC patients.

Overall survival (Kaplan-Meier plots) and mortality (HR from Cox proportional hazards regression analysis) according to CC localisation. For adjustment and stratification, we used age, sex, ASA score (the American Society of Anaesthesiologists score), tumour location and stage, number of lymph nodes harvested at operation, number of lymph nodes with metastases and presence of distant metastases.

Patients with RCC had a higher median age at diagnosis (74.3 years) than patients with LCC (71.8 years; p<0.0001). Overall, the proportion of patients who were women increased the closer the tumour site was to the small intestine. Although RCC patients had higher ASA scores than LCC patients (p<0.0001), the highest ASA scores were observed in patients with cancer in the transverse and descending colon and at both colon flexures. While RCCs overall were more advanced than LCCs (p<0.0001), the most advanced CCs were those of the descending colon, splenic flexure and caecum. RCC mortality was higher than LCC mortality only during the first 2 years (women: HR 1.13; 95% CI 1.06 to 1.20; men: HR 1.27; 95% CI 1.20 to 1.35), and relative to mortality from sigmoid CC, the highest mortality was observed from splenic flexure cancer (HR 1.75; 95% CI 1.54 to 2.00).

The present data challenge the simple categorisation of CC into RCC and LCC.

This study utilised a retrospective cross-sectional study design.

This study took place at a university hospital ED over a 3-month period.

A follow-up telephone interview was performed with 163 players aged ≥16 years to reflect voluntary versus obligatory helmet use.

The hand was most often injured (n=85, 52.1%). Hand injury most commonly occurred from a blow of a hurley (n=104, 65%), and fracture was confirmed in 62% of cases. Two-thirds of players (66.3%) had multiple previous (1–5) hand injuries. Most patients 149 (91.4%) had tried commercially available hand protection, but only 4.9% used hand protection regularly. Univariate analysis showed a statistically significant association between wearing a helmet and faceguard and hand injury; OR 2.76 (95% CI 1.42 to 5.37) p=0.003. On further analysis adjusting simultaneously for age, prior injury, foul play and being struck by a hurley, this relationship remained significant (OR 3.15 95% CI 1.51 to 6.56, p=0.002).

We report that hurling-related hand injury is common. We noted the low uptake of hand protection. We found that hand injury was significantly associated with the use of helmet and faceguard protection, independent of the other factors studied. Further studies are warranted to develop strategies to minimise the occurrence of this injury.

Case–control.

Healthy participants.

24 healthy volunteers (11 men, 13 women, 19–28 years) spent six consecutive nights in the sleep laboratory.

All participants slept during one habituation night, one control and four experimental nights in which train noise and vibration were reproduced. In the experimental nights, 20 or 36 trains with low-vibration or high-vibration characteristics were presented.

Polysomnographical data and ECG were recorded.

The train exposure led to a significant change of HR within 1 min of exposure onset (p=0.002), characterised by an initial and a delayed increase of HR. The high-vibration condition provoked an average increase of at least 3 bpm per train in 79% of the participants. Cardiac responses were in general higher in the high-vibration condition than in the low-vibration condition (p=0.006). No significant effect of noise sensitivity and gender was revealed, although there was a tendency for men to exhibit stronger HR acceleration than women.

Freight trains provoke HR accelerations during sleep, and the vibration characteristics of the trains are of special importance. In the long term, this may affect cardiovascular functioning of persons living close to railways.

PCR was used to identify P ovale curtisi and P ovale wallikeri infections among archived blood from UK malaria patients. Latency periods, estimated as the time between entry into the UK and diagnosis of malaria, were compared between the two groups.

UK National Reference Laboratory.

None. Archived parasite material and surveillance data for 74 P ovale curtisi and 60 P ovale wallikeri infections were analysed. Additional epidemiological data were taken from a database of 1045 imported cases.

None.

No differences between the two species were identified by a detailed comparison of parasite morphology (N=9, N=8, respectively) and sex ratio (N=5, N=4) in archived blood films. The geometric mean latency period in P ovale wallikeri was 40.6 days (95% CI 28.9 to 57.0), whereas that for P ovale curtisi was more than twice as long at 85.7 days (95% CI 66.1 to 111.1; p=0.002). Further, the proportion of ovale malaria sensu lato which occurred in patients reporting chemoprophylaxis use was higher than for Plasmodium falciparum (OR 7.56; p<0.0001) or P vivax (OR 1.82; p<0.0001).

These findings provide the first difference of epidemiological significance observed between the two parasites which cause ovale malaria, and suggest that control measures aimed at P falciparum may not be adequate for reducing the burden of malaria caused by P ovale curtisi and P ovale wallikeri.

Cross-sectional survey of 345 National Health Service (NHS) staff members.

The study was conducted across 11 English Primary Care Trusts between 2010 and 2011.

A total of 440 staff involved in commissioning decisions and employed at NHS band 7 or above were invited to participate in the study. Of those, 345 (78%) completed all or a part of the survey.

Participants were asked to rate how important different sources of evidence (empirical or practical) were in a recent decision that had been made. Backwards stepwise logistic regression analyses were undertaken to assess the contributions of age, gender and professional background, as well as the years of experience in NHS commissioning, pay grade and work role.

The extent to which empirical evidence was used for commissioning decisions in the NHS varied according to the professional background. Only 50% of respondents stated that clinical guidelines and cost-effectiveness evidence were important for healthcare decisions. Respondents were more likely to report use of empirical evidence if they worked in Public Health in comparison to other departments (p<0.0005, commissioning and contracts OR 0.32, 95%CI 0.18 to 0.57, finance OR 0.19, 95%CI 0.05 to 0.78, other departments OR 0.35, 95%CI 0.17 to 0.71) or if they were female (OR 1.8 95% CI 1.01 to 3.1) rather than male. Respondents were more likely to report use of practical evidence if they were more senior within the organisation (pay grade 8b or higher OR 2.7, 95%CI 1.4 to 5.3, p=0.004 in comparison to lower pay grades).

Those trained in Public Health appeared more likely to use external empirical evidence while those at higher pay scales were more likely to use practical evidence when making commissioning decisions. Clearly, National Institute for Clinical Excellence (NICE) guidance and government publications (eg, National Service Frameworks) are important for decision-making, but practical sources of evidence such as local intelligence, benchmarking data and expert advice are also influential. New Clinical Commissioning Groups will need a variety of different evidence sources and expert involvement to ensure that effective decisions are made for their populations.

Observational prospective study.

3 paediatric oncology centres in the Parisian region in France.

53 parents were approached to participate in a RCT for their child with malignant solid tumour, over a 1-year period. 40 parents have been interviewed in our study.

Parental understanding of information in RCTs, parents’ needs for decision-making. Parents were questioned by a psychologist, independent of the paediatric oncology teams, using a semidirected interview, 1 (M1) and 6 months (M6) after the consent was sought.

18 parents (45%) did not understand the concept of randomisation. Half of the parents could explain neither the aim of the clinical trial nor the potential benefit to their child of inclusion. 35 parents (87.5%) expressed very few specific risks related to the trial. Being mostly French-speaking (p=0.03) and the reading of the information sheet by the parents (p=0.0025) improved their understanding. The parental comprehension did not differ between M1 and M6. The principal factors underlying their decision were confidence in the medical team (39%), wish to access to the best treatment (37%) and the best quality of life (37%).

Despite medical explanations, parents have limited knowledge in some areas in first-line RCTs and improvements of information process are required. The risks specific to the randomised trial are underestimated by parents and the unproven nature of the treatment is not well-known or understood.

Cross-sectional cohort study (pilot).

Infectious diseases clinic at a single military treatment facility in San Diego, CA.

Ninety-nine HIV-positive men were evaluated—79% men who had sex with men, mean age 31 years, 36% black and 33% married. Inclusion criteria: male, HIV-infected, Department of Defense beneficiary. Exclusion criteria: any symptom related to the urethra, pharynx or rectum.

GC and CT screening results.

Twenty-four per cent were infected with either GC or CT. Rectal swabs were positive in 18% for CT and 3% for GC; pharynx swabs were positive in 8% for GC and 2% for CT. Only one infection was detected in the urine (GC). Anal sex (p=0.04), male partner (OR 7.02, p=0.04) and sex at least once weekly (OR 3.28, p=0.04) were associated with infection. Associated demographics included age <35 years (OR 6.27, p=0.02), non-Caucasian ethnicity (p=0.03), <3 years since HIV diagnosis (OR 2.75, p=0.04) and previous sexually transmitted infection (STI) (OR 5.10, p=0.001).

We found a high prevalence of extragenital GC/CT infection among HIV-infected military men. Only one infection was detected in the urine, signalling the need for aggressive three-site screening of MSM. Clinicians should be aware of the high prevalence in order to enhance health through comprehensive STI screening practices.

Qualitative study using focus group discussions and interpretative phenomenological analysis.

Discussions took place at churches in both rural and urban areas of the Mwanza region of northwest Tanzania.

We included 67 adult Christian churchgoers of both genders in a total of 10 single-gender focus groups.

Christians frequently reported perceiving MC as a Muslim practice, as a practice for the sexually promiscuous, or as unnecessary since they are taught to focus on ‘circumcision of the heart’. Only one person had ever heard MC discussed at church, but nearly all Christian parishioners were eager for their churches to address MC and felt that MC could be consistent with their faith.

Christian religious beliefs among Tanzanian churchgoers provide both obstacles and opportunities for increasing uptake of MC. Since half of adults in sub-Saharan Africa identify themselves as Christians, addressing these issues is critical for MC efforts in this region.

A prospective, controlled clinical trial was designed to include patients with upper trapezius MTrPs and volunteered healthy participants to receive one session of DN. The primary outcome measures are neuromuscular junction response and sympathetic skin response. The secondary outcomes are pain intensity and pressure pain threshold. Data will be collected at baseline and immediately after intervention.

This study protocol has been approved by the Research Council, School of Rehabilitation and the Ethics Committee of Tehran University of Medical Sciences. The results of the study will be disseminated in a peer-reviewed journal and presented at international congresses.

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

National Health Service in England and Wales.

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

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

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

Defining a model structure for any economic evaluation requires decisions to be made. Expert consultation and the explicit use of critical appraisal can inform these decisions. Although arbitrary choices have still been made, decision modelling allows investigation into such choices and the impact of assumptions that have to be made due to a lack of data.

Population-based cross-sectional study.

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

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

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

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

These initial hypotheses generating analyses provide no evidence that facial morphology is importantly related to cardiometabolic outcomes. Further examination might be warranted. Facial morphology assessment may have value in identifying other areas of disease risk.

Modelling study.

An 805-bed community hospital in the southeastern USA.

42302 inpatients admitted for any reason, excluding obstetrics, paediatric and psychiatric patients.

All-cause in-hospital and postdischarge mortalities, and associated correlations.

Pearson correlation coefficients comparing in-hospital risks with postdischarge risks for creatinine, heart rate and a set of 12 nursing assessments are 0.920, 0.922 and 0.892, respectively. Correlation between postdischarge risk heart rate and the Modified Early Warning System (MEWS) component for heart rate is 0.855. The minimal excess risk values for creatinine and heart rate roughly correspond to the normal reference ranges. We also provide the risks for values outside that range, independent of expert opinion or a regression model. By summing risk functions, a first-approximation patient risk score is created, which correctly ranks 6 discharge categories by average mortality with p<0.001 for differences in category means, and Tukey's Honestly Significant Difference Test confirmed that the means were all different at the 95% confidence level.

Quantitative or categorical clinical variables can be transformed into risk functions that correlate well with in-hospital risk. This methodology provides an empirical way to assess inpatient risk from data available in the Electronic Health Record. With just the variables in this paper, we achieve a risk score that correlates with discharge disposition. This is the first step towards creation of a universal measure of patient condition that reflects a generally applicable set of health-related risks. More importantly, we believe that our approach opens the door to a way of exploring and resolving many issues in patient assessment.

Retrospective cohort study. Four machine-learning techniques were used: logistic regression, k-nearest neighbours (k-NN), multifactor dimensionality reduction and support vector machines. The study uses fivefold cross validation to obtain generalisation accuracies and errors.

Kuwait Health Network (KHN) that integrates data from primary health centres and hospitals in Kuwait.

270 172 hospital visitors (of which, 89 858 are diabetic, 58 745 hypertensive and 30 522 comorbid) comprising Kuwaiti natives, Asian and Arab expatriates.

Incident type 2 diabetes, hypertension and comorbidity.

Classification accuracies of >85% (for diabetes) and >90% (for hypertension) are achieved using only simple non-laboratory-based parameters. Risk assessment tools based on k-NN classification models are able to assign ‘high’ risk to 75% of diabetic patients and to 94% of hypertensive patients. Only 5% of diabetic patients are seen assigned ‘low’ risk. Asian-specific models and assessments perform even better. Pathological conditions of diabetes in the general population or in hypertensive population and those of hypertension are modelled. Two-stage aggregate classification models and risk assessment tools, built combining both the component models on diabetes (or on hypertension), perform better than individual models.

Data on diabetes, hypertension and comorbidity from the cosmopolitan State of Kuwait are available for the first time. This enabled us to apply four different case–control models to assess risks. These tools aid in the preliminary non-intrusive assessment of the population. Ethnicity is seen significant to the predictive models. Risk assessments need to be developed using regional data as we demonstrate the applicability of the American Diabetes Association online calculator on data from Kuwait.

A 5-year prospective cross-sectional study of GPs in Ireland equipped with automated external defibrillators (AEDs) and immediate care training by the MERIT Project, with data collection every 3 months over the 5-year period. Practices reported CARAs by quarterly survey with an 89% mean response rate (81–97% for the period).

General practices throughout Ireland.

495 GP participated: 168 (33.9%) urban, 163 (32.9%) rural and 164 (33.1%) mixed.

All participating practices received a standard AED and basic life support kit. Training in immediate care was provided for at least one GP in the practice.

Incidence of CARA in participating practices. Return of spontaneous circulation (ROSC) and discharge alive from hospital.

36% of practices were involved in a CARA during the 5-year period and 13% were involved in more than one CARA. Of the 272 CARAs reported, ROSC occurred in 32% (87/272) and discharge from hospital in 18.7% (49/262). In 45% of cases, the first AED was brought by the GP and in 65%, the GP arrived before the ambulance service. More cases occurred in rural and mixed settings than urban ones, but the survival rates did not differ between areas. In 65% of cases, the GP was on duty at the time of the incident and 47% of cases occurred in the patient's home.

These outcomes are comparable with more highly structured components of the emergency response system and indicate that GPs have an important role to play in the care of patients in their own communities. GPs experience cardiac arrest cases during the course of their daily work and provide prompt care which results in successful outcomes in urban, mixed and rural settings.

Cross-sectional study.

All regions of Spain.

Students aged 11–18 years participating in the Spanish Health Behaviour in School-aged Children survey 2006. A total of 375 schools and 21 188 students were selected.

The frequency of undertaking MVPA was measured by a questionnaire, with the following four health indicators: self-rated health, health complaints, satisfaction with life and health-related quality of life. Linear and logistic regression models were used to analyse the association, adjusting for potential confounding variables and the modelling of the dose–response relationship.

As the frequency of MVPA increased, the association with health benefits was stronger. A linear trend (p<0.05) was found for self-rated health and health complaints in males and females and for satisfaction with life among females; for health-related quality of life this relationship was quadratic for both sexes (p<0.05). For self-reported health and health complaints, the effect was found to be of greater magnitude in males than in females and, in all scales, the benefits were observed from the lowest frequencies of MVPA, especially in males.

A protective effect of MVPA was found in both sexes for the four health indicators studied, and this activity had a gradient effect. Among males, health benefits were detected from very low levels of physical activity and the magnitude of the relationship was greater than that for females.

and analysis Non-controlled, experimental, pilot study. A selected group of patients with body mass index >25, with no severe psychiatric disorders, with no aesthetic or therapeutic motivation will be included in the study. A set of quantitative and qualitative measures will be utilised to evaluate the effects of a self-empowerment course in a 12 month time. Group therapy and medical examinations will also complete this observational phase. At the end of this pilot study, a set of appropriate measures and procedures to determine the effectiveness of individual empowerment will be identified and agreed among the different professional figures. Results will be recorded and analysed to start a randomised controlled trial to evaluate the effectiveness of the proposed methodology.

This protocol was approved by the local Ethics Committee of Udine in March 2012. The findings of the trial will be disseminated through peer-reviewed journals, national and international conference presentations and public events involving the local administrations of the towns where the trial participants are resident.

http://www.clinicalstrials.gov identifier NCT01644708.

Analysis of data from four Demographic and Health Surveys, conducted in 1996, 2001, 2006 and 2011.

Nepal.

31 842 women aged 15–49.

Conditional sex ratios (CSRs) were calculated, specifically the CSR for second-born children where the first-born was female. This CSR is where the evidence of sex-selective abortion will be most visible. CSRs were looked at over time to assess the impact of legalisation as well as for population sub-groups in order to identify characteristics of women using sex-selection.

From 2007 to 2010, the CSR for second-order births where the first-born was a girl was found to be 742 girls per 1000 boys (95% CI 599 to 913). Prior to legalisation of abortion (1998–2000), the same CSR was 1021 (906–1150). After legalisation, it dropped most among educated and richer women, especially in urban areas. Just 325 girls were born for every 1000 boys among the richest urban women.

The fall in CSRs witnessed post-legalisation indicates that sex-selective abortion is becoming more common. This change is very likely driven by both supply and demand factors. Falling fertility has intensified the need to bear a son sooner, while legal abortion services have reduced the costs and risks associated with obtaining an abortion.

Cross-sectional study.

Canadian Community Health Survey (CCHS).

Adult participants in the CCHS cycles 1.1, 2.1 and 3.1 were included. CCHS provides nationally representative data on health determinants, health status and health system utilisation. We have identified 40 817 self-reported OA subjects and selected 1:1 matched non-OA respondents by age, sex and CCHS cycles.

Self-reported heart disease was the primary outcome and MI, angina, CHF and stroke were considered as secondary outcomes. Multivariable logistic regression models were used to estimate the ORs after adjusting for sociodemographic status, obesity, physical activity, smoking status, fruit and vegetable consumption, medication use, diabetes, hypertension and chronic obstructive pulmonary disease.

The mean age of OA cases was 66 years and 71.6% were women. OA exhibited increased odds of prevalent heart disease, and adjusted overall OR (95% CI) was 1.45 (1.36 to 1.54), 1.35 (1.21 to 1.50) among men and 1.51 (1.39 to 1.64) among women with OA. OA showed increased ORs for angina and CHF in both men and women, and for MI in women. ORs (95% CI) for men and women, respectively, were 1.08 (0.91 to 1.28) and 1.49 (1.28 to 1.75) for MI, 1.76 (1.43 to 2.17) and 1.84 (1.59 to 2.14) for angina, 1.50 (1.13 to 1.97) and 1.81 (1.49 to 2.21) for CHF, and 1.08 (0.83 to 1.40) and 1.13 (0.93 to 1.37) for stroke.

Prevalent OA was associated with self-reported heart disease, particularly angina, and CHF in both men and women, after controlling for established risk factors for these conditions. This study provides a rationale for further investigation of the association between OA and heart disease in longitudinal studies for investigating possible biological and behavioural mechanisms.

Qualitative case study. Review of the published and grey literature and in-depth interviews with key informants and stakeholders using an HRH system conceptual framework developed by the authors (‘House Model’; Fujita et al, 2011). Interviews focused on the perceptions of respondents regarding their contributions to strengthening midwifery services and the other external influences which may have influenced the HRH system and reduction in the maternal mortality ratio (MMR).

Three rounds of interviews were conducted with senior and mid-level managers of the Ministries of Health (MoH) and Education, educational institutes and development partners.

A total of 49 interviewees, who were identified through a snowball sampling technique.

Scaling up the availability of 24 h maternal health services at all health centres contributing to MMR reduction.

The incremental development of the Cambodian HRH system since 2005 focused on the production, deployment and retention of midwives in rural areas as part of a systematic strategy to reduce maternal mortality. The improved availability and access to midwifery services contributed to significant MMR reduction. Other contributing factors included improved mechanisms for decision-making and implementation; political commitment backed up with necessary resources; leadership from the top along with a growing capacity of mid-level managers; increased MoH capacity to plan and coordinate; and supportive development partners in the context of a conducive external environment.

Lessons from this case study point to the importance of a systemic and comprehensive approach to health and HRH system strengthening and of ongoing capacity enhancement and leadership development to ensure effective planning, implementation and monitoring of HRH policies and strategies.

Case–control and longitudinal cohort study.

Landspitali—The National University Hospital, Iceland.

The Icelandic Sleep Apnea Cohort consisted of 822 untreated patients with OSA, referred for treatment with PAP. Of these, 700 patients were also assessed at a 2-year follow-up. The control group consisted of 703 randomly selected subjects from the general population.

PAP therapy in the OSA cohort.

Subjective reporting of nocturnal sweating on a frequency scale of 1–5: (1) never or very seldom, (2) less than once a week, (3) once to twice a week, (4) 3–5 times a week and (5) every night or almost every night. Full PAP treatment was defined objectively as the use for ≥4 h/day and ≥5 days/week.

Frequent nocturnal sweating (≥3x a week) was reported by 30.6% of male and 33.3% of female OSA patients compared with 9.3% of men and 12.4% of women in the general population (p<0.001). This difference remained significant after adjustment for demographic factors. Nocturnal sweating was related to younger age, cardiovascular disease, hypertension, sleepiness and insomnia symptoms. The prevalence of frequent nocturnal sweating decreased with full PAP treatment (from 33.2% to 11.5%, p<0.003 compared with the change in non-users).

The prevalence of frequent nocturnal sweating was threefold higher in untreated OSA patients than in the general population and decreased to general population levels with successful PAP therapy. Practitioners should consider the possibility of OSA in their patients who complain of nocturnal sweating.

Comprehensive searches of relevant electronic databases (eg, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials), websites of funding agencies and websites of healthcare provider organisations will be conducted to identify relevant material. We will include experimental, quasi-experimental and observational studies providing information on the sustainability of KT interventions targeting chronic disease management in adults and focusing on end-users including patients, clinicians, public health officials, health services managers and policy-makers. Two reviewers will pilot-test the screening criteria and data abstraction form. They will then screen all citations, full articles and abstract data in duplicate independently. The results of the scoping review will be synthesised descriptively and used to develop a framework to assess the sustainability of KT interventions.

Our results will help inform end-users (ie, patients, clinicians, public health officials, health services managers and policy-makers) regarding the sustainability of KT interventions. Our dissemination plan includes publications, presentations, website posting and a stakeholder meeting.

A systematic review and meta-analysis were conducted by searching MEDLINE and EMBASE for relevant prospective and case–control studies.

We included all prospective cohort, case–control, nested case-cohort and nested case–control studies that investigated the effect of dietary ALA intake on the incidence (or diagnosis) of prostate cancer and provided relative risk (RR), HR or OR estimates.

Data were pooled using the generic inverse variance method with a random effects model from studies that compared the highest ALA quantile with the lowest ALA quantile. Risk estimates were expressed as RR with 95% CIs. Heterogeneity was assessed by ² and quantified by I².

Data from five prospective and seven case–control studies were pooled. The overall RR estimate showed ALA intake to be positively but non-significantly associated with prostate cancer risk (1.08 (0.90 to 1.29), p=0.40; I²=85%), but the interpretation was complicated by evidence of heterogeneity not explained by study design. A weak, non-significant protective effect of ALA intake on prostate cancer risk in the prospective studies became significant (0.91 (0.83 to 0.99), p=0.02) without evidence of heterogeneity (I²=8%, p=0.35) on removal of one study during sensitivity analyses.

This analysis failed to confirm an association between dietary ALA intake and prostate cancer risk. Larger and longer observational and interventional studies are needed to define the role of ALA and prostate cancer.

A cross-sectional design was used.

The study was conducted in 42 of 47 primary schools in a major Irish urban centre.

EDI (teacher completed) scores were calculated for 1243 children in their first year of full-time education. Contextual data from a subset of 865 children were collected using a parental questionnaire.

Children scoring in the lowest 10% of the population in one or more domains were deemed ‘developmentally vulnerable’. Scores were correlated with contextual data from the parental questionnaire.

In the sample population, 29% of children were not developmentally ready to engage in school. Factors associated with increased risk of vulnerability were being male OR 2.1 (CI 1.6 to 2.7); under 5 years OR 1.5 (CI 1.1 to 2.1) and having English as a second language OR 3.7 (CI 2.6 to 5.2). Adjusted for these demographics, low birth weight, poor parent/child interaction and mother's lower level of education showed the most significant ORs for developmental vulnerability. Calculating population attributable fractions, the greatest population-level risk factors were being male (35%), mother's education (27%) and having English as a second language (12%).

The EDI and linked parental questionnaires are promising indicators of the extent, distribution and determinants of developmental vulnerability among children in their first year of primary school in Ireland.

Cost-effectiveness analysis using a Markov model.

Public dental patients in a low socioeconomic, socially disadvantaged area in the State of Queensland, Australia.

Children aged 6 months to 6 years received either a telephone prevention programme or usual care.

A mathematical model was used to assess caries incidence and public dental treatment costs for a cohort of children. Healthcare costs, treatment probabilities and caries incidence were modelled from 6 months to 6 years of age based on trial data from mothers and their children who received either a telephone prevention programme or usual care. Sensitivity analyses were used to assess the robustness of the findings to uncertainty in the model estimates.

By age 6 years, the telephone intervention programme had prevented an estimated 43 carious teeth and saved £69 984 in healthcare costs per 100 children. The results were sensitive to the cost of general anaesthesia (cost-savings range £36 043–£97 298) and the incidence of caries in the prevention group (cost-savings range £59 496–£83 368) and usual care (cost-savings range £46 833–£93 328), but there were cost savings in all scenarios.

A telephone intervention that aims to prevent early childhood caries is likely to generate considerable and immediate patient benefits and cost savings to the public dental health service in disadvantaged communities.

Follow-up assessment of children born to women randomly assigned by a village to receive either supplemental vitamin A (7000 µg retinol equivalents) or placebo weekly during a continuous 3.5-year period from 1994–1997. The participants came from 12 wards, a subset of 270 wards in the original trial. Trained staff tested children for cognition by the Universal Nonverbal Intelligence Test (UNIT) and motor ability using four subtests from the Movement Assessment Battery for Children (MABC). Data on schooling, home environment and nutritional and socioeconomic status were also collected.

Southern plains district of Sarlahi, Nepal.

390 Nepalese children 10–13 years of age.

Raw scores on UNIT and square-root transformed scores on an abridged version of the MABC tests, expressed as cluster-summarised (mean±SD) values to account for the design of the original trial.

There were no differences in UNIT (79.61±5.99 vs 80.69±6.71) or MABC (2.64±0.07 vs 2.49±0.09) test scores in children whose mothers were exposed to vitamin A vs placebo (mean differences: –1.07, 95% CI –7.10 to 9.26, p=0.78; 0.15, 95% CI 0.43 to –0.08, p=0.15), respectively. More children in the placebo group had repeated a grade in school (28% of placebo vs 16.7% of vitamin A, p=0.01).

Preconceptional to postpartum maternal vitamin A supplementation, in an undernourished setting, does not improve cognition or motor development at ages 10–13 years.

A thematic content analysis of OMERACT internal documents, publications and conference proceedings, followed by a responsive evaluation including 32 qualitative semistructured interviews.

The international, biannual research conference OMERACT 10 (Malaysia, 2010).

Senior researchers (n=10), junior researchers (n=2), representatives of the pharmaceutical industry and regulators (n=2), conference staff (n=2), new patient delegates (n=8) and experienced patient delegates (n=8).

The role of patients evolved over 10 years from a single patient focus group to full participation in all areas of the meeting and inclusion in research group meetings between conferences. Five main categories of impact emerged: widening the research agenda; including patient relevant outcomes in core sets; enhancing patient reported instruments; changing the culture of OMERACT and consequences outside OMERACT. Patient participants identified previously neglected outcome domains such as fatigue, sleep disturbances and flares which prompted collaborative working on new programmes of research. Specific benefits and challenges for patients and professionals were identified, such as personal fulfilment, widening of research interests, difficulties in establishing equal partnerships and concerns about loss of research rigour.

Including patients as partners in OMERACT conferences has widened its focus and adjusted the way of working. It has resulted in new developments in the research agenda and the use of more patient-relevant outcomes in clinical trials. These collaborations have influenced perceptions and beliefs among many patients and researchers, and led to wider patient involvement as partners in research.

Health facility assessment survey and population-based surveillance data.

Seven districts in Brong Ahafo Region, Ghana.

Heads of maternal/neonatal wards in all 64 facilities performing deliveries.

Indicators include: the availability of essential infrastructure, newborn equipment and drugs, and personnel; vignette scores and adequacy of reasons given for delayed discharge of newborn babies; and prevalence of key immediate ENC practices that facilities should promote. These are matched to the percentage of babies delivered in and admitted to each type of facility.

70% of babies were delivered in health facilities; 56% of these and 87% of neonatal admissions were in four referral level hospitals. These had adequate infrastructure, but all lacked staff trained in ENC and some essential equipment (including incubators and bag and masks) and/or drugs. Vignette scores for care of very low-birth-weight babies were generally moderate-to-high, but only three hospitals achieved high overall scores for quality of ENC. We estimate that only 33% of babies were born in facilities capable of providing high quality, basic resuscitation as assessed by a vignette plus the presence of a bag and mask. Promotion of immediate ENC practices in facilities was also inadequate, with coverage of early initiation of breastfeeding and delayed bathing both below 50% for babies born in facilities; this represents a lost opportunity.

Unless major gaps in ENC equipment, drugs, staff, practices and skills are addressed, strategies to increase facility utilisation will not achieve their potential to save newborn lives.

http://clinicaltrials.gov NCT00623337.

Prospective cohort study (the Aberdeen Children of the 1950s).

Aberdeen, Scotland.

12 500 live-births (6282 boys) between 1950 and 1956, who were followed up in the years 2001–2003 at age 46–51 with a postal questionnaire achieving a response rate of 64% (7183).

Psychological distress at age 46–51 (questionnaire).

Childhood intelligence and SES and education had indirect effects on psychological distress at midlife, mediated by adult SES. Adult SES was the only variable to have a significant direct effect on psychological distress at midlife; the effect was stronger in men than in women. Alternative measurement specifications of SES (reflective and formative) resulted in greatly different model parameters and fits.

Even though formative operationalisations of SES are theoretically appropriate, SES is better specified as reflective than as a formative latent variable in the context of life-course modelling.

Scoping review.

Medline, CENTRAL, ERIC, PubMed, CINAHL Plus Full Text, Academic Search Complete, Alt Health Watch, Health Source, Communication and Mass Media Complete, Web of Knowledge and ProQuest (2000–2012).

Studies reporting primary research on the use of social media (collaborative projects, blogs/microblogs, content communities, social networking sites, virtual worlds) by patients or caregivers.

Two reviewers screened studies for eligibility; one reviewer extracted data from relevant studies and a second performed verification for accuracy and completeness on a 10% sample. Data were analysed to describe which social media tools are being used, by whom, for what purpose and how they are being evaluated.

Two hundred eighty-four studies were included. Discussion forums were highly prevalent and constitute 66.6% of the sample. Social networking sites (14.8%) and blogs/microblogs (14.1%) were the next most commonly used tools. The intended purpose of the tool was to facilitate self-care in 77.1% of studies. While there were clusters of studies that focused on similar conditions (eg, lifestyle/weight loss (12.7%), cancer (11.3%)), there were no patterns in the objectives or tools used. A large proportion of the studies were descriptive (42.3%); however, there were also 48 (16.9%) randomised controlled trials (RCTs). Among the RCTs, 35.4% reported statistically significant results favouring the social media intervention being evaluated; however, 72.9% presented positive conclusions regarding the use of social media.

There is an extensive body of literature examining the use of social media in patient and caregiver populations. Much of this work is descriptive; however, with such widespread use, evaluations of effectiveness are required. In studies that have examined effectiveness, positive conclusions are often reported, despite non-significant findings.

We conducted a systematic review of available literature on the effect of contact with a podiatrist on the risk of LEA in people with diabetes. Eligible studies, published in English, were identified through searches of PubMed, CINAHL, EMBASE and Cochrane databases. The key terms, ‘podiatry’, ‘amputation’ and ‘diabetes’, were searched as Medical Subject Heading terms. Reference lists of selected papers were hand-searched for additional articles. No date restrictions were imposed.

Published randomised and analytical observational studies of the effect of contact with a podiatrist on the risk of LEA in people with diabetes were included. Cross-sectional studies, review articles, chart reviews and case series were excluded. Two reviewers independently assessed titles, abstracts and full articles to identify eligible studies and extracted data related to the study design, characteristics of participants, interventions, outcomes, control for confounding factors and risk estimates.

Meta-analysis was performed separately for randomised and non-randomised studies. Relative risks (RRs) with 95% CIs were estimated with fixed and random effects models as appropriate.

Six studies met the inclusion criteria and five provided data included in meta-analysis. The identified studies were heterogenous in design and included people with diabetes at both low and high risk of amputation. Contact with a podiatrist did not significantly affect the RR of LEA in a meta-analysis of available data from randomised controlled trials (RCTs); (1.41, 95% CI 0.20 to 9.78, 2 RCTs) or from cohort studies; (0.73, 95% CI 0.39 to 1.33, 3 Cohort studies with four substudies in one cohort).

There are very limited data available on the effect of contact with a podiatrist on the risk of LEA in people with diabetes.

Case series.

Public teaching university hospital (Paris, France).

During the study period, 368 cataract surgery cases performed on 285 patients were included, 85 cases were excluded from the final analysis. All patients who had uneventful phacoemulsification were included. Cases with any significant intraoperative adverse event or cases requiring additional anaesthesia other than topical were excluded. Resident performed cases were also excluded.

Procedures were timed (objective duration) and patients were asked, immediately afterwards, to assess the duration of their surgery (patient-assessed duration). The agreement between objective and patient-assessed durations as well as influencing factors was studied.

Mean objective duration (13.9±5 min) and patient-assessed duration (15.3±6.9 min) were significantly correlated (Spearman's r=0.452, p<0.0001). Furthermore, Bland-Altman analysis and the intraclass correlation coefficient (0.341, 95% CI 0.23 to 0.44) were quite in agreement. On univariate analysis, senior-performed procedures were significantly shorter than those performed by juniors (13.4 vs 17.8 min, p=0.0001). Pain was recorded as ‘no sensation’ (31.5% of the cases), ‘mild sensation’ (41%), ‘moderate pain’ (23.3%), ‘intense pain’ (3.5%) and ‘unbearable pain’ (0.7%). Groups with high pain score had significantly longer procedures (p<0.001). Multivariate analysis revealed that the only independent factors associated with both the objective and patient-assessed durations of surgery were surgeon's experience and pain-score.

In our study, patients’ estimated and real duration of the surgery showed moderate agreement, suggesting that emotions associated with eye surgery under topical anaesthesia did not dramatically hinder the patients’ perception of time. However, the benefit of preoperative counselling regarding the duration of surgery will need further evaluation.

Multisite, randomised trial comparing usual care with an education and support package.

Two acute stroke units.

Patients and their carers (N=138) were randomised (control n=67, intervention n=71) of which data for 119 participants (control n=59, intervention n=60) were analysed.

The package consisted of a computer-generated, tailored written information booklet and verbal reinforcement provided prior to, and for 3 months following, discharge.

Outcome measures were administered prior to hospital discharge and at 3-month follow-up by blinded assessors. The primary outcome was stroke knowledge (score range: 0–25). Secondary outcomes were: self-efficacy (1–10), anxiety and depression (0–21), ratings of importance of information (1–10), feelings of being informed (1–10), satisfaction with information (1–10), caregiver burden (carers) (0–13) and quality of life (patients) (1–5).

Intervention group participants reported better: self-efficacy for accessing stroke information (adjusted mean difference (MD) of 1.0, 95% CI 0.3 to 1.7, p=0.004); feeling informed (MD 0.9, 95% CI 0.2 to 1.6, p=0.008); and satisfaction with medical (MD 2.0, 95% CI 1.1 to 2.8, p<0.001); practical (MD 1.1, 95% CI 0.3 to 1.9, p=0.008), services and benefits (MD 0.9, 95% CI 0.1 to 1.8, p=0.036) and secondary prevention information (MD 1.7, 95% CI 0.9 to 2.5, p<0.001). There was no significant effect on other outcomes.

Intervention group participants had improved self-efficacy for accessing stroke information and satisfaction with information, but other outcomes were not significantly affected. Evaluation of a more intensive intervention in a trial with a larger sample size is required to establish the value of an educational intervention that uses tailoring and reinforcement strategies.

ACTRN12608000469314

A cross-sectional survey.

The UK's four largest deaneries (Schools of Ophthalmology).

Trainee ophthalmologists, all having completed three or more years of training, who were appointed to the new ophthalmic specialty training programme.

The mean annual surgical rate for each deanery in phacoemulsification cataract extractions and experience in other common elective and emergency surgical operations. Second, to calculate the mean timetabled clinical activity.

The responses of 40 doctors were analysed, with a response rate of 83%. Overall, the phacoemulsification rate was 73.52±29.24 operations/year. This was significantly higher in the South Thames Deanery (99.69±26.16, p=0.0005) and significantly lower in the North Western Deanery (48.08±19.72, p=0.0008). The annual mean complex cataract rate was 5.21±4.38. Only 40% were confident in dealing with the most common complication of cataract surgery (vitreous loss). The mean trabeculectomy (surgery for glaucoma) rate was 0.47±1.16 and for squint surgery it was 3.54±2.82 operations/year. Regarding the common ocular trauma surgery, 42.5% had not sutured a corneal laceration and 60% a globe rupture. 50% thought the training programme would adequately prepare them surgically. The timetabled clinical activity was highest in the South Thames Deanery (48.17 h/week) and lowest in the North Western Deanery (40.82 h/week) due to variations in the European Working Time Directive implementation and on-call commitments.

Significant regional variations in surgical training experience exist between UK deaneries, particularly with respect to cataract surgery, and they appear to be correlated to timetabled activity. Experience and confidence levels in managing complex cataract surgery and complications were low and experience with previously commonly performed elective and emergency operations was minimal. Although doctors from all the regions surveyed were very likely to achieve the minimum cataract extractions required for specialist training completion, we have identified shortcomings of the current training programme that need attention.

Interview and postal survey.

UK and Eire Glaucoma Society national meeting 2011 in Manchester, UK, with a second round of surveys administered by post.

All consultant glaucoma specialists in England and Wales were invited to complete the survey.

(1) Compliance of assigned follow-up VF intervals with NICE guidelines for three hypothetical patient scenarios, with satisfactory treated intraocular pressure and (a) no evidence of VF progression; (b) evidence of VF progression and (c) uncertainty about VF progression, and respondents were asked to provide typical follow-up intervals representative of their practice; (2) attitudes to research recommendations for six VF in the first 2 years for newly diagnosed patients with glaucoma.

70 glaucoma specialists completed the survey. For each of the clinical scenarios a, b and c, 14 (20%), 33 (47%) and 28 (40%) responses, respectively, fell outside the follow-up interval recommended by NICE. Nearly half of the specialists (46%) agreed that 6 VF tests in the first 2 years was ideal practice, while 16 (28%) said this was practice ‘not possible’, with many giving resources within the NHS setting as a limiting factor.

The results from this survey suggest that there is a large variation in attitudes to follow-up intervals for patients with glaucoma in the UK, with assigned intervals for VF testing which are, in many cases, inconsistent with the guidelines from NICE.

Scoping review. Two independent reviewers assessed studies for inclusion and extracted data from each study.

Search strategies were developed and the following databases were searched: MEDLINE, ISI, SCOPUS and Lilacs, from 2000 to 2010.

Research articles and reviews published in English, Spanish and Portuguese were included. Studies including only high-income countries were excluded, as well as those carried out in very limited settings and discussion papers.

The 77 articles retained were categorised through consensus among the research team according to the level of the health system addressed, ATM domain and research issues covered. Publications on ATM have increased over time during the study period (r 0.93, p=0.00; R² 0.85). The top five countries covered were Brazil (68.8%), Mexico (15.6%), Colombia (11.7%), Argentina (10.4%) and Peru (10.4%). ‘Health services delivery’ and ‘patients, household and communities’ were the health system levels most frequently covered. The ATM domains ‘leadership and governance’, ‘sustainable financing, affordability and price of medicines’, ‘medicines selection and use’ and ‘availability of medicines’ were the top four explored. There are research gaps in important areas such as ‘human resources for health’, ‘global policies and human rights’, ‘production of medicines’ and ‘traditional medicine’.

The upward trend on scientific publication reflects a growing research capacity in the region, which is concentrated on research teams in selected countries. The gaps on research capacity could be overcome through research collaboration among countries. It is important to strengthen these collaborations, assuring that interests and needs from the LMIC are addressed and local capacity building is promoted.

Cross-sectional population database analysis.

Data on all dispensed drugs in 2010 to the entire Swedish population (9.3 million inhabitants) were obtained from the Swedish Prescribed Drug Register. All pharmacological groups with ambulatory care prescribing accounting for >75% of the total volume in Defined Daily Doses and a prevalence of >1% were included in the analysis. Crude and age-adjusted differences in prevalence and incidence were calculated as risk ratios (RRs) of women/men.

In all, 2.8 million men (59%) and 3.6 million women (76%) were dispensed at least one prescribed drug during 2010. Women were dispensed more drugs in all age groups except among children under the age of 10. The largest sex difference in prevalence in absolute numbers was found for antibiotics that were more common in women, 265.5 patients (PAT)/1000 women and 191.3 PAT/1000 men, respectively. This was followed by thyroid therapy (65.7 PAT/1000 women and 13.1 PAT/1000 men) and antidepressants (106.6 PAT/1000 women and 55.4 PAT/1000 men). Age-adjusted relative sex differences in prevalence were found in 48 of the 50 identified pharmacological groups. The pharmacological groups with the largest relative differences of dispensed drugs were systemic antimycotics (RR 6.6 CI 6.4 to 6.7), drugs for osteoporosis (RR 4.9 CI 4.9 to 5.0) and thyroid therapy (RR 4.5 CI 4.4 to 4.5), which were dispensed to women to a higher degree. Antigout agents (RR 0.4 CI 0.4 to 0.4), psychostimulants (RR 0.6 CI 0.6 to 0.6) and ACE inhibitors (RR 0.7 CI 0.7 to 0.7) were dispensed to men to a larger proportion.

Substantial differences in the prevalence and incidence of dispensed drugs were found between men and women. Some differences may be rational and desirable and related to differences between the sexes in the incidence or prevalence of disease or by biological differences. Other differences are more difficult to explain on medical grounds and may indicate unequal treatment.

Qualitative study using in-depth interviews and a theoretically informed biographic disruption theory.

Interviews were conducted in two Nairobi slums (Kenya).

41 HIV-infected heterosexual men and women aged 18 years or older.

People living with HIV have divergent experiences surrounding HIV diagnosis. Postdiagnosis, there are multiple phases of identity transition, including status (non-)disclosure, and attempts at identity repair and normalcy. For some people, this process involves a transition to a new self-identity, incorporating both HIV and antiretroviral treatment (ART) into their lives. For others, it involves a partial transition, with some aspects of their prediagnosis identity persisting, and for others it involves a rejection of HIV identity. Those people who were able to incorporate HIV/AIDS in their identity, without it being disruptive to their biography, were pursuing safer sexual and reproductive lives. By contrast, those people with a more continuous biography continued to reflect their prediagnosis identity and sexual behaviour.

People living with HIV/AIDS (PLWHA) had to rework their sense of identity following diagnosis in the context of living in a slum setting. Men and women living with HIV in slums are poorly supported by health systems and services as they attempt to cope with a diagnosis of HIV. Given the availability of ART, health services and professionals need to support the rights of PLWHA to be sexually active if they want to and achieve their fertility goals, while minimising HIV transmission risk.

Cross-sectional study.

2 Japanese municipalities.

A total of 2505 residents aged over 40 years, who participated in health check-ups conducted in 2010. OAB symptom assessed via overactive bladder symptom score (OABSS) was divided into six categories based on distribution and Japanese clinical guidelines. Mobility problems and depressive symptoms were assessed via the Timed Up and Go test and the short form of the Center for Epidemiologic Studies Depression Scale, respectively.

Self-reported any fall and frequent fall (≥2) over the 1-month period. Independent contributions to any fall and frequent falls were assessed via logistic regression to generate population-attributable fractions (PAFs), assuming separate causal relationships between OAB symptoms, mobility problems and depressive symptoms and any or frequent falls.

Among the total 1350 participants (mean age: 68.3 years) analysed, any fall and frequent falls were reported by 12.7% and 4.4%, respectively. Compared with no OABSS score, moderate-to-severe OAB and mild OAB were associated with any fall (adjusted ORs 2.37 (95% CI 1.12 to 4.98) and 2.51 (95% CI 1.14 to 5.52), respectively). Moderate-to-severe OAB was also strongly associated with frequent falls (adjusted OR 6.90 (95% CI 1.50 to 31.6)). Adjusted PAFs of OAB symptoms were 40.7% (95% CI 0.7% to 64.6%) for any fall and 67.7% (95% CI –23.1% to 91.5%) for frequent falls. Further, these point estimates were similar to or larger than those of mobility problems and depressive symptoms.

An association does indeed exist between OAB symptom severity and falls, and OAB symptoms might be important contributors to falls among community-dwelling adults. Further longitudinal studies are warranted to examine whether or not OAB symptoms predict risk of future falls and fall-related injuries.

Case series.

22 children with nodding syndrome brought to Mulago National Referral Hospital for assessment.

Clinical features, physical and functional disabilities, EEG and brain MRI findings and a staging system with a progressive development of symptoms and complications.

The median age of symptom onset was 6 (range 4–10) years and median duration of symptoms was 8.5 (range 2–11) years. 16 of 22 families reported multiple affected children. Physical manifestations and complications included stunting, wasting, lip changes and gross physical deformities. The bone age was delayed by 2 (range 1–6) years. There was peripheral muscle wasting and progressive generalised wasting. Four children had nodding as the only seizure type; 18 in addition had myoclonic, absence and/or generalised tonic–clonic seizures developing 1–3 years after the onset of illness. Psychiatric manifestations included wandering, aggression, depression and disordered perception. Cognitive assessment in three children demonstrated profound impairment. The EEG was abnormal in all, suggesting symptomatic generalised epilepsy in the majority. There were different degrees of cortical and cerebellar atrophy on brain MRI, but no hippocampal changes. Five stages with worsening physical, EEG and brain imaging features were identified: a prodrome, the development of head nodding and cognitive decline, other seizure types, multiple complications and severe disability.

Nodding syndrome is a neurological disorder that may be characterised as probably symptomatic generalised epilepsy. Clinical manifestations and complications develop in stages which might be useful in defining treatment and rehabilitation. Studies of risk factors, pathogenesis, management and outcome are urgently needed.

Repeated measures.

Community venues at 37 locations across the UK.

440 overweight or obese children (42% boys; mean age 6.1 years; body mass index (BMI) z-score 2.86) and their parents/carers participated in the intervention.

MEND 5-7 is a 10-week, family-based, child weight-management intervention consisting of weekly group sessions. It includes positive parenting, active play, nutrition education and behaviour change strategies. The intervention is designed to be scalable and delivered by a range of health and social care professionals.

The primary outcome was BMI z-score. Secondary outcome measures included BMI, waist circumference, waist circumference z-score, children's psychological symptoms, parenting self-efficacy, physical activity and sedentary behaviours and the proportion of parents and children eating five or more portions of fruit and vegetables.

274 (62%) children were measured preintervention and post-intervention (baseline; 10-weeks). Post-intervention, mean BMI and waist circumference decreased by 0.5 kg/m² and 0.9 cm, while z-scores decreased by 0.20 and 0.20, respectively (p<0.0001). Improvements were found in children's psychological symptoms (–1.6 units, p<0.0001), parent self-efficacy (p<0.0001), physical activity (+2.9 h/week, p<0.01), sedentary activities (–4.1 h/week, p<0.0001) and the proportion of parents and children eating five or more portions of fruit and vegetables per day (both p<0.0001). Attendance at the 10 sessions was 73% with a 70% retention rate.

Participation in the MEND 5-7 programme was associated with beneficial changes in physical, behavioural and psychological outcomes for children with complete sets of measurement data, when implemented in UK community settings under service level conditions. Further investigation is warranted to establish if these findings are replicable under controlled conditions.

Pharmacoepidemiological cohort study.

From nationwide registers, we identified patients with an in-hospital or outpatient-clinic AF diagnosis who claimed a prescription of dabigatran 110 or 150 mg, or vitamin K antagonist (VKA), between 22 August and 31 December 2011. HRs of thromboembolic events (ischaemic stroke, transitory ischaemic attack and peripheral artery embolism) and bleedings were estimated using Cox regression analyses in all patients and stratified by previous VKA use.

Overall, 1612 (3.1%) and 1114 (2.1%) patients claimed a prescription of dabigatran 110 and 150 mg, and 49640 (94.8%) of VKA. Patients treated with dabigatran 150 mg were younger with less comorbidity than those treated with dabigatran 110 mg and VKA, as were VKA naïve patients compared with previous VKA users. Recommendations set by the European Medicine Agency (EMA) for dabigatran were met in 90.3% and 55.5% of patients treated with 110 and 150 mg. Patients treated with 150 mg dabigatran, who did not fulfil the recommendations by EMA, were >80 years, patients with liver or kidney disease, patients with previous bleeding. Compared with VKA, the thromboembolic risk associated with dabigatran 110 and 150 mg was HR 3.52 (1.40 to 8.84) and 5.79 (1.81 to 18.56) in previous VKA users, and HR 0.95(0.47 to 1.91) and 1.14(0.60 to 2.16) in VKA naïve patients. Bleeding risk was increased in previous VKA users receiving dabigatran 110 mg, but not in patients with 150 mg dabigatran, nor in the VKA naïve users.

Deviations from the recommended use of dabigatran were frequent among patients treated with 150 mg. With cautious interpretation, dabigatran use in VKA naïve patients seems safe. Increased risk of thromboembolism and bleeding with dabigatran among previous VKA users was unexpected and may reflect patient selection and ‘drug switching’ practices.

Retrospective cohort study.

Failure to publish findings from research is a significant area of research waste. It has previously been suggested that potentially over 50% of studies funded are never published.

All NIHR HTA projects with a planned submission date for their final report for publication in the journal series on or before 9 December 2011 were included.

The projects were classified according to the type of research, whether they had been published or not; if not yet published, whether they would be published in the future or not. The reasons for non-publication were investigated.

628 projects were included: 582 (92.7%) had published a monograph; 19 (3%) were expected to publish a monograph; 13 (2.1%) were discontinued studies and would not publish; 12 (1.9%) submitted a report which did not lead to a publication as a monograph; and two (0.3%) did not submit a report. Overall, 95.7% of HTA studies either have published or will publish a monograph: 94% for those commissioned in 2002 or before and 98% for those commissioned after 2002. Of the 27 projects for which there will be no report, the majority (21) were commissioned in 2002 or before. Reasons why projects failed to complete included failure to recruit; issues concerning the organisation where the research was taking place; drug licensing issues; staffing issues; and access to data.

The percentage of HTA projects for which a monograph is published is high. The advantages of funding organisations requiring publication in their own journal include avoidance of publication bias and research waste.

Case–control study.

Coronary care unit, acute cardiology and acute surgical admission wards in a major teaching hospital in London, UK.

134 participants (70 cases and 64 controls) aged ≥40 years hospitalised for acute myocardial infarction and acute surgical conditions between 21 September 2009 and 28 February 2010, frequency-matched for gender, 5-year age-band and admission week.

ILI (defined as feeling feverish with either a cough or sore throat) within the last month.

Acute respiratory illness within the last month not meeting ILI criteria; nasopharyngeal and throat swab positive for influenza virus.

29 of 134 (21.6%) participants reported respiratory illness within the last month, of whom 13 (9.7%) had illnesses meeting ILI criteria. The most frequently reported category for timing of respiratory symptom onset was 8–14 days before admission (31% of illnesses). Cases were more likely than controls to report ILI—adjusted OR 3.17 (95% CI 0.61 to 16.47)—as well as other key respiratory symptoms, and were less likely to have received influenza vaccination—adjusted OR 0.46 (95% CI 0.19 to 1.12)—although the differences were not statistically significant. No swabs were positive for influenza virus.

Point estimates suggested that recent ILI was more common in patients hospitalised with acute myocardial infarction than with acute surgical conditions during the second wave of the influenza A H1N1 pandemic, and influenza vaccination was associated with cardioprotection, although the findings were not statistically significant. The study was underpowered, partly because the age groups typically affected by acute myocardial infarction had low rates of infection with the pandemic influenza strain compared with seasonal influenza.

A secondary analysis of a subset of survey questions regarding self-reported confidence in healthcare from the 2010 Commonwealth Fund International Health Policy Survey.

Telephone survey of participants from the UK and the USA.

Our final analysis included 1511 UK residents (688 rural, 446 suburban, 372 urban, 5 uncategorised) and 2501 US residents (536 rural, 1294 suburban, 671 urban).

Questions assessed respondents’ confidence in the effectiveness and affordability of the treatment. We compared survey outcomes from these questions between, and within, the two regions and among, and within, residence types (rural, suburban and urban).

Significant differences were found in self-reported confidence in healthcare between the UK and US, among residence types, and between the two regions within residence types. Reported levels were higher in the UK. Within regions, significant differences by residence type were found for the US, but not the UK. Within the US, suburban respondents had the highest self-reported confidence in healthcare.

Significant differences exist between the UK and US in confidence in healthcare. In the US, but not in the UK, self-reported confidence is related to residence type. Within countries, significant differences by residence type were found for the US, but not the UK. Our findings warrant the examination of causes for relative confidence levels in healthcare between regions and among US residence types.

Multilevel logit regression was used to measure the association between ethnicity, social interactions, own-group ethnic density and scores of 22+ on the Kessler scale of psychological distress. Self-reported ancestry was used as a proxy for ethnicity. Measures of social interactions included a number of times in the past week were (i) spent with friends or family participants did not live with; (ii) talked to someone on the telephone; (iii) attended meetings of social groups and (iv) how many people could be relied upon outside their home, but within 1 h of travel. Per cent own-group ethnic density was measured at the Census Collection District scale.

Psychological distress was reported by 11% of Australians born in Australia. The risk of experiencing psychological distress varied among ethnic minorities and by country of birth (eg, 33% for the Lebanese born in Lebanon and 4% for the Swiss born in Switzerland). These differences remained after full adjustment. Social interactions varied between ethnic groups and were associated with lower psychological distress and ethnic density. Ethnic density was associated with reduced psychological distress for some groups. This association, however, was explained by individual and neighbourhood characteristics and not by social interactions.

Social interactions are important correlates of mental health, but fully explain neither the ethnic differences in psychological distress nor the protective effect of own-group density.

Population-based, retrospective cohort study.

Public and private hospitals in Western Australia.

Included in this study were 155 646 births to nulliparous women during 1996–2008.

Caesarean section rates were calculated separately for four patient type groups defined according to mothers’ funding source at the time of birth (public/private) and type of delivery hospital (public/private). The average annual per cent change (AAPC) for the caesarean section rates was calculated using joinpoint regression.

Overall, there were 45 903 caesarean sections performed (29%) during the study period, 24 803 in-labour and 21 100 prelabour. Until 2005, the rate of caesarean deliveries increased most rapidly on average annually for private patients delivering in private hospitals (AAPC=6.5%) compared with public patients in public hospitals (AAPC=4.3%, p<0.0001). This increase could mostly be attributed to an increase in prelabour caesarean deliveries for this group of women and could not be explained by an increase in breech deliveries, placenta praevia or multiple pregnancies.

Our results indicate that an increase in the prelabour caesarean delivery rate for private patients in private hospitals has been driving the increase in the caesarean section rate for nulliparous women since 1996. Future research with more detailed information on indication for the prelabour caesarean section is needed to understand the reasons for these findings.

Retrospective database review.

Single institution high volume oncological tertiary care referral centre.

From our comprehensive oesophageal cancer database consisting of 709 patients, we stratified patients according to BMI: 155 normal-weight (BMI 20–24), 198 overweight (BMI 25–29) and 187 obese (BMI ≥30) patients.

All patients underwent oesophagectomy for cancer.

Incidences of preoperative risk factors and perioperative complications in each group were analysed.

The patient cohort consisted of 474 men and 66 women with a mean age of 64.3 years (28–86). They were similar in terms of demographics and comorbidities, with the exception of a younger age (65.2 vs 65.4 vs 62.5 years, p=0.0094), and a higher incidence of diabetes (9.1% vs 13.2% vs 22.7%, p=0.001), hiatal hernia (16.8% vs 17.8% vs 28.8%, p=0.009) and Barrett oesophagus (24.7% vs 25.4% vs 36.2%, p=0.025) for obese patients. The type of surgery performed, overall blood loss, extent of lymphadenectomy, R0 resections and complications were not influenced by BMI on univariate and multivariate analysis.

In our experience, patients with an elevated BMI and oesophageal adenocarcinoma do not experience an increase in morbidity and mortality after oesophagectomy as stated in previous reports, when performed at a high volume centre. Additionally, BMI did not affect the quality of oncological resection as determined by number of harvested lymph-nodes and rates of R0 resections.

MCC 15030, IRB 105286.

Systematic review.

We searched MEDLINE and EMBASE for studies published from 1 January 2006 to 31 December 2010.

We included prospective cohort, case–control studies or retrospective analyses of databases or disease registers where the effect of risk factors for mortality or survival was examined. Studies must have included more than 1000 participants receiving RBCT for any cause. We assessed the effects of RBCT versus no RBCT and different volumes and age of RBCT.

–32 studies were included in the review; 23 assessed the effects of RBCT versus no RBCT; 5 assessed different volumes and 4 older versus newer RBCT. There was a considerable variability in the patient populations, study designs and level of statistical adjustment. Overall, most studies showed a higher rate of mortality when comparing patients who received RBCT with those who did not, even when these rates were adjusted for confounding; the majority of these increases were statistically significant. The same pattern was observed in studies where protection from bias was likely to be greater, such as prospective studies.

Recent observational studies do show a consistently adverse effect of RBCT on mortality. Whether this is a true effect remains uncertain as it is possible that even the best conducted adjustments cannot completely eliminate the impact of confounding.

A national, cross-sectional study and direct enumeration, multiplier and benchmark methods with integrated bio-behavioural surveys, capture/recapture and methods with Wald and Clopper-Pearson CIs were used.

This study was carried out in the three largest cities and main regions of Serbia, the capital city, Belgrade, (population 1 639 121 persons), the Vojvodina region with main city Novi Sad (population 335 701) and the rest of Serbia with main city Nis (population 257 867).

A total of 1301 respondents from the defined MARPs completed the survey in the 2009/2010 period across the three cities.

Estimates of the hidden numbers at risk of HIV/AIDS.

It was estimated that there were 1775–6027 SW between 18 and 49 years in Serbia in 2009. For MSM, national estimates for 2009 ranged from 20 789 to 90 104 individuals aged between 20 and 49 years. For IDU, a possible range of 12 682–48 083 individuals aged between 15 and 59 years in 2009 was estimated.

For service planning across Central and Eastern Europe, it is important to highlight how credible estimates can be achieved and compared with numbers within HIV/AIDS-prevention programmes. Within needle exchange programmes, only 5.4–20.5% of the estimated population was observed and this proportion was lower within methadone treatment data. Results have implications for future IDU treatment and HIV incidence and spread across all populations at risk.

All female patients with breast cancer who attend the Oncology Out-patient Services for the first time will provide an informed consent to participate in the study. They are randomly assigned to the intervention or to the control group. The intervention consists of the presentation of a list of relevant illness-related questions, called a question prompt sheet. The primary outcome measure of the efficacy of the intervention is the number of questions asked by patients during the consultation. Secondary outcomes are the involvement of the patient by the oncologist; the patient's perceived achievement of her information needs; the patient's satisfaction and ability to cope; the quality of the doctor–patient relationship in terms of patient-centeredness; and the number of questions asked by the patient's companions and their involvement during the consultation. All outcome measures are supposed to significantly increase in the intervention group.

The study was approved by the local Ethics Committee of the Hospital Trust of Verona. Study findings will be disseminated through peer-reviewed publications and conference presentations.

ClinicalTrials.gov identifier: NCT01510964

A cross-sectional study from 2006.

18 primary care health centres (HCs) from five municipalities in Finland.

Aggregated survey data on perceived job strain and supervisor support from healthcare personnel (doctors, n=122, mean age 45.5 years, nurses, n=300, mean age 47.1 years) were combined with registered data (Electronic Medical Records) from 8975 patients (51% men, mean age 67 years) with type 2 diabetes.

Poor glycaemic control (glycated haemoglobin (HbA1c) ≥7%).

The mean HbA1c level among patients with type 2 diabetes was 7.1 (SD 1.2, range 4.5–19.1), and 43% had poor glycaemic control (HbA1c ≥7%). Multilevel logistic regression analyses, adjusted for patient's age and sex, and HC and HC service area-level characteristics, showed that patients’ HbA1c-levels were less optimal in high-strain HCs than in low-strain HCs (OR 1.44, 95% CI 1.12 to 1.86). Supervisor support in HCs was not associated with the outcome of care.

The level of job strain among healthcare personnel may play a role in achieving good glycaemic control among patients with type 2 diabetes.

The study utilised a cross-sectional survey, using Likert scales, to assess attitudes towards specialist care. Responses were grouped using model-based clustering methods implemented in LatentGold 4.5.

Participants from 98 NHS trusts in the UK were invited to participate in the study.

691 healthcare professionals involved in the management of TYA patients were approached; of these, 338 responded.

338 healthcare professionals responded (51.9% of those invited). Responses were grouped into three clusters according to the pattern of responses to the questions. One cluster rated age-appropriate care above all else, the second rated both age and site-appropriate care highly while the third assigned more importance to site-specific care. Overall, the psychosocial and supportive aspects of care were rated highest while statements relating to factors known to be important (access to clinical trials, treatment at a high volume centre and specialist diagnostics) were not rated as highly as expected.

Attitudes varied widely between professionals treating TYA patients with cancer as to what constitutes key aspects of specialist care. Further work is needed to quantify the extent to which this influences practice.

Retrospective cohort study.

MarketScan Commercial Claims and Encounters/Health and Productivity Management Databases 2003–2009.

Adult employees with T2DM who were previously treated with oral antidiabetic drugs and/or glucagon-like-peptide 1 receptor agonists and initiated GLA or NPH were included if they were continuously enrolled in healthcare and short-term-disability coverages for 3 months before (baseline) and 1 year after (follow-up) initiation. Treatment selection bias was addressed by 2:1 propensity score matching. Sensitivity analyses were conducted using different matching ratios.

Outcomes during 1-year follow-up were measured and compared: insulin treatment persistence and adherence; hypoglycaemia rates and daily average consumption of insulin; total and diabetes-specific healthcare resource utilisation and costs and loss in productivity, as measured by short-term disability, and the associated costs.

A total of 534 patients were matched and analysed (GLA: 356; NPH 178) with no significant differences in baseline characteristics. GLA patients were more persistent and adherent (both p<0.05), had lower rates of hospitalisation (23% vs 31.4%; p=0.036) and endocrinologist visits (19.1% vs 26.9%; p=0.038), similar hypoglycaemia rates (both 4.4%; p=1.0), higher diabetes drug costs ($2031 vs $1522; p<0.001), but similar total healthcare costs ($14 550 vs $16 093; p=0.448) and total diabetes-related healthcare costs ($4686 vs $5604; p=0.416). Short-term disability days and costs were numerically lower in the GLA cohort (16.0 vs 24.5 days; p=0.086 and $2824 vs $4363; p=0.081, respectively). Sensitivity analyses yielded similar findings.

Insulin GLA results in better persistence and adherence, compared with NPH insulin, with no overall cost disadvantages. Better persistence and adherence may lead to long-term health benefits for employees with T2DM.

Cross-sectional study.

Data were collected from four general hospital EDs in four geographically diverse regions of Korea: Seoul, Suwon, Chuncheon and Gwangju.

Information was collected on 1989 patients aged 18 and above. A representative probability sample was drawn from patients admitted to each ED for the first time within 6 h of injury.

Alcohol-related non-fatal injuries.

Among 467 persons with alcohol-related injuries, 33 (7.1%), were self-inflicted intentional injuries and 137 (29.3%) were intentional injuries caused by someone else. The adjusted odds of self-inflicted intentional injury verses unintentional injury were calculated for heavy (OR 1.764; 95% CI 0.783 to 3.976), binge (OR 2.125; 95% CI 0.930 to 4.858) and moderate drinking (OR 3.039; 95% CI 1.129 to 8.178) after controlling for demographic variables. Similar odds were reported for pooled intentional injury data (self-inflicted and caused by someone else) and drinking patterns.

These data show a strong association between all patterns of acute alcohol consumption and self-inflicted intentional injury in the Republic of Korea.

Cross-sectional, coordinated studies of Japanese young men included from university areas. The men had to be 18–24 years, and both the man and his mother had to be born in Japan. Background information was obtained from questionnaires. Standardised and quality-controlled semen analyses were performed, reproductive hormones analysed centrally and results adjusted for confounding factors.

Four study centres in Japan (Kawasaki, Osaka, Kanazawa and Nagasaki).

1559 men, median age 21.1 years, included during 1999–2003.

Semen volume, sperm concentration, total sperm count, sperm motility, sperm morphology and reproductive hormone levels.

Median sperm concentration was 59 (95% CI 52 to 68) million/ml, and 9% and 31.9% had less than 15 and 40 million/ml, respectively. Median percentage of morphologically normal spermatozoa was 9.6 (8.8 to 10.3)%. Small, but statistically significant, differences were detected for both semen and reproductive hormone variables between men from the four cities. Overall, the semen values were lower than those of a reference population of 792 fertile Japanese men.

Assuming that the investigated men were representative for young Japanese men, a significant proportion of the population had suboptimal semen quality with reduced fertility potential, and as a group they had lower semen quality than fertile men. However, the definitive role—if any—of low semen quality for subfertility and low fertility rates remain to be investigated.

A cohort study.

A prefectural stroke registry.

We analysed 13 788 stroke patients identified from January 1999 to December 2009 inclusive in the entire Kyoto prefecture and registered in the Kyoto Stroke Registry (KSR).

We investigated the relationship between consciousness levels, based on JCS at stroke onset and activities of daily living (ADL) at 30 days or deaths within 30 days in a large population-based stroke registry. We calculated Spearman's coefficient for the correlation between JCS and the ADL scale, generated estimated survival curves by the Kaplan-Meier method and finally compared HRs for death within 30 days after onset, comparing patients with different conscious levels based on JCS.

A total of 13 406 (97.2%) patients were graded based on JCS. JCS correlated to the ADL scale with Spearman's correlation coefficient of 0.61. HRs for death within 30 days were 1 (reference) (95% CIs), 5.55 (4.19 to 7.37), 9.54 (7.16 to 12.71) and 35.21 (26.10 to 44.83) in those scored as JCS0, JCS1, JCS2 and JCS3, respectively.

Using a single test of eye response, JCS has outstanding merits as a coma scale, that is, simplicity and applicability. The present study adds predictability for early outcome in stroke patients. JCS is valuable, especially in an emergency setting, when a prompt assessment of consciousness levels is needed.

A randomised controlled trial with an intervention group and a usual care group.

Heart failure clinic in a large tertiary referral hospital in Brisbane, Australia.

Eligible participants were those with known systolic heart failure who were over 50  years of age and lived in Southeast Queensland. Participants were excluded if they lived in a residential aged care facility, had incontinence or were unable to give informed consent. Fifty-five participants were randomised and 50 completed.

Participants randomised to the intervention received two thermal hats and tops and a digital thermometer.

The primary outcome was the mean number of days in hospital. Secondary outcomes were the number of general practitioner (GP) visits and self-rated health.

The mean number of days in hospital per 100 winter days was 2.5 in the intervention group and 1.8 in the usual care group, with a mean difference of 0.7 (95% CI –1.5 to 5.4). The intervention group had 0.2 fewer GP visits on average (95% CI –0.8 to 0.3), and a higher self-rated health, mean improvement –0.3 (95% CI –0.9 to 0.3). The thermal tops were generally well used, but even in cold temperatures the hats were only worn by 30% of the participants.

Thermal clothes are a cheap and simple intervention, but further work needs to be done on increasing compliance and confirming the health and economic benefits of providing thermals to at-risk groups.

The study was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612000378820)

Diagnostic accuracy study. We compared information from patient history by a retrospective review of notes and used a central database of child immunisation records as the reference standard.

Paediatric emergency department in a tertiary hospital in Oxford, UK.

Consecutive children aged 6 months to 6 years presenting over a 2-month period.

Proportion of children with documented immunisation history; sensitivity and specificity of detecting overdue immunisations by history compared to central records.

1166 notes were surveyed. 76.3% children were asked about immunisations. The proportion of children who were fully immunised on central records was 93.1%. History had a sensitivity of 41.3% (95% CI 27% to 56.8%) and a specificity of 98.7% (95% CI 97.5% to 99.4%) for detecting those who were overdue. Negative predictive value was 95.8% (95% CI 93.9% to 97.2%). Only around a third of children with overdue immunisations are detected by the current screening methods, and approximately 1 in 20 children stated as being up to date are in fact overdue.

History had poor sensitivity for identifying overdue immunisation. Strategies to improve detection of children overdue with immunisation should focus on alternative strategies for alerting clinicians, such as linkage of community and hospital electronic records.

A scoping study of the scientific literature from January 1980 to March 2013 will be undertaken to summarise and disseminate research findings about the influence of the institutional dimension on CR. Numerous databases (n=18) from three relevant fields (healthcare, health law and politics and management) will be searched. Extended search strategies will include the manual search of bibliographies, health-related websites, public registries and journals of interest. Data will be collected and analysed using a thematic chart and content analysis. A systematic multidisciplinary team approach will allow optimal identification of relevant studies, as well as effective and valid content analysis and dissemination of the results.

This scoping study will provide a rigorous, accurate and up-to-date synthesis of existing knowledge regarding: (1) those aspects of the institutional dimension of health professionals’ societal and practice contexts that impact their CR and (2) how these aspects influence health professionals’ CR. Through the synergy of a multidisciplinary research team from a wide range of expertise, clinical pertinence and an exhaustive dissemination of results to knowledge-users will be ensured.

To develop a comprehensive portrait of all rural emergency departments in Quebec, data will be gathered from databases at the Quebec Ministry of Health and Social Services, the Quebec Trauma Registry and from emergency departments and ambulance services managers. Statistics Canada data will be used to describe populations and rural regions. To evaluate the use of the 2006 Emergency Department Management Guide and the implementation of its various recommendations, an online survey and a phone interview will be administered to emergency department managers. Two online surveys will evaluate quality of work life among physicians and nurses working at rural emergency departments. Quality-of-care indicators will be collected from databases and patient medical files. Data will be analysed using statistical (descriptive and inferential) procedures.

This protocol has been approved by the CSSS Alphonse–Desjardins research ethics committee (Project MP-HDL-1213-011). The results will be published in peer-reviewed scientific journals and presented at one or more scientific conferences.

Cohort study using population-based medical databases.

Outcomes registered from all hospitals in Denmark from 1977 onwards.

6502 men born in 1955 and eligible for conscription in Northern Denmark.

Follow-up began at participants’ 22nd birthday and continued until death, emigration or 55 years of age, whichever came first. Using regression analyses, we calculated the risks and HRs, adjusting for cognitive test score and years of education.

48% of all obese young men (BMI ≥30 kg/m²) were either diagnosed with type 2 diabetes, hypertension, myocardial infarction, stroke or venous thromboembolism or died before reaching 55 years of age. Comparing obese men with normal weight men (BMI 18.5 to <25.0 kg/m²), the risk difference for any outcome was 28% (95% CI 19% to 38%) and the HR was 3.0 (95% CI 2.3 to 4.0). Compared with normal weight, obesity was associated with an event rate that was increased more than eightfold for type 2 diabetes, fourfold for venous thromboembolism and twofold for hypertension, myocardial infarction and death.

In this cohort of young men, obesity was strongly associated with adverse cardiometabolic events before 55 years of age, including venous thromboembolism. Compared with those of normal weight, young obese men had an absolute risk increase for type 2 diabetes, cardiovascular morbidity or premature death of almost 30%.

A dynamic cohort study.

General practices (N=42) participating in the Dutch Sentinel General Practice Network at Nivel with a nationally representative patient population by age, gender, regional distribution and population density.

HIV-related consultations from 1988 to 2009 were recorded using a questionnaire in which patient's characteristics, interventions and test results were recorded. Trends over time and effects of urbanisation (3 categories) were assessed by multilevel analysis to control for clustering of observations within general practices.

Time trend analyses show an increasing trend in HIV-related consultations and in the total number of HIV tests per 10 000 registered patients from 1988 to 1996, followed by a declining period and an increase again in the period 2007–2009. Over the whole period, the number of HIV-related consultations was highest in the urban areas with a maximum of 18 per 10 000 patients in 1996. The proportion of people high at risk, men who have sex with men, decreased. The proportion of HIV-related consultations initiated by the GPs increased from 11% in 1988 to 23% in 2009.

In this 22-year period, HIV-related consultations and provider-initiated HIV testing in the Dutch general practice have increased. More attention for sexual health in general practice is required that focuses on high-risk groups and on more routine testing in high prevalence areas.

Cross-sectional internet-based study.

Multinational.

Pregnant women and women with children less than 25 weeks.

The need for information about medicines was assessed by a question: ‘Did you need information about medicines during the course of your pregnancy?’ A list of commonly used sources of information was given to explore those that are used.

Altogether, 7092 eligible women responded to the survey (5090 pregnant women and 2002 women with a child less than 25 weeks). Of the respondents, 57% (n=4054, range between different countries 46–77%) indicated a need for information about medicines during their pregnancy. On average, respondents used three different information sources. The most commonly used information sources were healthcare professionals—physicians (73%), pharmacy personnel (46%) and midwifes or nurses (33%)—and the internet (60%). There were distinct differences in the information needs and information sources used in different countries.

A large proportion of pregnant women have perceived information needs about medicines during pregnancy, and they rely on healthcare professionals. The internet is also a widely used information source. Further studies are needed to evaluate the use of the internet as a medicines information source by pregnant women.

A retrospective study.

Tertiary referral centre.

52 eyes (46 patients) with RP.

Cataract surgery was undertaken between October 2002 and May 2010.

Visual acuity, secondary cataract, capsular contraction syndrome (CCS), intraocular pressure, cystoid macular edema (CME), intraocular lens dislocation and endophthalmitis.

The mean age at surgery was about 53 years and the overall mean follow-up was 26 months (range 3–60 months). The mean preoperative logarithm of the minimal angle of resolution of the best corrected visual acuity (LogMAR BCVA) in the entire group was 1.45±0.85 (95% CI 1.21 to 1.69) and had increased to 1.32±0.95 (95% CI 1.06 to 1.58, p=0.02). The mean preoperative and the mean postoperative LogMAR BCVA in the non-CTR group (group 1) improved from 1.16±0.8 (95% CI 0.83 to 1.48) to 0.98±0.88 (95% CI 0.62 to 1.33, p=0.02) and in the CTR group (group 2) from 1.74±0.81 (95% CI 1.42 to 2.07) to 1.66±0.90 (95% CI 1.3 to 2.03, p=0.31), respectively. Secondary cataract was observed in a total of 23 eyes (44%), of which 13 (50%) were belonged to group 1 and 10 (38%) to group 2. CCS was seen in a total of two eyes (4%) all under group 1. CME was noted in two eyes (4%), of which one belonged to group 1 and a second one to group 2. Endophthalmitis was not observed in any group.

Both surgical approaches were beneficial to the RP patients. Eyes under group 2 showed less long-term postoperative complications. This includes secondary cataract and CCS. Eyes under group 1 performed significantly better in respect of visual acuity. Further research would include insights into the genetic subsets.

A follow-up study between 1981 and 2002 based on the total population.

Sweden.

Swedes aged 25–64 years (n=1 748 069).

Suicide from the Swedish cause of death register.

An increased risk of mortality from suicide was found among persons who had experienced the death of a sibling. In women, the suicide risk was 1.55 times that of non-bereaved persons (95% CI 0.99 to 2.44), and in men it was 1.28 times higher (95% CI 0.93 to 1.77). If one sibling committed suicide, the risk of the remaining sibling also committing suicide was 3.19 (95% CI 1.23 to 8.25) among women and 2.44 (95% CI 1.34 to 4.45) among men. Associations with other main causes of death—such as external other than suicide, cardiovascular diseases or cancer—were generally much smaller and statistically not significant in either sex. We found no clear support for a specific time pattern according to time since a sibling's death.

Our study provided evidence for suicide risk associated with the death of a sibling at adult age, revealing that bereaved persons’ risk of suicide is higher when siblings die from suicide, even when adjusting for intrafamily correlation in death risks.

We conducted systematic searches in bibliographical databases to identify relevant studies, and conducted a meta-analysis of studies meeting inclusion criteria.

Mental healthcare.

Patients with depressive disorders.

CBT and pharmacotherapy for depression.

Relapse rates at long-term follow-up.

9 studies with 506 patients were included. The quality was relatively high. Short-term outcomes of CBT and pharmacotherapy were comparable, although drop out from treatment was significantly lower in CBT. Acute phase CBT was compared with pharmacotherapy discontinuation during follow-up in eight studies. Patients who received acute phase CBT were significantly less likely to relapse than patients who were withdrawn from pharmacotherapy (OR=2.61, 95% CI 1.58 to 4.31, p<0.001; numbers-needed-to-be-treated, NNT=5). The acute phase CBT was compared with continued pharmacotherapy at follow-up in five studies. There was no significant difference between acute phase CBT and continued pharmacotherapy, although there was a trend (p<0.1) indicating that patients who received acute phase CBT may be less likely to relapse following acute treatment termination than patients who were continued on pharmacotherapy (OR=1.62, 95% CI 0.97 to 2.72; NNT=10).

We found that CBT has an enduring effect following termination of the acute treatment. We found no significant difference in relapse after the acute phase CBT versus continuation of pharmacotherapy after remission. Given the small number of studies, this finding should be interpreted with caution pending replication.

Twenty patients with type 2 diabetes and ESRD will be compared with 20 matched patients with type 2 diabetes and normal kidney function in a randomised, parallel, placebo-controlled (1 : 1), double-blinded setting. All participants will receive 12 weeks of daily treatment with liraglutide/placebo in an individually titrated dose of 0.6, 1.2 or 1.8 mg. Over nine visits, plasma liraglutide, glycaemic control, β-cell response, cardiovascular parameters, various biomarkers and adverse events will be assessed. The primary endpoint will be evaluated from dose-corrected plasma trough liraglutide concentration at the final trial visit to determine potential accumulation in the ESRD group.

The study has been approved by the Danish Medicines Agency, the Scientific-Ethical Committee of the Capital Region of Denmark and the Danish Data Protection Agency. An external monitoring committee (The Good Clinical Practice Unit at Copenhagen University Hospitals) will oversee the study. The results of the study will be presented at national and international scientific meetings, and publications will be submitted to peer-reviewed journals.

ClinicalTrials.gov Identifier: NCT01394341

Retrospective cohort study.

Level III neonatal intensive care unit (NICU) and outpatient NICU follow-up clinic of an academic medical centre in New York City.

929 HUS of 502 infants with gestational age of 23–36 weeks in African-American infants were initially studied. Exclusion criteria included those who died, had gross abnormalities in HUS, infants with race other than African-American, infants with suboptimal quality of HUS, late preterm infants and infants who did not participate in ND follow-up. A total of 173 infants completed the study.

CC size (length and thickness) was measured in a subset of 87 infants who had routine HUS between 23 and 29 weeks (0–6 postnatal weeks). Relevant clinical variables were collected from chart reviews. ND assessments were completed in outpatient follow-up clinics. A statistical model was developed to assess the clinical utility and possible predictive value of CC measurements for adverse short-term ND outcome, while adjusting for perinatal morbidities.

CC size and ND status.

Measurements of CC size did not add substantial predictive power to predict short-term ND outcome beyond the information provided by the presence of morbidities related to prematurity.

No association was found between morbidities related to prematurity and short-term ND outcome and CC size in preterm infants. CC measurements in HUS early in life did not have an additional value in predicting short-term ND outcome, therefore did not seem to provide further clinical utility.

Observational cross-sectional study.

The study was conducted in one maternity hospital, one general hospital maternity department and one provincial hospital maternity department. Researchers observed vaginal deliveries and recorded observations to later check against data recorded in patient medical records and facility registers.

We determined the sensitivity, specificity, area under the receiver operator characteristics curves (AUROCs), proportions correctly classified and the tendency to make performance seem better than it actually was.

600 observations across the three shifts and three hospitals showed high compliance with active management of the third stage of labour, measuring blood loss and uterine contraction at 30 min, cord care, drying and wrapping newborns and Apgar scores and low compliance with monitoring vital signs. Compliance with quality indicators was high and specificity was lower than sensitivity. For adverse outcomes in birth registries, specificity was higher than sensitivity. Overall AUROCs were between 0.5 and 0.6. Of 17 variables that showed biased errors, 12 made performance or outcomes seem better than they were, and five made them look worse (71% vs 29%, p=0.143). Compliance, sensitivity and specificity varied less among the three shifts than among hospitals.

Medical record accuracy was generally poor. Errors by clinicians did not appear to follow a pattern of self-enhancement of performance. Because successful improvement activities, surveillance and research in these settings are heavily reliant on collecting accurate data on processes and outcomes of care, substantial improvement is needed in medical record accuracy.

Cross-sectional survey.

Online survey.

Parental report of the number of hours per weekday that they and, separately, their 6-year-old to 8-year-old child spent watching TV, using a games console, a smart-phone and multiscreen viewing. Parental screen-viewing, parental attitudes and pieces of media equipment were exposures.

Over 75% of the parents and 62% of the children spent more than 2 h/weekday watching TV. Over two-thirds of the parents and almost 40% of the children spent more than an hour per day multiscreen viewing. The mean number of pieces of media equipment in the home was 5.9 items, with 1.3 items in the child's bedroom. Children who had parents who spent more than 2 h/day watching TV were over 7.8 times more likely to exceed the 2 h threshold. Girls and boys who had a parent who spent an hour or more multiscreen viewing were 34 times more likely to also spend more than an hour per day multiscreen viewing. Media equipment in the child's bedroom was associated with higher TV viewing, computer time and multiscreen viewing. Each increment in the parental agreement that watching TV was relaxing for their child was associated with a 49% increase in the likelihood that the child spent more than 2 h/day watching TV.

Children who have parents who engage in high levels of screen-viewing are more likely to engage in high levels of screen-viewing. Access to media equipment, particularly in the child's bedroom, was associated with higher levels of screen-viewing. Family-based strategies to reduce screen-viewing and limit media equipment access may be important ways to reduce child screen-viewing.

The intervention group of 428 mothers lived in metropolitan Adelaide and the comparison group of 239 mothers lived in regional towns where the programme was not yet available. All participating mothers met health service eligibility criteria for enrolment in the home-visiting programme. Participants in both groups were assessed at baseline (mean child age=14.4 weeks SD=2.3), prior to programme enrolment, and again when the children were aged 9, 18 and 24 months.

State-wide community child health service.

667 socially disadvantaged mothers enrolled consecutively. 487 mothers (73%) completed the 24-month assessment.

Two-year postnatal home-visiting programme based on the Family Partnership Model.

Parent Stress Index (PSI), Kessler Psychological Distress Scale and the Ages and Stages Questionnaire.

Mixed models adjusting for baseline differences were used to compare outcomes in the two groups. The mothers in the home-visiting group reported greater improvement on the PSI subscales assessing a mother's perceptions on the quality of their relationship with their child (1.10, 95% CI 0.06 to 2.14) and satisfaction with their role as parents (0.46, 95% CI –0.15 to 1.07) than mothers in the comparison group. With the exception of childhood sleeping problems, there were no other significant differences in the outcomes across the two groups.

The findings suggest that home-visiting programmes delivered by community health nurses as part of routine clinical practice have the potential to improve maternal–child relationships and help mothers adjust to their role as parents.

Australian and New Zealand Clinical Trials Registry ACTRN12608000275369.

The study involved three phases: (1) A retrospective analysis of deidentified occupational health records from our tertiary care urban US hospital to clearly identify NSI risk and rates to an HCW during invasive catheter placement; (2) 95 residents were surveyed regarding their knowledge and experience with NSIs and SEDs; (3) A random sample of six residents participated in a focus group session discussing barriers to the use of SED.

A single urban US tertiary care teaching hospital.

A retrospective analysis of NSI to HCWs in a tertiary care urban US hospital was conducted over a 4-year period (July 2007–June 2011). Ninety-five residents from specialties that often place CVC during training (surgery, surgical subspecialties, internal medicine, anaesthesia and emergency medicine) were surveyed regarding their experience with NSIs and SEDs. A random sample of six residents participated in a focus group session discussing barriers to the use of SED.

314 NSIs were identified via occupational health records. 16% (21 of 131) of NSIs occurring in residents and fellows occurred during the securement of an invasive catheter such as a CVC. If an SED device had been used, the 5.25 NSIs/year could have been avoided. Each NSI occurring in an HCW incurred at least $2723 in charges. Thus, utilisation of the SED could have saved a minimum of $57 183 over the 4-year period.

SEDs are currently available and can be used as an alternative to sharps. If safety and efficacy can be demonstrated, then implementation of such devices can significantly reduce the number of NSIs.

Propensity score-matched cohort study from the database of the Tampere ACS registry.

A single academic hospital in Finland.

1149 patients with a recent ACS, but no serious coexisting conditions: recurrent ischaemic episodes despite adequate medical therapy, haemodynamic instability, overt congestive heart failure and serious ventricular arrhythmias.

The composite endpoint of major acute cardiovascular events (MACEs): unstable angina requiring rehospitalisation, stroke, myocardial infarction and all-cause mortality, at 6-month follow-up.

Compared with standard medical treatment, revascularisation was associated with a lower rate of MACEs at 6 months in patients of the first quintile (HR 0.81; 95% CI 0.66 to 0.99), but a higher rate of MACEs in the fifth quintile (HR 4.74, CI 1.36 to 16.49; p=0.014). There were no significant differences in the rates of MACEs in the remaining three quintiles. Patients of the first quintile were the oldest (79.7±8.3 years) and had a more significant (p<0.001) history of prior myocardial infarction (37%) and poor renal function (creatine, µmol/l: 114.9±70.7). They also showed the highest C reactive protein (7.3±9.5 mg/l) levels.

Our findings suggest that in-hospital coronary revascularisation did not lead to any advantage with signal of possible harm in the great majority of patients who stabilised after an ACS. An early invasive management strategy may be best reserved for elderly patients having high-risk clinical features and biochemical evidence of a strong inflammatory activity.

Post hoc cluster analysis of patients from two randomised clinical trials of salmeterol/fluticasone propionate (SFC) and salmeterol (SAL) that had primary endpoints of moderate/severe exacerbation rates.

Centres in North America.

1543 COPD patients were studied.

SFC 50/250 µg or SAL 50 µg, twice daily.

The analysis identified clusters of COPD patients more responsive to SFC versus SAL with respect to the annual rate of moderate/severe exacerbations and compared their baseline clinical characteristics.

Overall, SFC significantly reduced the annual rate of moderate/severe exacerbations as compared with SAL alone (rate ratio (RR)=0.701, p<0.001). Three-patient clusters were identified: COPD patients receiving diuretics (RR=0.56, p<0.001); patients not receiving diuretics but with forced expiratory volume in 1 s (FEV₁) reversibility ≥12% (RR=0.67, p<0.001) exhibited a substantial reduction in the annual rate of moderate/severe exacerbations relative to SAL. A third cluster, consisting of patients not receiving diuretics and without FEV₁ reversibility, demonstrated no difference for SFC versus SAL. Patients receiving diuretics had a significantly higher prevalence of comorbid cardiovascular disease.

COPD patients receiving diuretics and those not receiving diuretics but with FEV₁ reversibility >12% at baseline were significantly more likely to experience a reduction in COPD-associated exacerbations with SFC versus SAL alone.

NCT00115492, NCT00144911

Population-based cohort study.

Denmark.

All singleton births in Denmark between 1 January 1995 and 31 December 2006 were identified. These newborns were then linked to mothers, fathers, grandparents and siblings using individually assigned civil personal registration numbers.

We identified that data on childhood injuries were obtained from the Danish National Patient Registry, which contains data on all hospital stays and outpatient visits. Incidence rate ratios (IRRs) were estimated from birth using log-linear Poisson regression models, and person-years were used as the offset variable. Age, residence, calendar period, maternal education, maternal income and parental-cohabitation status are treated as time-dependent variables (records were extracted from the offspring's birth year).

Exposure to maternal bereavement due to a father's death had the strongest association with childhood injuries, especially when the cause of death was due to a traumatic event (adjusted estimates of IRR (aIRR): 1.25, 95%CI: 0.99 to 1.58). We did not find an association for childhood injuries and maternal bereavement due to grandparent's death, and we only found an association for sibling death when restricting to deaths due to traumatic events (aIRR: 1.20, 95%CI:1.03 to 1.39).

The aetiology of childhood injuries is complex and may be related to events that take place during prenatal life. This study suggests that exposure to a stressful life event during gestation may be linked to injury susceptibility in childhood. However, changes in postnatal family conditions related to loss or genetic factors may also play a role.

Developmental plasticity related to early life exposures leading to disease programming in offspring is a theory with substantial theoretical and empirical support. Prenatal stress exposure has been linked to neurological outcomes, such as temperament, behavioural problems, cognitive function and affective disorders. If exposure modifies risk-seeking behaviour, perceived danger and reaction time, it is also expected to modify injury risk.

Retrospective cohort study.

The emergency department of a large tertiary university hospital in Brussels, with over 20 000 yearly visits for children below age 16.

All medical records (from 2008 to 2010) of children between ages 2 and 16, who were diagnosed with pharyngitis, tonsillitis or sore throat and having a throat swab culture for GABHS. Children with underlying chronic respiratory, cardiac, haematological or immunological diseases and children who had already received antibiotics (AB) prior to the PED consult were excluded. Only records with a full disease history were selected. Out of a total 2118 visits for sore throats, 441 met our criteria. The children were divided into two age groups, 2–5 and 5–16 years.

The prevalence of GABHS was higher in the older children compared to the preschoolers (38.7 vs 27.6; p=0.01), and the overall prevalence was 32%. There was no significant difference in the prevalence of GABHS for all different Centor scores within an age group. Likelihood ratios (LR) demonstrate that none of the individual symptoms or a Centor score of ≥3 seems to be effective in ruling in or ruling out GABHS. Pooled LR (CI) for Centor ≥3 was 0.67 (CI 0.50 to 0.90) for the preschoolers and 1.37 (CI 1.04 to 1.79) for the older children.

Our results confirm the ineffectiveness of Centor criteria as a predicting factor for finding GABHS in a throat swab culture in children.

A qualitative focus group study with purposive sampling and thematic analysis, in which overdiagnosis information was presented.

Community and university settings in London.

40 women within the breast screening age range (50–71 years) including attenders and non-attenders were recruited using a recruitment agency as well as convenience sampling methods.

Women expressed surprise at the possible extent of overdiagnosis and recognised the information as important, although many struggled to interpret the numerical data. Overdiagnosis was viewed as less-personally relevant than the possibility of ‘under diagnosis’ (false negatives), and often considered to be an issue for follow-up care decisions rather than screening participation. Women also expressed concern that information on overdiagnosis could deter others from attending screening, although they rarely saw it as a deterrent. After discussing overdiagnosis, few women felt that they would make different decisions about breast screening in the future.

Women regard it as important to be informed about overdiagnosis to get a complete picture of the risks and benefits of mammography, but the results of this study indicate that understanding overdiagnosis may not always influence women's attitudes towards participation in breast screening. The results also highlight the challenge of communicating the individual significance of information derived from population-level modelling.

Population-based cohort study between 2005 and 2009, mean follow-up 3.9 years.

Hospital outpatient clinics and primary care in Sweden.

Men and women with type 2 diabetes, free from CVD, including atrial fibrillation and congestive heart failure, at baseline, registered in the Swedish National Diabetes Register, with continuous low-dose aspirin treatment (n=4608) or no aspirin treatment (n=14 038).

Risks of CVD, coronary heart disease (CHD), stroke, mortality and bleedings, associated with aspirin compared with no aspirin, were analysed in all patients and in subgroups by gender and estimated cardiovascular risk. Propensity scores were used to adjust for several baseline risk factors and characteristics at Cox regression, and the effect of unknown covariates was evaluated in a sensitivity analysis.

There was no association between aspirin use and beneficial effects on risks of CVD or death. Rather, there was an increased risk of non-fatal/fatal CHD associated with aspirin; HR 1.19 (95% CI 1.01 to 1.41), p=0.04. The increased risk of cardiovascular outcomes associated with aspirin was seen when analysing women separately; HR 1.41 (95% CI 1.07 to 1.87), p=0.02, and HR 1.28 (95% CI 1.01 to 1.61), p=0.04, for CHD and CVD, respectively, but not for men separately. There was a trend towards increased risk of a composite of bleedings associated with aspirin, n=157; HR 1.41 (95% CI 0.99 to 1.99).

The results support the trend towards more restrictive use of aspirin in patients with type 2 diabetes and no previous CVD. More research is needed to explore the differences in aspirin's effects in women and men.

Prospective (non-interventional) cohort study, using an online questionnaire.

The Bonn marathon 2010.

3913 of 7048 participants in the Bonn marathon 2010 returned their questionnaires.

Intensity of analgesic consumption before sports; incidence of AEs in the cohort of analgesic users as compared to non-users.

There was no significant difference between the premature race withdrawal rate in the analgesics cohort and the cohort who did not take analgesics (‘controls’). However, race withdrawal because of gastrointestinal AEs was significantly more frequent in the analgesics cohort than in the control. Conversely, withdrawal because of muscle cramps was rare, but it was significantly more frequent in controls. The analgesics cohort had an almost 5 times higher incidence of AEs (overall risk difference of 13%). This incidence increased significantly with increasing analgesic dose. Nine respondents reported temporary hospital admittance: three for temporary kidney failure (post-ibuprofen ingestion), four with bleeds (post-aspirin ingestion) and two cardiac infarctions (post-aspirin ingestion). None of the control reported hospital admittance.

The use of analgesics before participating in endurance sports may cause many potentially serious, unwanted AEs that increase with increasing analgesic dose. Analgesic use before endurance sports appears to pose an unrecognised medical problem as yet. If verifiable in other endurance sports, it requires the attention of physicians and regulatory authorities.

A prospective, open-label study of Dysport (500 U; Ipsen Biopharm Ltd) administered according to a defined intramuscular injection algorithm.

German and Austrian outpatient clinics.

516 male and female patients (aged ≥18 years) with de novo CD. The majority of patients had torticollis (78.1%). 35 patients had concomitant depression (MedDRA-defined).

Change from baseline to weeks 4 and 12 in Craniocervical Dystonia Questionnaire (CDQ-24) total and subscale scores, patient diary items (‘day-to-day capacities and activities’, ‘pain’ and ‘duration of pain’) and global assessment of pain.

Significant improvements were observed in CDQ-24 total and subscale scores at week 4 and were sustained up to week 12 (p<0.001). Changes in CDQ-24 scores did not significantly differ between the torticollis and laterocollis groups or between patients with or without depression. There were also significant reductions in patient diary item scores for activities of daily living, pain and pain duration at weeks 4 and 12 (p<0.001). Pain relief (less or no pain) was reported by 66% and 74.1% of patients at weeks 4 and 12, respectively. Changes in pain parameters demonstrated a positive relationship with change in Tsui score.

After standardised open-label treatment with Dysport 500 U, improvements in QoL and pain intensity up to 12 weeks in patients with CD were observed.

Cost-effectiveness modelling using the information from a randomised controlled trial.

Two hypothetical modelled cohorts of 1000 individuals undergoing total laparoscopic hysterectomy and total abdominal hysterectomy.

Surgery costs; hospital bed days used; total healthcare costs; quality-adjusted life years; and net monetary benefits.

For 1000 individuals receiving total laparoscopic hysterectomy surgery, the costs were $509 575 higher, 3548 hospital fewer bed days were used and total health services costs were reduced by $3 746 221. There were 39.13 more quality-adjusted life years for a 5 year period following surgery.

The adoption of total laparoscopic hysterectomy is almost certainly a good decision for health services policy makers. There is 100% probability that it will be cost saving to health services, a 86.8% probability that it will increase health benefits and a 99.5% chance that it returns net monetary benefits greater than zero.

Systematic review and meta-analysis.

Searches of PubMed and EMBASE and reference lists of the retrieved articles.

Randomised double-blind controlled trials comparing the administration of antibiotics before skin incision with administration after cord clamping.

Data on maternal total infectious morbidity, endometritis and wound infection, as well as neonatal intensive care unit admission, neonatal infection and neonatal sepsis were extracted and combined using random effects meta-analysis.

Five studies reporting on 1777 parturients were included in our systematic review. The relative risk (RR) for maternal total infectious morbidity for antibiotic administration before incision compared with antibiotic administration after cord clamping was 0.64 (95% CI 0.36 to 1.15). Likewise, there was no difference in the risk of wound infection (RR 0.72, 95% CI 0.41 to 1.27). Parturients receiving the antibiotic preoperatively had a significantly reduced risk of endometritis (RR 0.48, 95% CI 0.27 to 0.87; number needed to treat 41, 95% CI 23 to 165). Analyses of the neonatal outcome parameters revealed no differences between the regimens of antibiotic administration, but were based on few studies.

In contrast to a recent NICE guideline, we did not find a reduction in total infectious morbidity with antibiotic administration before skin incision; we confirmed a reduction in the risk of endometritis and a lack of effect on the risk for wound infection.

Observational cohort study.

Using data from the Veterans Affairs (VA) Surgical Quality Improvement Programme, a quality assurance programme for major surgical procedures in the VA healthcare system, we assessed the association of current smoking at the time of the surgery with 6-month and 1-year mortality.

Using mediation analyses, we calculated the relative contribution of each smoking-associated complication to smoking-associated postoperative mortality, both unadjusted and adjusted for age, race/ethnicity, work relative value unit of the operation, surgeon specialty, American Society of Anesthesiologists class and year of surgery. Smoking-associated complications included surgical site infection (SSI), cardiovascular complications (myocardial infarction, cardiac arrest and/or stroke) and pulmonary complications (pneumonia, failure to wean and/or reintubation).

There were 186 632 never smokers and 135 741 current smokers. The association of smoking and mortality was mediated by smoking-related complications with varying effects. In unadjusted analyses, the proportions of mediation of smoking to 6-month mortality explained by the complications were as follows: SSIs 22%, cardiovascular complications 12% and pulmonary complications 89%. In adjusted analyses, the per cents mediated by each complication were as follows: SSIs 2%, cardiovascular complications 4% and pulmonary complications 22%. In adjusted analyses for 1-year mortality, respective per cents mediated were 2%, 3% and 16%.

Pulmonary complications, followed by cardiovascular complications and SSIs were mediators of smoking-associated 6-month and 1-year mortality. Interventions targeting smoking cessation and prevention and early treatment of pulmonary complications has the likelihood of reducing postoperative mortality after elective surgery.

Population register-based cohort study with a 20-year follow-up.

Sweden.

The entire population of Sweden (n=10.6 million) of whom 17 101 persons were diagnosed with bipolar disorder between 1987 and 2006.

Mortality rate ratios (MRR), excess mortality (excess deaths), cardiovascular disorder (CVD) and specifically cerebrovascular disease, coronary heart disease, acute myocardial infarction, sudden cardiac deaths and hospital admission rate ratio (ARR).

Persons with bipolar disorder died of CVD approximately 10 years earlier than the general population. One third (38%) of all deaths in persons with bipolar disorder were caused by CVD and almost half (44%) by other somatic diseases, whereas suicide and other external causes accounted for less than a fifth of all deaths (18%). Excess mortality of both CVD (n=824) and other somatic diseases (n=988) was higher than that of suicide and other external causes (n=675 deaths). MRRs for cerebrovascular disease, coronary heart disease and acute myocardial infarction were twice as high in persons with bipolar disorder compared to the general population. Despite the increased mortality of CVD, hospital admissions (ARR) for CVD treatment were only slightly increased in persons with bipolar disorder when compared to the general population.

The increased cardiovascular mortality in persons with bipolar disorder calls for renewed efforts to prevent and treat somatic diseases in this group. Specifically, our findings further imply that it would be critical to ensure that persons with bipolar disorder receive the same quality care for CVD as persons without bipolar disorder.

Diagnostic accuracy study of WVT, through acoustic analysis of whispers of experienced and inexperienced practitioners (experiment 1) and behavioural validation of these recordings (experiment 2).

Research institute with a pool of patients sourced from local clinics in the Greater Glasgow area.

22 people had their whispers recorded and analysed in experiment 1; 4 older experienced (OE), 4 older inexperienced (OI) and 14 younger inexperienced (YI). In experiment 2, 73 people (112 individual ears) took part in a digit recognition task using 2 OE and 2 YI whisperers from experiment 1.

Average level (dB sound pressure level) across frequency, average level across all utterances (dB A) and within/across-digit deviation (dB A) for experiment 1. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of WVT for experiment 2.

In experiment 1, OE whisperers were 8–10 dB more intense than inexperienced whisperers across all whispered utterances. Variability was low and comparable regardless of age or experience. In experiment 2, at an optimum threshold of 40 dB HL, sensitivity and specificity were 63% (95% CI of 58% to 68%) and 93% (92% to 94%), respectively, for OE whisperers. PPV was 56% (51% to 61%), NPV was 95% (94% to 96%). For YI whisperers at an optimum threshold of 29 dB HL, sensitivity and specificity were 80% (78% to 82%) and 52% (50% to 55%), respectively. PPV was 65% (63% to 67%) and NPV was 70% (67% to 72%).

WVT is an effective screening test, providing the level of the whisperer is considered when setting the test's hearing-loss criterion. Possible implications are voice measurement while training for inexperienced whisperers.

A 30-month randomised, double-blind, placebo-controlled, parallel design, phase II proof-of-concept clinical study.

Cyprus Institute of Neurology and Genetics.

80 participants were randomised into four groups of 20 each. A total of 41 (51%) patients completed the 30-month trial. The eligibility criteria were an age of 18–65; a diagnosis of relapsing–remitting MS according to the McDonald criteria; a score of 0.0–5.5 on the Expanded Disability Status Scale (EDSS); MRI showing lesions consistent with MS; at least one documented clinical relapse and either receiving or not a disease-modifying treatment within the 24-month period before enrolment in the study. Patients were excluded because of a recent (<30 days) relapse, prior immunosuppressant or monoclonal antibody therapy, pregnancy or nursing, other severe disease compromising organ function, progressive MS, history of recent drug or alcohol abuse, use of any additional food supplements, vitamins or any form of polyunsaturated fatty acids, and a history of severe allergic or anaphylactic reactions or known specific nutritional hypersensitivity.

The first intervention (A) was composed of -3 and -6 polyunsaturated fatty acids at 1:1 wt/wt. Specifically, the -3 fatty acids were docosahexaenoic acid and eicosapentaenoic acid at 3:1 wt/wt, and the -6 fatty acids were linoleic acid and -linolenic acid at 2:1 wt/wt. This intervention also included minor quantities of other specific polyunsaturated, monounsaturated and saturated fatty acids as well as vitamin A and vitamin E (α-tocopherol). The second intervention (B, PLP10) was a combination of A and -tocopherol. The third intervention (C) was -tocopherol alone. The fourth group of 20 participants received placebo. The interventions were administered per os (by mouth) once daily, 30 min before dinner for 30 months.

The primary end point was the annualised relapse rate (ARR) of the three interventions versus the placebo at 2 years. The secondary end point was the time to confirmed disability progression at 2 years.

A total of 41 (51%) patients completed the 30-month trial. Overall, for the per-protocol analysis of the 2-year primary end point, eight relapses were recorded in the PLP10 group (n=10; 0.40 ARR) versus 25 relapses in the placebo group (n=12; 1.04 ARR), representing a 64% adjusted relative rate reduction for the PLP10 group (RRR 0.36, 95% CI 0.15 to 0.87, p=0.024). In a subgroup analysis that excluded patients on monoclonal antibody (natalizumab) treatment, the observed adjusted RRR became stronger (72%) over the 2 years (RRR 0.28, 95% CI 0.10 to 0.79, p=0.016). The per-protocol analysis for the secondary outcome at 2 years, the time to disability progression, was significantly longer only for PLP10. The cumulative probability of disability progression at 2 years was 10% in the PLP10 group and 58% in the placebo group (unadjusted log-rank p=0.019). In a subgroup analysis that excluded patients on natalizumab, the cumulative probability of progression was 10% for the 10 patients in the PLP10 group and 70% for the 12 patients in the placebo group, representing a relative 86% decrease in the risk of the sustained progression of disability in the PLP10 group (unadjusted log-rank p=0.006; adjusted HR, 0.11; 95% CI 0.01 to 0.97, p=0.047). No adverse events were reported. Interventions A (10 patients) and C (9 patients) showed no significant efficacy.

In this small proof-of-concept, randomised, double-blind clinical trial; the PLP10 treatment significantly reduced the ARR and the risk of sustained disability progression without any reported serious adverse events. Larger studies are needed to further assess the safety and efficacy of PLP10.

International Standard Randomised Controlled Trial, number ISRCTN87818535.

Cross-sectional study.

314 primary care practices in Scotland.

9677 people with a primary care record of schizophrenia or a related psychosis and 1 414 701 controls. Main outcome measures Primary care records of 32 common chronic physical-health conditions and combinations of one, two and three or more physical-health comorbidities adjusted for age, gender and deprivation status.

Compared with controls, people with schizophrenia were significantly more likely to have one physical-health comorbidity (OR 1.21, 95% CI 1.16 to 1.27), two physical-health comorbidities (OR 1.37, 95% CI 1.29 to 1.44) and three or more physical-health comorbidities (OR 1.19, 95% CI 1.12 to 1.27). Rates were highest for viral hepatitis (OR 3.98, 95% CI 2.81 to 5.64), constipation (OR 3.24, 95% CI 3.00 to 4.49) and Parkinson's disease (OR 3.07, 95% CI 2.42 to 3.88) but people with schizophrenia had lower recorded rates of cardiovascular disease, including atrial fibrillation (OR 0.62, 95% CI 0.51 to 0.73), hypertension (OR 0.71, 95% CI 0.67 to 0.76), coronary heart disease (OR 0.75, 95% CI 0.61 to 0.71) and peripheral vascular disease (OR 0.83, 95% CI 0.71 to 0.97).

People with schizophrenia have a wide range of comorbid and multiple physical-health conditions but are less likely than people without schizophrenia to have a primary care record of cardiovascular disease. This suggests a systematic under-recognition and undertreatment of cardiovascular disease in people with schizophrenia, which might contribute to substantial premature mortality observed within this patient group.

Cross-sectional study: multilevel analysis.

Wales, UK, adult population ~2.2 million.

58 282 respondents aged 18 years and over to four successive annual Welsh Health Surveys (2003/2004–2007), nested within 32 692 households, 1839 census lower super output areas and the 22 unitary authority areas in Wales.

Maximal daily alcohol consumption during the past week was categorised using the UK Department of Health definition of ‘none/never drinks’, ‘within guidelines’, ‘excess consumption but less than binge’ and ‘binge’. The data were analysed using continuation ratio ordinal multilevel models with multiple imputation for missing covariates.

Respondents in the most deprived neighbourhoods were more likely to binge drink than in the least deprived (adjusted estimates: 17.5% vs 10.6%; difference=6.9%, 95% CI 6.0 to 7.8), but were less likely to report excess consumption (17.6% vs 21.3%; difference=3.7%, 95% CI 2.6 to 4.8). The effect of deprivation varied significantly with age and gender, but not with SES. Younger men in deprived neighbourhoods were most likely to binge drink. Men aged 35–64 showed the steepest increase in binge drinking in deprived neighbourhoods, but men aged 18–24 showed a smaller increase with deprivation.

This large-scale population study is the first to show that neighbourhood deprivation acts differentially on the risk of binge drinking between men and women at different age groups. Understanding the socioeconomic patterns of harmful alcohol consumption is important for public health policy development.

A retrospective cohort study.

16 medical facilities in Japan providing information on laboratory tests performed in and claims received by their facilities between 1 April 2004 and 31 December 2010.

A database representing a cohort of 35 903 adult statin (atorvastatin, fluvastatin, pitavastatin, pravastatin, rosuvastatin and simvastatin) users was studied. Use of interacting drugs (fibrates, triazoles, macrolides, amiodarone and ciclosporin) by these patients was determined.

Statin-associated muscle toxicity (the ‘event’) was identified based on a diagnosis of muscle-related disorders (myopathy or rhabdomyolysis) and/or abnormal elevation of creatine kinase (CK) concentrations. Events were excluded if the patients had CK elevation-related conditions other than muscle toxicity. Incidence rates for muscle toxicity were determined per 1000 person-years, with 95% CI determined by Poisson regression.

A total of 18 036 patients accounted for 42 193 person-years of statin therapy, and 43 events were identified. The incidence of muscle toxicity in the patients treated with statins was 1.02 (95% CI 0.76 to 1.37)/1000 person-years. The estimates varied when outcome definitions were modified from 0.09/1000 person-years, which met both diagnosis and CK 10x greater than the upper limit of normal range (ULN) criteria, to 2.06/1000 person-years, which met diagnosis or CK 5x ULN criterion. The incidence of muscle toxicity was also influenced by the statin therapies selected, but no significant differences were observed. Among 2430 patients (13.5%) received interacting drugs with statins, only three muscle toxicity cases were observed (incidence: 1.69/1000 person-years).

This database study suggested that statin use is generally well tolerated and safe; however, the risk of muscle toxicity related to the use of interacting drugs requires further exploration.

Longitudinal study assessing baseline performance and improvements in service delivery, clinical care and selected outcomes against key performance indicators 2009–2010.

27 Aboriginal and Islander Community Controlled Health Services (AICCHSs) in Queensland, who are members of the Queensland Aboriginal and Islander Health Council (QAIHC).

22 AICCHS with medical clinics.

Implementation and use of an electronic clinical information system that integrates with electronic health records supported by the QAIHC quality improvement programme—the Close the Gap Collaborative.

Proportion of patients with current recording of key healthcare activities and the prevalence of risk factors and chronic disease.

Aggregated performance was high on a number of key risk factors and healthcare activities including assessment of tobacco use and management of hypertension but low for others. Performance between services showed greatest variation for care planning and health check activity.

Data collected by the QAIHC health information system highlight the risk factor workload facing the AICCHS in Queensland, demonstrating the need for ongoing support and workforce planning. Development of targets and weighting models is necessary to enable robust between-service comparisons of performance, which has implications for health reform initiatives in Australia. The limited information available suggests that although performance on key activities in the AICCHS sector has potential for improvement in some areas, it is nonetheless at a higher level than for mainstream providers.

The work demonstrates the role that the Community Controlled sector can play in closing the gap in Aboriginal and Torres Strait Islander health outcomes by leading the use of clinical data to record and assess the quality of services and health outcome.

Cross-sectional study.

A private university in Lebanon.

545 randomly selected students were approached. A stratified cluster sample of classes offered in the spring semester of the 2008/2009 academic year was selected. Students completed a self-administered paper and pencil survey during class time.

The main outcomes were compliance with and attitudes towards the ban. Other secondary outcomes were the perception of barriers to implementation of the ban and attitudes towards tobacco control in general.

535 students participated in the study. Smokers were generally compliant with the ban (72.7%) and for some (20%) it led to a decrease in their smoking. Students' attitude towards the ban and the enforcement of a non-smoking policy in public places across Lebanon varied according to their smoking status whereby non-smokers possessed a more favourable attitude and strongly supported such policies compared with smokers; overall, the largest proportions of students were satisfied to a large extent with the ban and considered it justified (58.6% and 57.2%, respectively). While much smaller percentages reported that the ban would help in reducing smoking to a large extent (16.7%) or it would help smokers quit (7.4%). Perceived barriers to implementation of the non-smoking policy in AUB included the lack of compliance with and strict enforcement of the policy as well as the small number and crowdedness of the smoking areas.

An education campaign, smoking cessation services and strict enforcement of the policy might be necessary to boost its effect in further reducing students' cigarette use.

A cross-sectional study. Data were analysed from the 45 and Up Study, the largest study of healthy ageing ever undertaken in the Southern Hemisphere.

New South Wales, Australia.

266 848 participants of the 45 and Up Study.

Participants’ use of -3, demographics (geographical location, marital status, education level, income and level of healthcare insurance) and health status (quality of life, history of smoking and alcohol consumption, health conditions) were measured.

Of the 266 848 participants, 32.6% reported having taken -3 in the 4 weeks prior to the survey. Use of -3 fatty acid supplements was higher among men, non-smokers, non-to-mild (alcoholic) drinkers, residing in a major city, having higher income and private health insurance. Osteoarthritis, osteoporosis, high cholesterol and anxiety and/or depression were positively associated with  -3 fatty acid supplement use, while cancer and high blood pressure were negatively associated with use of -3 fatty acid supplements.

This study, analysing data from the 45 and Up Study cohort, suggests that a considerable proportion of older Australians consume -3 fatty acid supplements. There is a need for primary healthcare practitioners to enquire with patients about this supplement use and for work to ensure provision of good-quality information for patients and providers with regard to -3 fatty acid products.

The study is a prospective follow-up of a birth cohort.

A total of 41 724 women and their children from The Danish National Birth Cohort were categorised according to maternal occupational exposure. Exposure information was obtained by combining job title in pregnancy and 18 months after pregnancy with a commonly used asthma Job Exposure Matrix.

Primary outcome was parent-reported asthma among their 7-year-old children in an internet-based questionnaire. Secondary outcome was asthma among the same children with or without atopic dermatitis and among boys and girls, respectively.

Prenatal exposure to low molecular weight (LMW) agents was borderline associated with asthma in children with OR 1.17 (0.95 to 1.44) for children with atopic dermatitis and 1.10 (0.98 to 1.22) for children without. Maternal postnatal exposure was associated with asthma (OR 1.15 (1.04 to 1.28). After mutual adjustment,postnatal exposure (OR 1.13 (0.99 to 1.29) and the combined effects of prenatal and postnatal exposure (OR 1.34 (1.19 to 1.51)) seem to increase the risk of asthma in children. No significant associations were observed for other prenatal or postnatal exposures. The gender of the child did not modify the aforementioned associations.

Maternal occupational exposures during pregnancy do not seem to be a substantial risk factor for the development of asthma in 7-year-old children. Maternal prenatal and postnatal exposures to LMW agents may predispose the propensity of the children to develop asthma. Future studies should prioritise the characterisation of the timing of exposure in relation to the birth.

Prospective cohort study.

A UK secondary care maternity unit (March 2011–January 2012).

Mothers and infants within 72 h of delivery were eligible. Unwell individuals, mothers less than 18 years of age, and infants born at less than 36 weeks gestation, or weighing less than 2500 g, were excluded. HIV-infected mothers were included. 112 mother–infant pairs were recruited. Samples from 111 mothers and 109 infants (108 pairs) were available for analysis.

Specific antibody levels were determined using standard commercial ELISAs. Specific antibody to pertussis antigens (PT and FHA) of >50 IU/ml, defined as ‘positive’ by the test manufacturer, were interpreted as protective. Antitetanus antibody titres >0.1 IU/ml and anti-Hib antibody titres >1 mg/l were regarded as protective.

Only 17% (19/111) of women exhibited a protective antibody response against pertussis. 50% (56/111) of women had levels of antibody protective against Hib and 79% (88/111) against tetanus. There was a strong positive correlation between maternal-specific and infant-specific antibodies’ responses against pertussis (r_s=0.71, p<0.001), Hib (r_s=0.80, p<0.001), tetanus (r_s=0.90, p<0.001) and pneumococcal capsular polysaccharide (r_s=0.85, p<0.001). Only 30% (33/109) and 42% (46/109) of infants showed a protective antibody response to pertussis and Hib, respectively. Placental transfer (infant:mother ratio) of specific IgG to pertussis, Hib, pneumococcus and tetanus was significantly reduced from HIV-infected mothers to their HIV-exposed, uninfected infants (n=12 pairs) compared with HIV-uninfected mothers with HIV-unexposed infants (n=96 pairs) by 58% (<0.001), 61% (<0.001), 28% (p=0.034) and 32% (p=0.035), respectively.

Low baseline antibody levels against pertussis in this cohort suggest the recently implemented UK maternal pertussis immunisation programme has potential to be effective.

Questionnaire study with prospective follow-up.

Urgent gynaecology clinic in secondary care, England.

57 women participated in the study. Entry criteria: referral to the urgent gynaecology clinic with pain and/or bleeding in early pregnancy; gestation less than 16 weeks (the clinic's own ‘cut-off’); no previous attendance at the clinic during the current pregnancy. Exclusion criteria: inability to understand English or to provide informed consent.

Incidence of primary care follow-up among women referred to the urgent gynaecology clinic; incidence of women with measured mental health scores suggesting significant symptoms of distress.

Fewer than 1 in 10 women referred for ultrasound assessment of pain and/or bleeding in early pregnancy had follow-up arrangements made with their general practitioner (GP). Most women who had GP follow-up found it helpful and a significant minority of women who did not have GP follow-up felt that it would have been helpful. Following ultrasound assessment, more than one-third of women had significant symptoms of distress. Symptoms of distress, particularly anxiety, were present among those women found to have viable pregnancies, as well as among those with non-viable pregnancies.

GPs are advised to consider offering follow-up to all women referred for ultrasound assessment of pain and/or bleeding in early pregnancy. Researchers in this area are advised to consider the experiences of women with pain and/or bleeding in early pregnancy whose pregnancies are ultimately found to be viable on ultrasound scan.

A complex intervention development study.

North East Scotland and Glasgow.

Semistructured interviews with people with colorectal cancer (n=28), cancer specialists (n=16) and primary care health professionals (n=14) and pilot testing with patients (n=12).

A single, 1 h nurse home visit 6–12 weeks after diagnosis, and telephone follow-up 1 week later (with a view to ongoing follow-up in future).

Qualitative assessment of intervention feasibility and acceptability.

Modifiable predictors of QoL identified previously were symptoms (fatigue, pain, diarrhoea, shortness of breath, insomnia, anorexia/cachexia, poor psychological well-being, sexual problems) and impaired activities. To modify these symptoms and activities, an intervention based on Control Theory was developed to help participants identify personally important symptoms and activities; set appropriate goals; use action planning to progress towards goals; self-monitor progress and identify (and tackle) barriers limiting progress. Interview responses were generally favourable and included recommendations about timing and style of delivery that were incorporated into the intervention. The pilot study demonstrated the feasibility of intervention delivery.

Through multidisciplinary collaboration, a theory-based, acceptable and feasible intervention to improve QoL in colorectal cancer patients was developed, and can now be evaluated.

Recruiting centres to all three trials (Selective Elective Neck Dissection (SEND), Positron Emission Tomography (PET)-Neck and Hyperbaric Oxygen in the Prevention of Osteoradionecrosis (HOPON)) were contacted by email by the chief investigators. Responders were asked to complete a web-based survey in order to identify the barriers to recruitment in their centre and grade each by severity.

Secondary care: 44 head and neck oncology regional referral centres.

Analysis was based on 85 responses evenly distributed between the three trials.

The most commonly identified perceived barriers to recruitment (more than 50% of responders identified the item as a barrier in all the three trials) in the order of frequency were: patients consent refusal because of expressed treatment preference, patients consent refusal owing to aversion to randomisation, excess complexity/amount of information provided to patients and lack of time in clinic to accommodate research. The most severely rated of these problems was consent refusal because of the expressed treatment preference and lack of time in the clinic.

Our findings confirm others’ work in surgery that the most significant barrier to trial recruitment in head and neck cancer surgery is the patient's preference for one arm of the trial. It may be that additional training for those taking consent may be helpful in this regard. It is also important to adequately resource busy surgical clinics to support clinical trial recruitment.

A retrospective data simulation study.

Participants 65 years and older included in six different studies.

Estimated renal function by CG based on uncompensated (‘old Jaffe’ method) creatinine (CG_old) or by MDRD4 based on standardised compensated P-creatinine traceable to isotope-dilution mass spectrometry, and the resulting doses.

790 participants (432 females), mean age (±SD) 77.6±5.7 years. Mean estimated creatinine clearance (eCrCl) by the CG_old equation was 44.2±14.8 ml/min, versus eGFR 59.6±20.7 ml/min/1.73 m² with MDRD4 (p<0.001), absolute median difference 13.5, 95% CI 12.9 to 14.2. MDRD4 gave a significantly higher mean dose (valaciclovir +21%, dabigatran +25% and gabapentin +37%) of all drugs (p<0.001). With MDRD4 58% of the women would be recommended a full dose of dabigatran compared with 18% if CG_old is used.

MDRD4 would result in higher recommended doses of the three studied drugs to elderly participants compared with CG, particularly in women, and thus increased the risk of dose and concentration-dependent adverse reactions. It is important to know which method of estimation of renal function the Summary of Products Characteristics was based on, and use only that one when prescribing renally excreted drugs with narrow safety window. Doses based on recently developed methods for estimation of renal function may be associated with considerable risk of overtreatment in the elderly.

A within-subjects experimental design was used.

Academic.

34 general practitioners (GPs) were assigned to two experimental conditions (time pressure vs no time pressure) consecutively, and presented with two scenarios involving virus respiratory tract infections.

Outcome measures included adherence to guidelines on history taking, clinical examination and advice giving.

Under time pressure, GPs asked significantly less questions concerning presenting symptoms, than the ones indicated by the guidelines, (p=0.019), conducted a less-thorough clinical examination (p=0.028), while they gave less advice on lifestyle (p=0.05).

As time pressure increases as a result of high workload, there is a need to examine how adherence to guidelines is affected to safeguard patient's safety.

A qualitative content analysis was conducted of responses to a single open-ended free-text question placed at the end of the cross-sectional population-based postal questionnaire.

Individuals were identified through three UK Cancer Registries and questionnaires were posted to their home addresses.

A random sample of individuals (n=4992) diagnosed with breast, colorectal, non-Hodgkins lymphoma or prostate cancer at 1, 2, 3 and 5 years earlier.

3300 participants completed the survey (68% response rate). Of these 1056 (32%) completed the free-text comments box, indicating a high level of commitment to provide written feedback on patient experience. Almost a fifth (19%) related experiences of excellent care during the treatment phase, with only 8% reporting negative experiences. This contrasted with experiences of care after primary cancer treatment where the majority were negative. Factors impacting negatively upon patient-reported outcomes included the emotional impact of cancer; poor experiences of treatment and care; comorbidities, treatment side effects, social difficulties and inadequate preparation for a wide range of sometimes long-lasting on-going physical and psychological problems. Mediating factors assisting recovery incorporated both professional-led factors, such as quality of preparation for anticipated problems and aftercare services, and participant-led factors, such as learning from other cancer survivors and self-learning through trial and error. The support of friends and family was also a factor in participants' outcomes.

This analysis of free-text comments complements quantitative analysis of PROMs measure's by illuminating relationships between factors that impact on quality of life (QoL) and indicate why cancer patients may experience significantly worse QoL than the general population. The data suggest more systematic preparation and aftercare for individuals to self-manage post-treatment problems might improve QoL outcomes among cancer survivors.

Cross-sectional postal survey of cancer survivors using a population-based sampling approach.

English National Health Service.

4992 breast, colorectal, prostate and non-Hodgkin's lymphoma (NHL) survivors 1–5 years from diagnosis.

Implementation issues, response rates, cancer-specific morbidities utilising items including the EQ5D, tumour-specific subscales of the Functional Assessment of Cancer Therapy and Social Difficulties Inventory.

3300 (66%) survivors returned completed questionnaires. The majority aged 85+ years did not respond and the response rates were lower for those from more deprived area. Response rates did not differ by gender, time since diagnosis or cancer type. The presence of one or more long-term conditions was associated with significantly lower QoL scores. Individuals from most deprived areas reported lower QoL scores and poorer outcomes on other measures, as did those self-reporting recurrent disease or uncertainty about disease status. QoL scores were comparable at all time points for all cancers except NHL. QoL scores were lower than those from the general population in Health Survey for England (2008) and General Practice Patient Survey (2012). 47% of patients reported fear of recurrence, while 20% reported moderate or severe difficulties with mobility or usual activities. Bowel and urinary problems were common among colorectal and prostate patients. Poor bowel and bladder control were significantly associated with lower QoL.

This method of assessing QoL of cancer survivors is feasible and acceptable to most survivors. Routine collection of national population-based PROMs will enable the identification of, and the support for, the specific needs of survivors while allowing for comparison of outcome by service provider.

Cross-sectional observation study.

Obu Study of Health Promotion for the Elderly (Obu, Aichi) and Tsukui Ordered Useful Care for Health (241 day-care centres) cohorts in Japan.

A total of 10 351 individuals aged 65 years or older (6791 with personal care and 3560 without personal care) participated in the study.

Physical performance tests included grip strength, the chair stand test, walking speed at a comfortable pace, and the timed up-and-go test. Personal care was defined as participants who had been certified in the national social long-term care insurance in Japan.

Individuals who received personal care showed a significantly poorer performance than those without personal care for all physical performance tests (p<0.001). Gait speed was the most useful of the physical performance tests to determine the demand for personal care (receiver operating characteristic curve statistics: men, 0.92; women, 0.94; sensitivity: men, 86; women, 90; specificity: men, 85; women, 85). After adjustment for age, sex, cognitive impairment and other physical tests, all physical performance tests were individually associated with the demand for personal care. A slow gait speed (<1 m/s) was more strongly correlated with the demand for personal care than other performance measures (gait speed OR: 5.9; 95% CI: 5.0 to 6.9).

Clinical tests of physical performance are associated with the demand for personal care in older people. Preventive strategies to maintain physical independence may be required in older adults who show a gait speed slower than 1 m/s. Further research is necessary to confirm these preliminary results.

In this protocol, we describe a study exploring differences in speed and accuracy when searching clinical information using the paper-based patient record or the Elektronische DateneRfassung (EDeR). Designed as a randomised vignette study, we hypothesise that the EDeR increases efficiency, that is, reduces time on reading the patient history and looking for relevant examination results, helps finding mistakes and missing information quicker and more reliably. In exploratory analyses, we aim at exploring factors associated with a higher performance.

The ethics committee of the Canton Lucerne, Switzerland, approved this study. We presume that the implementation of the EMR software EDeR will have a positive impact on the efficiency of the doctors, which will result in an increase of consultations per day. We believe that the results of our study will provide a valid basis to quantify the added value of an EMR system in an ophthalmological environment.

Prospective pilot study.

Medical ICU in an academic medical centre.

Postgraduate medical trainees.

A 5-day-simulated ICU patient was developed in the EHR including labs, hourly vitals, medication administration, ventilator settings, nursing and notes. Fourteen medical issues requiring recognition and subsequent changes in management were included. Issues were chosen based on their frequency of occurrence within the ICU and their ability to test different aspects of the EHR–user interface. ICU residents, blinded to the presence of medical errors within the case, were provided a sign-out and given 10 min to review the case in the EHR. They then presented the case with their management suggestions to an attending physician. Participants were graded on the number of issues identified. All participants were provided with immediate feedback upon completion of the simulation.

To determine the frequency of error recognition in an EHR simulation. To determine factors associated with improved performance in the simulation.

38 participants including 9 interns, 10 residents and 19 fellows were tested. The average error recognition rate was 41% (range 6–73%), which increased slightly with the level of training (35%, 41% and 50% for interns, residents, and fellows, respectively). Over-sedation was the least-recognised error (16%); poor glycemic control was most often recognised (68%). Only 32% of the participants recognised inappropriate antibiotic dosing. Performance correlated with the total number of screens used (p=0.03).

Despite development of comprehensive EHRs, there remain significant gaps in identifying dangerous medical management issues. This gap remains despite high levels of medical training, suggesting that EHR-specific training may be beneficial. Simulation provides a novel tool in order to both identify these gaps as well as foster EHR-specific training.

Children with congenital hemiplegia will be recruited to participate in this waitlist control, matched pairs, single-blind randomised trial. Children be matched at baseline and randomly allocated to receive 20 weeks of 30 min of daily Mitii training immediately, or waitlisted for 20 weeks before receiving the same Mitii training (potential total dose=70 h). Outcomes will be assessed at 20 weeks after the start of Mitii, and retention effects tested at 40 weeks. The primary outcomes will be the Assessment of Motor and Process Skills (AMPS), the Assisting Hand Assessment (AHA) and unimanual upper-limb capacity using the Jebsen-Taylor Test of Hand Function (JTTHF). Advanced brain imaging will assess use-dependant neuroplasticity. Measures of body structure and functions, activity, participation and quality of life will be used to assess Mitii efficacy across all domains of the International Classification of Functioning, Disability and Health framework.

This project has received Ethics Approval from the Medical Ethics Committee of The University of Queensland (2011000608) and the Royal Children's Hospital Brisbane (HREC/11/QRCH/35). Findings will be disseminated widely through conference presentations, seminars and peer-reviewed scientific journals.

ACTRN12611001174976

Prospective cohort study.

Single National Health Service (NHS) teaching hospital.

4709 individuals undergoing primary lower limb joint replacement over a 4-year period (January 2006–December 2010).

Overall patient satisfaction, clinical outcomes as measured by PROMs (Oxford Hip or Knee Score, SF-12), satisfaction with five specific aspects of surgical outcome, attitudes towards further surgery, length of hospital stay.

Overall patient satisfaction was predicted by: (1) meeting preoperative expectations (OR 2.62 (95% CI 2.24 to 3.07)), (2) satisfaction with pain relief (2.40 (2.00 to 2.87)), (3) satisfaction with the hospital experience (1.7 (1.45 to 1.91)), (4) 12 months (1.08 (1.05 to 1.10)) and (5) preoperative (0.95 (0.93 to 0.97)) Oxford scores. These five factors contributed to a model able to correctly predict 97% of the variation in overall patient satisfaction response. The factors having greatest effect were the degree to which patient expectations were met and satisfaction with pain relief; the Oxford scores carried little weight in the algorithm. Various factors previously reported to influence clinical outcomes such as age, gender, comorbidities and length of postoperative hospital stay did not help explain variation in overall patient satisfaction.

Three factors broadly determine the patient's overall satisfaction following lower limb joint arthroplasty; meeting preoperative expectations, achieving satisfactory pain relief, and a satisfactory hospital experience. Pain relief and expectations are managed by clinical teams; however, a fractured access to surgical services impacts on the patient's hospital experience which may reduce overall satisfaction. In the absence of complications, how we deliver healthcare may be of key importance along with the specifics of what we deliver, which has clear implications for units providing surgical services.

Qualitative study employing culturally appropriate methods within a clinical ethnographic framework.

One rural and two remote towns in Western Australia.

Thirty-two Aboriginal people with chronic low-back pain (CLBP; 21 men, 11 women). Participants included those who were highly, moderately and mildly disabled.

Most participants held biomedical beliefs about the cause of CLBP, attributing pain to structural/anatomical vulnerability of their spine. This belief was attributed to the advice from healthcare practitioners and the results of spinal radiological imaging. Negative causal beliefs and a pessimistic future outlook were more common among those who were more disabled. Conversely, those who were less disabled held more positive beliefs that did not originate from interactions with healthcare practitioners.

Findings are consistent with research in other populations and support that disabling CLBP may be at least partly iatrogenic. This raises concerns for all populations exposed to Western biomedical approaches to examination and management of low back pain. The challenge for healthcare practitioners dealing with people with low back pain from any culture is to communicate in a way that builds positive beliefs about low back pain and its future consequences, enhancing resilience to disability.

Secondary analysis of a systematic review.

Medline, the Cochrane Effective Practice and Organisation of Care (EPOC) database (from inception to July 2010) and references of included studies.

Randomised trials assessing 11 predefined QI strategies or financial incentives targeting health systems, healthcare professionals or patients to improve the management of adult outpatients with diabetes.

Risk of bias (low, unclear or high) was assessed for the 142 trials in the review across nine domains using the EPOC version of the Cochrane Risk of Bias Tool. We used Cochran-Armitage tests for trends to evaluate the improvement over time.

There was no significant improvement over time in any of the risk of bias domains. Attrition bias (loss to follow-up) was the most common source of bias, with 24 trials (17%) having high risk of bias due to incomplete outcome data. Overall, 69 trials (49%) had at least one domain with high risk of bias. Inadequate reporting frequently hampered the risk of bias assessment: allocation sequence was unclear in 82 trials (58%) and allocation concealment was unclear in 78 trials (55%). There were significant reductions neither in the proportions of studies at high risk of bias over time nor in the adequacy of reporting of risk of bias domains.

Nearly half of the included QI trials in this review were judged to have high risk of bias. Such trials have serious limitations that put the findings in question and therefore inhibit evidence-based QI. There is a need to limit the potential for bias when conducting QI trials and improve the quality of reporting of QI trials so that stakeholders have adequate evidence for implementation.

We performed a retrospective analysis of lung transplant candidates who had undergone equilibrium radionuclide angiography (ERNA), to determine baseline and exercise RVEF. Lung function, gas exchange and pulmonary haemodynamics were also assessed.

152 patients (mean age 47±11 years; 59% women) were included in the study. Primary endpoint was death on the waiting list for LTx. Main diagnoses were α-1 antitrypsin deficiency (n=35), chronic obstructive pulmonary disease (n=41), cystic fibrosis (n=10), interstitial lung disease (n=34) and pulmonary arterial hypertension (n=32). Twenty-five patients died (16, 4%). LTx was performed in 121 patients. The mean RVEF at rest was equal to mean RVEF during exercise (38±12%). In univariate analysis RVEF at rest, RVEF during exercise, heart rate and forced volume capacity (FVC) % of predicted were factors significantly associated with risk of death. In multivariate analysis RVEF during exercise and FVC% of predicted were independent predictors of death.

In lung transplant candidates, right ventricular function during exercise is a stronger predictor of outcome than right ventricular function at rest. RVEF during exercise assessed by ERNA could be incorporated into priority-based allocation algorithms for LTx.

Programme monitoring data and results from two rounds of cross-sectional integrated biological and behavioural assessment (IBBA) in 2006 (Round 1) and 2009 (Round 2) were used for current analysis.

Programme monitoring data and cross-sectional surveys from Andhra Pradesh, India.

Data from 1218 and 1203 participants in Rounds 1 and 2 of the IBBA, respectively, and field level programme monitoring data from the intervention districts.

(1) Assess the reach of intervention in the HR-MSM/TG population; (2) evaluate the association between intervention and the intermediate outcomes (such as condom use and STIs) and (3) assess the association between HIV/STIs and the intervention.

By July 2008, the intervention contacted 83% of the estimated HR-MSM/TG population monthly and 16% were attending the STI clinic monthly. HR-MSM/TG exposed to the intervention were significantly more likely to use condom consistently with a regular male partner (adjusted OR 4.62, 95% CI 1.40 to 15.22). Consistent condom use with all types of male partners increased significantly in survey Round 2 compared with Round 1. The proportion of HR-MSM/TG who tested positive for HIV-1 antibodies was similar in both rounds (15.5% in Round 1 vs 17.3% in Round 2, p=0.52).

The Avahan intervention achieved a good population coverage, and delivered high-intensity peer and STI clinical services in Andhra Pradesh in the highly mobile target population of HR-MSM/TG; this also resulted in positive behavioural outcomes including increased condom use. However, the high prevalence of HIV in this group is an important public health priority.

A mixed methods study involving clinical record audit, focus groups and nurse interviews as a companion study investigating the processes used in the TrueBlue randomised trial.

Australian general practices involved in the TrueBlue trial.

Five practice nurses and five general practitioners (GPs) who had experienced nurse-managed care planning following the TrueBlue model of collaborative care.

The practice nurse acted as case manager, providing screening and protocol-management of depression and diabetes, coronary heart disease or both.

Proportion of patients provided with stepped care when needed, identification and response to suicide risk and acceptability of the model to practice nurses and GPs.

Almost half the patients received stepped care when indicated. All patients who indicated suicidal ideations were identified and action taken. Practice nurses and GPs acknowledged the advantages of the TrueBlue care-plan template and protocol-driven care, and the importance of peer support for the nurse in their enhanced role.

Practice nurses were able to identify, assess and manage mental-health risk in patients with diabetes or heart disease.

Population-based register study.

Finland, nationwide individual-level data.

All persons in Finland with any record of diabetes in the national health and population registers from 1991 to 2007 (FinDM II database).

Three outcome indicators were measured: the incidence of first major amputation, the ratio of first minor/major amputations and the 2-year survival with preserved leg after the first minor amputation. SEP was measured using income fifths. The data were analysed using Poisson and Cox regression as well as age-standardised ratios.

The risk ratio of the first major amputation in the lowest SEP group was 2.16 (95% CI 1.95 to 2.38) times higher than the risk in the highest SEP group (p<0.001). The incidence of first major amputation decreased by more than 50% in all SEP groups from 1993 to 2007, but there was a stronger relative decrease in the highest compared with the lowest SEP group (p=0.0053). Likewise, a clear gradient was detected in the ratio of first minor/major amputations: the higher the SEP group, the higher the ratio. After the first minor amputation, the 2-year and 10-year amputation-free survival rates were 55.8% and 9.3% in the lowest and 78.9% and 32.3% in the highest SEP group, respectively.

According to all indicators used, lower SEP was associated with worse outcomes in the population with diabetes. Greater attention should be paid to prevention of diabetes complications, adherence to treatment guidelines and access to the established pathways for early expert assessment when diabetic complications arise, with a special attention to patients from lower SEP groups.

Longitudinal case study over 2–5 years.

Consecutive referrals of patients with mild dementia to dementia clinics in western Norway.

50 patients (27 men and 23 women; mean age at baseline of 74 (range 52–88)) with (¹²³I)FP-CIT SPECT images underwent cluster analysis: 20/50 patients allocated to a ‘DLB’ and 8 to a ‘non-DLB’ cluster were included.

Scores on standardised clinical rating scales for hallucinations, parkinsonism, fluctuations, rapid eye movement (REM) sleep behaviour disorder and visually rated (¹²³I)FP-CIT SPECT.

During the follow-up period, in the S+CF– group (n=7), frequency and severity of DLB symptoms tended to increase, particularly parkinsonism (7/7) and cognitive fluctuations (7/7), while severity of visual hallucinations and REM sleep behaviour disorder remained stable. The S–CF+ (n=3) fulfilled the operationalised criteria for probable DLB both at baseline and at the end of the follow-up.

The findings suggest that systematic visual analyses of (¹²³I)FP-CIT SPECT can detect people with DLB prior to the development of the full clinical syndrome. In addition, the study indicates that some patients fulfilling clinical criteria for probable DLB have a normal scan, and further studies are required to characterise these patients better.

Prospective multicentre cohort study.

Tertiary referral and community hospitals.

We prospectively evaluated 40 PAH patients undergoing right-heart catheterisation with contemporaneous digital acoustic cardiography (intensity and complexity) and two-dimensional transthoracic echocardiography. To normalise for differences in body habitus, acoustic variables were also expressed as a ratio (S2/S1). 130 participants (55 also had haemodynamic and/or echocardiographic assessment) without clinical or haemodynamic evidence of PAH or congestive heart failure acted as controls.

Patients with PAH had higher mean pulmonary artery pressure (mPA; 40±13 vs 16±4 mm Hg, p<0.0001) and pulmonary vascular resistance (9±6 vs 1±1 Wood Units, p<0.0001) compared with controls, but cardiac index and mean pulmonary capillary wedge pressure were similar. More PAH patients had evidence of right ventricular (RV) dilation (50% vs 19%) and RV systolic dysfunction (41% vs 9%) in the moderate–severe range (all p<0.05). Compared with controls, the acoustic profiles of PAH patients were characterised by increased S2 complexity, S2/S1 complexity and S2/S1 intensity (all p<0.05). In the PAH cohort, S2 complexity was inversely related to S1 complexity. mPA was the only independent multivariate predictor of S2 complexity. The severity of RV enlargement and systolic impairment had reciprocal effects on the complexity of S2 (increased) and S1 (decreased). Decreased S1 complexity was also related to evidence of a small left ventricular cavity.

Acoustic characteristics of both S1 and S2 are related to the severity of PAH and are associated with RV enlargement and systolic dysfunction. The reciprocal relationship between S2 and S1 complexity may also reflect the underlying ventricular interaction associated with PAH.

Qualitative interviews with parents or guardians.

Interviews occurred in the homes of London children recruited to a national multicentre clinical trial following primary and secondary care attendance with wheeze.

42 parents (20 of Bangladeshi origin, 10 white UK, 12 other ethnicities) of preschool children enrolled in a clinical trial.

Bangladeshi families were relatively reluctant to participate in the qualitative study, despite strong engagement with the parent study. Anxiety related to wheezing was a common primary motive for trial enrolment. Parents viewed the trial as a route to improved treatment. Verbal delivery of trial information appeared more effective than study literature, especially for Bangladeshi families, with low parental literacy and high levels of trust in medical professionals potential contributors to this effect. All ethnic groups expressed a low understanding and/or retention of essential study concepts such as randomisation and genetic testing.

Bangladeshi families are particularly motivated to participate in clinical trials despite variable comprehension of study concepts. This motivation is more strongly contingent on strong researcher-subject rapport than on the quality of study literature. Trial teams seeking to recruit from South Asian populations should emphasise face-to-face verbal explanation of trial concepts and procedures and consider modified trial literature.

We used a cross-sectional survey design with a community sample.

The San Francisco Bay Area in California.

400 community-dwelling adults from diverse racial/ethnic backgrounds (Whites, African Americans, Latinos and Asians/Pacific Islanders) aged 55 and older (mean=67 years); 61% were women.

We measured attitudes towards schooling, extracurricular activities and adult encouragement and discouragement during the childhood/teen years. Bivariate analysis tested racial/ethnic differences on the various measures. Multivariate regression models estimated the extent to which retrospective circumstances were independently associated with adult educational attainment and adult health.

Most of the childhood circumstances measures differed across racial/ethnic groups. In general, Whites reported more positive circumstances than non-Whites. Family financial circumstances, respondent's perception of schooling as a means to get ahead, high school extracurricular activities, summer travel and summer reading were each statistically significantly associated with adult SES. Family composition, age began work, high school extracurricular activities, attitudes towards schooling and adult discouragement were associated with adult health.

An exploratory randomised controlled trial.

Six general practices with prescribing pharmacists in Grampian (3) and East Anglia (3).

Patients on repeat prescribed pain medication (4815) were screened by general practitioners (GPs), and mailed invitations (1397). 196 were randomised and 180 (92%) completed. Exclusion criteria included: severe mental illness, terminally ill, cancer related pain, history of addiction.

Patients were randomised using a remote telephone service to: (1) pharmacist medication review with face-to-face pharmacist prescribing; (2) pharmacist medication review with feedback to GP and no planned patient contact or (3) treatment as usual (TAU). Blinding was not possible.

Outcomes were the SF-12v2, the Chronic Pain Grade (CPG), the Health Utilities Index 3 and the Hospital Anxiety and Depression Scale (HADS). Outcomes were collected at 0, 3 and 6 months.

In the prescribing arm (n=70) two patients were excluded/nine withdrew. In the review arm (n=63) one was excluded/three withdrew. In the TAU arm (n=63) four withdrew. Compared with baseline, patients had an improved CPG in the prescribing arm, 47.7% (21/44; p=0.003) and in the review arm, 38.6% (17/44; p=0.001), but not the TAU group, 31.3% (15/48; ns). The SF-12 Physical Component Score showed no effect in the prescribing or review arms but improvement in TAU (p=0.02). The SF-12 Mental Component Score showed no effect for the prescribing or review arms and deterioration in the TAU arm (p=0.002). HADS scores improved within the prescribing arm for depression (p=0.022) and anxiety (p=0.007), between groups (p=0.022 and p=0.045, respectively).

This is the first randomised controlled trial of pharmacist prescribing in the UK, and suggests that there may be a benefit for patients with chronic pain. A larger trial is required.

Trial registration: www.isrctn.org/ISRCTN06131530. Medical Research Council funding.

A retrospective cohort study.

Administrative databases of the USA Department of Veterans Affairs.

An incident cohort of 13 254 patients with newly diagnosed RA was identified.

Trends and choice of DMARDs and biological agents’ usage, and time intervals between RA diagnosis and treatment

Methotrexate use as first-line agent increased from 39.9% to 57.2% over the study period (p<0.001). Although biological dispensations increased over other DMARDs and biological agents, from 3.4% to 25% from 1999 to 2009, the percentage of RA patients diagnosed between 1999 and 2007 who had biologics dispensations remained steady at 23.3–26.7%. Compared with Caucasian, African Americans were less likely to receive biologics (HR 0.71, 95% CI 0.63 to 0.81). Patients aged 75 and older were less likely to receive biologics than those younger than 45 (HR 0.29, 95% CI 0.23 to 0.36). The time interval between RA diagnosis and treatment with DMARDs and biological agents decreased significantly over time (median: 51 days in 1999–2001 to 28 days in 2006–2007).

Methotrexate use increased as it became the preferred first-line agent, while other traditional agents declined. Dispensation of biologics increased significantly, but the proportion of RA patients eventually given biologics stabilised below 30%. A significant shorter time between RA diagnosis and DMARD or biological agent initiation in recent years suggests improvements in quality of care. There were disproportionately lower use of biologics in certain age and ethnic groups, and further studies will be needed to elucidate these observations.

Prospective observational study.

Tertiary cardiac center.

Male smokers with atypical chest pain were screened with a treadmill exercise test (TMT). A total of 31 such patients aged 49.8±10.5 years, in whom TMT was either negative or mildly positive were included. Heart rate variability (HRV) parameters of smokers were compared to those of 15 healthy non-smoking participants.

All patients underwent a 24 h Holter monitoring to assess ECG changes during smoking periods.

Heart rate increased acutely during smoking. Mean heart rate increased from 83.8±13.7 bpm 10 min before smoking, to 90.5±16.4 bpm during smoking, (p<0.0001) and returned to baseline after 30 min. Smoking was also associated with increased ectopic beats (mean of 5.3/h prior to smoking to 9.8/h during smoking to 11.3/h during the hour after smoking; p<0.001). Three patients (9.7%) had significant ST–T changes after smoking. HRV index significantly decreased in smokers (15.2±5.3) as compared to non-smoking controls participants (19.4±3.6; p=0.02), but the other spectral HRV parameters were comparable.

Heart rate and ectopic beats increase acutely following smoking. Ischaemic ST–T changes were also detected during smoking. Spectral parameters of HRV analysis of smokers remained in normal limits, but more importantly geometrical parameter—HRV index—showed significant abnormality.

Systematic searching of the published health literature will be conducted to identify the existing ICU discharge planning tools and supporting evidence. Literature (research and non-research) reporting on the tools used to facilitate decision making and/or communication at ICU discharge with patients of any age will be included. Outcomes will include adverse events and provider and patient/family-reported outcomes. Two investigators will independently review the abstracts (screen 1) to identify those meeting the inclusion criteria and then independently assess the full text articles (screen 2) to determine if they meet the inclusion criteria. Data collection will include information on citations and identified tools. A quality assessment will be performed on original research studies. A descriptive summary will be developed for each tool.