Objective The primary objective was to investigate temporal trends and between-practice variability of paediatric test use in primary care.Methods and analysis This was a descriptive study of population-based data fro...Objective The primary objective was to investigate temporal trends and between-practice variability of paediatric test use in primary care.Methods and analysis This was a descriptive study of population-based data from Clinical Practice Research Datalink Aurum primary care consultation records from 1 January 2007 to 31 December 2019.Children aged 0–15 who were registered to one of the eligible 1464 general practices and had a diagnostic test code in their clinical record were included.The primary outcome measures were(1)temporal changes in test rates measured by the average annual percent change,stratified by test type,gender,age group and deprivation level and(2)practice variability in test use,measured by the coefficient of variation.Results 14299598 diagnostic tests were requested over 27.8 million child-years of observation for 2542101 children.Overall test use increased by 3.6%/year(95%CI 3.4 to 3.8%)from 399/1000 child-years to 608/1000 child-years,driven by increases in blood tests(8.0%/year,95%CI 7.7 to 8.4),females aged 11–15(4.0%/year,95%CI 3.7 to 4.3),and children from the most socioeconomically deprived group(4.4%/year,95%CI 4.1 to 4.8).Tests subject to the greatest temporal increases were faecal calprotectin,fractional exhaled nitric oxide and vitamin D.Tests classified as high-use and high-practice variability were iron studies,coeliac testing,vitamin B12,folate,and vitamin D.Conclusions In this first nationwide study of paediatric test use in primary care,we observed significant temporal increases and practice variability in testing.This reflects inconsistency in practice and diagnosis rates and a scarcity of evidence-based guidance.Increased test use generates more clinical activity with significant resource implications but conversely may improve clinical outcomes.Future research should evaluate whether increased test use and variability are warranted by exploring test indications and test results and directly examine how increased test use impacts on quality of care.展开更多
BACKGROUND Antipsychotic medications such as risperidone,olanzapine and aripiprazole are used to treat psychological and behavioural symptoms among dementia patients.Current evidence indicate prescription rates for an...BACKGROUND Antipsychotic medications such as risperidone,olanzapine and aripiprazole are used to treat psychological and behavioural symptoms among dementia patients.Current evidence indicate prescription rates for antipsychotics vary and wider consensus to evaluate clinical epidemiological outcomes is limited.AIM To investigate the potential impact of atypical antipsychotics on the mortality of patients with dementia.METHODS A retrospective clinical cohort study was developed to review United Kingdom Clinical Record Interactive Search system based data between January 1,2013 to December 31,2017.A descriptive statistical method was used to analyse the data.Mini Mental State Examination(MMSE)scores were used to assess the severity and stage of disease progression.A cox proportional hazards model was developed to evaluate the relationship between survival following diagnosis and other variables.RESULTS A total of 1692 patients were identified using natural language processing of which,587 were prescribed olanzapine,quetiapine or risperidone(common group)whilst 893(control group)were not prescribed any antipsychotics.Patients prescribed olanzapine showed an increased risk of death[hazard ratio(HR)=1.32;95%confidence interval(CI):1.08-1.60;P<0.01],as did those with risperidone(HR=1.35;95%CI:1.18-1.54;P<0.001).Patients prescribed quetiapine showed no significant association(HR=1.09;95%CI:0.90-1.34;P=0.38).Factors associated with a lower risk of death were:High MMSE score at diagnosis(HR=0.72;95%CI:0.62-0.83;P<0.001),identifying as female(HR=0.73;95%CI:0.64-0.82;P<0.001),and being of a White-British ethnic group(HR=0.82;95%CI:0.72-0.94;P<0.01).CONCLUSION A significant mortality risk was identified among those prescribed olanzapine and risperidone which contradicts previous findings although the study designs used were different.Comprehensive research should be conducted to better assess clinical epidemiological outcomes associated with diagnosis and therapies to improve clinical management of these patients.展开更多
BACKGROUND Preterm birth(PTB)is one of the main causes of neonatal deaths globally,with approximately 15million infants are born preterm.Women from the Black,Asian,and Minority Ethnic(BAME)populations maybe at higher ...BACKGROUND Preterm birth(PTB)is one of the main causes of neonatal deaths globally,with approximately 15million infants are born preterm.Women from the Black,Asian,and Minority Ethnic(BAME)populations maybe at higher risk of PTB,therefore,the mental health impact on mothers experiencing a PTB is particularly important,within the BAME populations.AIM To determine the prevalence of mental health conditions among BAME women with PTB as well as the methods of mental health assessments used to characterise the mental health outcomes.METHODS A systematic methodology was developed and published as a protocol in PROSPERO(CRD420-20210863).Multiple databases were used to extract relevant data.I2 and Egger's tests were used to detect the heterogeneity and publication bias.A trim and fill method was used to demonstrate the influence of publication bias and the credibility of conclusions.RESULTS Thirty-nine studies met the eligibility criteria from a possible 3526.The prevalence rates of depression among PTB-BAME mothers were significantly higher than full-term mothers with a standardized mean difference of 1.5 and a 95%confidence interval(CI)29%-74%.The subgroup analysis indicated depressive symptoms to be time sensitive.Women within the very PTB category demonstrated a significantly higher prevalence of depression than those categorised as non-very PTB.The prevalence rates of anxiety and stress among PTB-BAME mothers were significantly higher than in full-term mothers(odds ratio of 88%and 60%with a CI of 42%-149%and 24%-106%,respectively).CONCLUSION BAME women with PTB suffer with mental health conditions.Many studies did not report on specific mental health outcomes for BAME populations.Therefore,the impact of PTB is not accurately represented in this population,and thus could negatively influence the quality of maternity services they receive.展开更多
Purpose'. To examine adolescent experiences and perspectives of the GoActive intervention (ISRCTN31583496) using mixed methods processevaluation to determine satisfaction with intervention components and interpret...Purpose'. To examine adolescent experiences and perspectives of the GoActive intervention (ISRCTN31583496) using mixed methods processevaluation to determine satisfaction with intervention components and interpret a*dolescents experiences of the intervention process in order toprovide insights for future intervention design.Methods'. Participants (n = 1542;13.2 土 0.4 years, mean 土 SD) provided questionnaire data at baseline (shyness, activity level) and post-intervention(intervention acceptability, satisfaction with components). Between-group differences (boys vs. girls and shy/inactive vs. others) weretested with linear regression models, accounting for school clustering. Data from 16 individual interviews (shy/inactive) and 11 focus groupswith 48 participants (mean = 4;range 2—7) were thematically coded. Qualitative and quantitative data were merged in an integrative mixedmethods convergence matrix, which denoted convergence and dissonance across datasets.Results'. Effect sizes for quantitative results were small and may not represent substantial between-group differences. Boys (vs. girls) preferredclass-based sessions (0 = 0.2, 95% confidence interval (CI): 0.1—0.3);qualitative data suggested that this was because boys preferred competition,which was supported quantitatively (0 = 0.2, 95%CI: 0.1-0.3). Shy/inactive students did not enjoy the competition (0 = -0.3, 95%CI:—0.5 to —0.1). Boys enjoyed trying new activities more (0 = 0.1, 95%CI: 0.1 -0.2);qualitative data indicated a desire to try new activities acrossall subgroups but identified barriers to choosing unfamiliar activities with self-imposed choice restriction leading to boredom. Qualitative datahighlighted critique of mentorship;adolescents liked the idea, but older mentors did not meet expectations.Conclusion. We interpreted adolescent perspectives of intervention components and implementation to provide insights into future complexinterventions aimed at increasing young people's physical activity in school-based settings. The intervention component mentorship was liked inprinciple, but implementation issues undesirably impacted satisfaction;competition was disliked by girls and shy/inactive students. The resultshighlight the importance of considering gender differences in preference of competition and extensive mentorship training.展开更多
The combination of urbanization and global warming leads to urban overheating and compounds the frequency and intensity of extreme heat events due to climate change.Yet,the risk of urban overheating can be mitigated b...The combination of urbanization and global warming leads to urban overheating and compounds the frequency and intensity of extreme heat events due to climate change.Yet,the risk of urban overheating can be mitigated by urban green-blue-grey infrastructure(GBGI),such as parks,wetlands,and engineered greening,which have the potential to effectively reduce summer air temperatures.Despite many reviews,the evidence bases on quantified GBGI cooling benefits remains partial and the practical recommendations for implementation are unclear.This systematic literature review synthesizes the evidence base for heat mitigation and related co-benefits,identifies knowledge gaps,and proposes recommendations for their implementation to maximize their benefits.After screening 27,486 papers,202 were reviewed,based on 51 GBGI types categorized under 10 main divisions.Certain GBGI(green walls,parks,street trees)have been well researched for their urban cooling capabilities.However,several other GBGI have received negligible(zoological garden,golf course,estuary)or minimal(private garden,allotment)attention.The most efficient air cooling was observed in botanical gardens(5.0±3.5℃),wetlands(4.9±3.2℃),green walls(4.1±4.2℃),street trees(3.8±3.1℃),and vegetated balconies(3.8±2.7℃).Under changing climate conditions(2070–2100)with consideration of RCP8.5,there is a shift in climate subtypes,either within the same climate zone(e.g.,Dfa to Dfb and Cfb to Cfa)or across other climate zones(e.g.,Dfb[continental warm-summer humid]to BSk[dry,cold semi-arid]and Cwa[temperate]to Am[tropical]).These shifts may result in lower efficiency for the current GBGI in the future.Given the importance of multiple services,it is crucial to balance their functionality,cooling performance,and other related co-benefits when planning for the future GBGI.This global GBGI heat mitigation inventory can assist policymakers and urban planners in prioritizing effective interventions to reduce the risk of urban overheating,filling research gaps,and promoting community resilience.展开更多
The current health system aims to cope with the epidemic of chronic pain.The narrative urgently needs to be reset to one that strives for excellence.This reflection illustrates what excellence may look like and also h...The current health system aims to cope with the epidemic of chronic pain.The narrative urgently needs to be reset to one that strives for excellence.This reflection illustrates what excellence may look like and also highlights where system biases are preventing positive change from occurring。展开更多
Ben Goklacre和Brian MacKenna认为改善患者医疗服务以造福公众的巨大潜力并不是被数据获取技术的复杂性所阻碍,而是被文化、合同、政治障碍所阻碍。在2016-2017年度.英格兰的国家健康体系(NHS)在药品上花费了174亿英镑,约占全部预算的...Ben Goklacre和Brian MacKenna认为改善患者医疗服务以造福公众的巨大潜力并不是被数据获取技术的复杂性所阻碍,而是被文化、合同、政治障碍所阻碍。在2016-2017年度.英格兰的国家健康体系(NHS)在药品上花费了174亿英镑,约占全部预算的14%。事实上,从2010-2011年度的130亿英镑起,药品支出已快速增长,主要原因是医院处方金额在6年里从42亿英镑增长到83亿英镑(见图)。展开更多
循证医学评述来源:Jeske DR,Zhang Z,Smith S.Construction,visualisation and application of neutral zone classifiers.Stat Methods Med Res 2019.doi:10.1177/0962280219863823.►在设计或者评价一个诊断试验时,对于不确定的诊断结...循证医学评述来源:Jeske DR,Zhang Z,Smith S.Construction,visualisation and application of neutral zone classifiers.Stat Methods Med Res 2019.doi:10.1177/0962280219863823.►在设计或者评价一个诊断试验时,对于不确定的诊断结果允许给出"中立"结论,或可有助于降低误诊率、减少总体所需的检查量。按照"先初步分类、再选择不同的进一步检查方案"的两阶段流程,或许有助于改进现有诊断试验的准确性和经济成本。但在实际应用时,必须参考预测模型的方法学指南以避免模型的过度拟合,并结合卫生经济学分析评估该方法对患者利益和成本效益的影响。展开更多
基金funded by a grant from the NIHR SPCR grant(Award 624).
文摘Objective The primary objective was to investigate temporal trends and between-practice variability of paediatric test use in primary care.Methods and analysis This was a descriptive study of population-based data from Clinical Practice Research Datalink Aurum primary care consultation records from 1 January 2007 to 31 December 2019.Children aged 0–15 who were registered to one of the eligible 1464 general practices and had a diagnostic test code in their clinical record were included.The primary outcome measures were(1)temporal changes in test rates measured by the average annual percent change,stratified by test type,gender,age group and deprivation level and(2)practice variability in test use,measured by the coefficient of variation.Results 14299598 diagnostic tests were requested over 27.8 million child-years of observation for 2542101 children.Overall test use increased by 3.6%/year(95%CI 3.4 to 3.8%)from 399/1000 child-years to 608/1000 child-years,driven by increases in blood tests(8.0%/year,95%CI 7.7 to 8.4),females aged 11–15(4.0%/year,95%CI 3.7 to 4.3),and children from the most socioeconomically deprived group(4.4%/year,95%CI 4.1 to 4.8).Tests subject to the greatest temporal increases were faecal calprotectin,fractional exhaled nitric oxide and vitamin D.Tests classified as high-use and high-practice variability were iron studies,coeliac testing,vitamin B12,folate,and vitamin D.Conclusions In this first nationwide study of paediatric test use in primary care,we observed significant temporal increases and practice variability in testing.This reflects inconsistency in practice and diagnosis rates and a scarcity of evidence-based guidance.Increased test use generates more clinical activity with significant resource implications but conversely may improve clinical outcomes.Future research should evaluate whether increased test use and variability are warranted by exploring test indications and test results and directly examine how increased test use impacts on quality of care.
文摘BACKGROUND Antipsychotic medications such as risperidone,olanzapine and aripiprazole are used to treat psychological and behavioural symptoms among dementia patients.Current evidence indicate prescription rates for antipsychotics vary and wider consensus to evaluate clinical epidemiological outcomes is limited.AIM To investigate the potential impact of atypical antipsychotics on the mortality of patients with dementia.METHODS A retrospective clinical cohort study was developed to review United Kingdom Clinical Record Interactive Search system based data between January 1,2013 to December 31,2017.A descriptive statistical method was used to analyse the data.Mini Mental State Examination(MMSE)scores were used to assess the severity and stage of disease progression.A cox proportional hazards model was developed to evaluate the relationship between survival following diagnosis and other variables.RESULTS A total of 1692 patients were identified using natural language processing of which,587 were prescribed olanzapine,quetiapine or risperidone(common group)whilst 893(control group)were not prescribed any antipsychotics.Patients prescribed olanzapine showed an increased risk of death[hazard ratio(HR)=1.32;95%confidence interval(CI):1.08-1.60;P<0.01],as did those with risperidone(HR=1.35;95%CI:1.18-1.54;P<0.001).Patients prescribed quetiapine showed no significant association(HR=1.09;95%CI:0.90-1.34;P=0.38).Factors associated with a lower risk of death were:High MMSE score at diagnosis(HR=0.72;95%CI:0.62-0.83;P<0.001),identifying as female(HR=0.73;95%CI:0.64-0.82;P<0.001),and being of a White-British ethnic group(HR=0.82;95%CI:0.72-0.94;P<0.01).CONCLUSION A significant mortality risk was identified among those prescribed olanzapine and risperidone which contradicts previous findings although the study designs used were different.Comprehensive research should be conducted to better assess clinical epidemiological outcomes associated with diagnosis and therapies to improve clinical management of these patients.
基金support from Southern Health NHS Foundation Trust,University College London and Liverpool Women’s hospital.part of the multifaceted ELEMI project that is sponsored by Southern Health NHS Foundation Trust and in collaboration with the University of Liverpool,Liverpool Women’s Hospital,University College London,University College London NHS Foundation Trust,University of Southampton,Robinson Institute-University of Adelaide,Ramaiah Memorial Hospital(India),University of Geneva and Manchester University NHS Foundation Trust。
文摘BACKGROUND Preterm birth(PTB)is one of the main causes of neonatal deaths globally,with approximately 15million infants are born preterm.Women from the Black,Asian,and Minority Ethnic(BAME)populations maybe at higher risk of PTB,therefore,the mental health impact on mothers experiencing a PTB is particularly important,within the BAME populations.AIM To determine the prevalence of mental health conditions among BAME women with PTB as well as the methods of mental health assessments used to characterise the mental health outcomes.METHODS A systematic methodology was developed and published as a protocol in PROSPERO(CRD420-20210863).Multiple databases were used to extract relevant data.I2 and Egger's tests were used to detect the heterogeneity and publication bias.A trim and fill method was used to demonstrate the influence of publication bias and the credibility of conclusions.RESULTS Thirty-nine studies met the eligibility criteria from a possible 3526.The prevalence rates of depression among PTB-BAME mothers were significantly higher than full-term mothers with a standardized mean difference of 1.5 and a 95%confidence interval(CI)29%-74%.The subgroup analysis indicated depressive symptoms to be time sensitive.Women within the very PTB category demonstrated a significantly higher prevalence of depression than those categorised as non-very PTB.The prevalence rates of anxiety and stress among PTB-BAME mothers were significantly higher than in full-term mothers(odds ratio of 88%and 60%with a CI of 42%-149%and 24%-106%,respectively).CONCLUSION BAME women with PTB suffer with mental health conditions.Many studies did not report on specific mental health outcomes for BAME populations.Therefore,the impact of PTB is not accurately represented in this population,and thus could negatively influence the quality of maternity services they receive.
基金funded by the National Institute for Health Research (NIHR) Public Health Research Programme (13/90/18)supported by the Medical Research Council (Unit Program number MC_UU_12015/7)and was undertaken under the auspices of the Centre for Diet and Activity Research (CEDAR),a UKCRC Public Health Research Centre of Excellence+2 种基金Funding from the British Heart Foundation, Cancer Research UK,Economic and Social Research Council, Medical Research Council,National Institute for Health Research,and Wellcome Trust,under the auspices of the UK Clinical Research Collaboration,is gratefully acknowledged(087636/Z/08/ZES/G007462/1MR/K023187/1)
文摘Purpose'. To examine adolescent experiences and perspectives of the GoActive intervention (ISRCTN31583496) using mixed methods processevaluation to determine satisfaction with intervention components and interpret a*dolescents experiences of the intervention process in order toprovide insights for future intervention design.Methods'. Participants (n = 1542;13.2 土 0.4 years, mean 土 SD) provided questionnaire data at baseline (shyness, activity level) and post-intervention(intervention acceptability, satisfaction with components). Between-group differences (boys vs. girls and shy/inactive vs. others) weretested with linear regression models, accounting for school clustering. Data from 16 individual interviews (shy/inactive) and 11 focus groupswith 48 participants (mean = 4;range 2—7) were thematically coded. Qualitative and quantitative data were merged in an integrative mixedmethods convergence matrix, which denoted convergence and dissonance across datasets.Results'. Effect sizes for quantitative results were small and may not represent substantial between-group differences. Boys (vs. girls) preferredclass-based sessions (0 = 0.2, 95% confidence interval (CI): 0.1—0.3);qualitative data suggested that this was because boys preferred competition,which was supported quantitatively (0 = 0.2, 95%CI: 0.1-0.3). Shy/inactive students did not enjoy the competition (0 = -0.3, 95%CI:—0.5 to —0.1). Boys enjoyed trying new activities more (0 = 0.1, 95%CI: 0.1 -0.2);qualitative data indicated a desire to try new activities acrossall subgroups but identified barriers to choosing unfamiliar activities with self-imposed choice restriction leading to boredom. Qualitative datahighlighted critique of mentorship;adolescents liked the idea, but older mentors did not meet expectations.Conclusion. We interpreted adolescent perspectives of intervention components and implementation to provide insights into future complexinterventions aimed at increasing young people's physical activity in school-based settings. The intervention component mentorship was liked inprinciple, but implementation issues undesirably impacted satisfaction;competition was disliked by girls and shy/inactive students. The resultshighlight the importance of considering gender differences in preference of competition and extensive mentorship training.
基金This work has been commissioned by the UKRI(EPSRC,NERC,AHRC)funded by RECLAIM Network Plus project(EP/W034034/1,EP/W033984)under its synthesis review seriesThe following authors acknowledge the funding received through their grants:P.K.and L.J.(NE/X002799/1,NE/X002772/1),L.J.(H2020 REGREEN,EU Grant agreement No.821016,2021YFE93100),G.M.L.(FAPESP 2019/08783-0),C.D.F.R.(EP/R017727),L.M.(ARC Grant No.IC220100012),H.G.(RGC Grant No.C5024-21G),M.F.A.and E.D.F.(FAPESP Grant No.2016/18438-0,2022/02365-5),S.J.C.(NSFC Grant No.52225005),R.Y.(NSFC Grant No.52278090),F.W.(NKP Grant No.2020YFC180700),J.E.(NE/X000443/1),and F.C.(NE/M010961/1,NE/V002171/1).The authors thank Andrea Sofia Majjul Fajardo for her contribution to the initial design of certain figures.We also thank the team members of GCARE and its Guildford Living Lab(GLL),as well as the participants in the RECLAIM Network Plus Horizon Scanning Workshop.
文摘The combination of urbanization and global warming leads to urban overheating and compounds the frequency and intensity of extreme heat events due to climate change.Yet,the risk of urban overheating can be mitigated by urban green-blue-grey infrastructure(GBGI),such as parks,wetlands,and engineered greening,which have the potential to effectively reduce summer air temperatures.Despite many reviews,the evidence bases on quantified GBGI cooling benefits remains partial and the practical recommendations for implementation are unclear.This systematic literature review synthesizes the evidence base for heat mitigation and related co-benefits,identifies knowledge gaps,and proposes recommendations for their implementation to maximize their benefits.After screening 27,486 papers,202 were reviewed,based on 51 GBGI types categorized under 10 main divisions.Certain GBGI(green walls,parks,street trees)have been well researched for their urban cooling capabilities.However,several other GBGI have received negligible(zoological garden,golf course,estuary)or minimal(private garden,allotment)attention.The most efficient air cooling was observed in botanical gardens(5.0±3.5℃),wetlands(4.9±3.2℃),green walls(4.1±4.2℃),street trees(3.8±3.1℃),and vegetated balconies(3.8±2.7℃).Under changing climate conditions(2070–2100)with consideration of RCP8.5,there is a shift in climate subtypes,either within the same climate zone(e.g.,Dfa to Dfb and Cfb to Cfa)or across other climate zones(e.g.,Dfb[continental warm-summer humid]to BSk[dry,cold semi-arid]and Cwa[temperate]to Am[tropical]).These shifts may result in lower efficiency for the current GBGI in the future.Given the importance of multiple services,it is crucial to balance their functionality,cooling performance,and other related co-benefits when planning for the future GBGI.This global GBGI heat mitigation inventory can assist policymakers and urban planners in prioritizing effective interventions to reduce the risk of urban overheating,filling research gaps,and promoting community resilience.
文摘The current health system aims to cope with the epidemic of chronic pain.The narrative urgently needs to be reset to one that strives for excellence.This reflection illustrates what excellence may look like and also highlights where system biases are preventing positive change from occurring。
基金support ongoing meetings was provided by ISPOR-The Professional Society for Health Economics and Outcomes ResearchThe funders had no role in considering the study design or in the collection,analysis,interpretation of data,or writing of the report.Funding for DH and the Delphi Panel exercise was provided by 9363980 Canada Ine+1 种基金the NIHR Applied Research Collaboration(ARC)West Midlandsthe NIHR Health Protection Research Unit(HPRU)Gastrointestinal Infections,and the NIHR HPRU Genomics and Enabling data.
文摘循证医学评述来源:Jeske DR,Zhang Z,Smith S.Construction,visualisation and application of neutral zone classifiers.Stat Methods Med Res 2019.doi:10.1177/0962280219863823.►在设计或者评价一个诊断试验时,对于不确定的诊断结果允许给出"中立"结论,或可有助于降低误诊率、减少总体所需的检查量。按照"先初步分类、再选择不同的进一步检查方案"的两阶段流程,或许有助于改进现有诊断试验的准确性和经济成本。但在实际应用时,必须参考预测模型的方法学指南以避免模型的过度拟合,并结合卫生经济学分析评估该方法对患者利益和成本效益的影响。
