by Clemens J. M. Hohl, Daryl Codron, Thomas M. Kaiser, Louise F. Martin, Dennis W. H. Müller, Jean-Michel Hatt, Marcus ClaussFeeding practice in herbivorous mammals can impact their dental wear, due to excessive or irregular abrasion. Previous studies indicated that browsing species display more wear when kept in zoos compared to natural habitats. Comparable analyses in tapirs do not exist, as their dental anatomy and chewing kinematics are assumed to prevent the use of macroscopic wear proxies such as mesowear. We aimed at describing tapir chewing, dental anatomy and wear, to develop a system allowing comparison of free-ranging and captive specimens even in the absence of known age. Video analyses suggest that in contrast to other perissodactyls, tapirs have an orthal (and no lateral) chewing movement. Analysing cheek teeth from 74 museum specimens, we quantified dental anatomy, determined the sequence of dental wear along the tooth row, and established several morphometric measures of wear. In doing so, we showcase that tapir maxillary teeth distinctively change their morphology during wear, developing a height differential between less worn buccal and more worn lingual cusps, and that quantitative wear corresponds to the eruption sequence. We demonstrate that mesowear scoring shows a stable signal during initial wear stages but results in a rather high mesowear score compared to other browsing herbivores. Zoo specimens had lesser or equal mesowear scores as specimens from the wild; additionally, for the same level of third molar wear, premolars and other molars of zoo specimens showed similar or less wear compared specimens from the wild. While this might be due to the traditional use of non-roughage diet items in zoo tapirs, these results indicate that in contrast to the situation in other browsers, excessive tooth wear appears to be no relevant concern in ex situ tapir management.
When adolescents experience complex psychiatric and social problems, numerous healthcare services usually become involved. In these cases, fragmentation of care services is a risk that often results in both ineffective care and in patients disengaging from care services. To address these issues, Youth Flexible Assertive Community Treatment (Youth Flexible ACT) was developed in the Netherlands. This client-centred service delivery model aims to tackle the fragmented care system by providing psychiatric treatment and support in a flexible and integrated manner. While Youth Flexible ACT is gaining in popularity, the effectiveness of the care model remains largely unexamined.
Here, we present an observational prospective cohort (2017–2021) in which a broad range of treatment outcomes will be monitored. The primary aim of the study is to examine change in treatment outcomes over the course of the Flexible ACT care. The secondary aim is to examine the association between (elements of) Youth Flexible ACT model fidelity and treatment outcomes. An estimated total number of 200 adolescents who receive care from one of the 16 participating Youth Flexible ACT teams will be included in the study. Participants will be asked to complete assessments at four time points in 6-month intervals, resulting in a study duration of 18 months. Latent growth curve analysis will be conducted to examine change in psychosocial functioning over time and its relation to model fidelity.
This study received ethical approval from Trimbos Ethics Committee (201607_75-FACT2). This approval applies for all participating institutions. The results of the study will be reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology statement. Results will be disseminated via peer-reviewed academic journals and presentations at conferences. In addition, results will be made available for participating sites, funders and researchers.
Speech recognition technology (SRT) recognises an individual's spoken word signals through a microphone and subsequently processes the user's words into digital text by means of a computer. SRT remains well established and continues to grow in popularity among the various health disciplines. Many studies have been done to examine the effects of SRT on nursing documentation, however, no previous systematic review (SR) on the effects of SRT on accuracy and efficiency of nursing documentation was identified.
To systematically review the impact of speech recognition technology on the accuracy and efficiency of clinical nursing documentation. A SR was conducted that measures the accuracy and efficiency (time to complete documentation) of SRT on nursing documentation. An extensive search of the literature included Web of Science, CINAHL via EBSCO host, Cochrane Library, Embase, MEDLINE and Google Scholar. The PRISMA checklist screened eligible papers. The quality of each paper was critically appraised, data extracted and analysed/synthesised.
A total of 10 studies were included. Various devices and systems have been used to examine the accuracy, efficiency and impact of SRT on nursing documentation. A positive impact of SRT with significant advances in accuracy/productivity of nursing documentation at the point of care was found. However, a substantial degree of initial costing, training requirements and studied interface modification to individual healthcare units are needful in incorporating SRT systems.
Speech recognition technology when applied to nursing documentation could open up a promising new interface for data entry from the point of care, though the full potential of the technology has not been explored.
The compatibility/effectiveness of SRT with existing computer systems remains understudied. SRT training, prompt on‐site technical support, maintenance and upgrades cannot be underestimated towards achieving high‐level accuracy and efficiency (time to complete documentation) with SRT.
Anaemia is common among people living with HIV (PLWH) and has been associated with certain, often older, antiretroviral medications. Information on current antiretroviral therapy (ART) and anaemia is limited. The objective was to compare the associations between anaemia incidence or haemoglobin change with core ART classes in the current ART era.
Retrospective cohort study.
USA-based prospective clinical cohort of PLWH aged 18 and above receiving care at eight sites between January 2010 and March 2018.
16 505 PLWH were included in this study.
Anaemia risk and haemoglobin change were estimated among PLWH for person-time on a protease inhibitor (PI) or an integrase strand transfer inhibitor (INSTI)-based regimen, relative to a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based reference. We also examined PLWH on regimens containing multiple core classes. Cox proportional hazards regression analyses were conducted to measure the associations between time-updated ART classes and incident anaemia or severe anaemia. Linear mixed effects models were used to examine the relationships between ART classes and haemoglobin change.
During a median of 4.9 years of follow-up, 1040 developed anaemia and 488 developed severe anaemia. Compared with NNRTI use, INSTI-based regimens were associated with an increased risk of anaemia (adjusted HR (aHR) 1.26, 95% CI 1.00 to 1.58) and severe anaemia (aHR 1.51, 95% CI 1.07 to 2.11) and a decrease in haemoglobin level. Time on multiple core classes was also associated with increased anaemia risk (aHR 1.39, 95% CI 1.13 to 1.70), while no associations were found for PI use.
These findings suggest INSTI use may increase the risk of anaemia. If confirmed, screening for anaemia development in users of INSTIs may be beneficial. Further research into the underlying mechanisms is warranted.
We aimed to develop a digital intervention to support antidepressant discontinuation in UK primary care that is scalable, accessible, safe and feasible. In this paper, we describe the development using a theory, evidence and person-based approach.
Intervention development using a theory, evidence and person-based approach.
Primary Care in the South of England.
Fifteen participants with a range of antidepressant experience took part in ‘think aloud’ interviews for intervention optimisation.
Our digital intervention prototype (called ‘ADvisor’) was developed on the basis of a planning phase consisting of qualitative and quantitative reviews, an in-depth qualitative study, the development of guiding principles and a theory-based behavioural analysis. Our optimisation phase consisted of ‘think aloud’ interviews where the intervention was iteratively refined.
The qualitative systematic review and in-depth qualitative study highlighted the centrality of fear of depression relapse as a key barrier to discontinuation. The quantitative systematic review showed that psychologically informed approaches such as cognitive–behavioural therapy were associated with greater rates of discontinuation than simple advice to reduce. Following a behavioural diagnosis based on the behaviour change wheel, social cognitive theory provided a theoretical basis for the intervention. The intervention was optimised on the basis of think aloud interviews, where participants suggested they like the flexibility of the system and found it reassuring. Changes were made to the tone of the material and the structure was adjusted based on this qualitative feedback.
‘ADvisor’ is a theory, evidence and person-based digital intervention designed to support antidepressant discontinuation. The intervention was perceived as helpful and reassuring in optimisation interviews. Trials are now needed to determine the feasibility, clinical and cost-effectiveness of this approach.
by Verena H. Menec, Nancy E. Newall, Corey S. Mackenzie, Shahin Shooshtari, Scott NowickiBackground
Although a large body of research has focused on social isolation and loneliness, few studies have examined social isolation and loneliness together. The objectives of this study were to examine: 1) the relationship between four groups derived from combining social isolation and loneliness (socially isolated and lonely; only socially isolated; only lonely; neither socially isolated nor lonely) and the desire for more social participation, and social support; and 2) the relationship between the four groups and psychological distress.Methods
The study was based on the Comprehensive Cohort of the Canadian Longitudinal Study on Aging. Using CLSA baseline data (unweighted N = 30,079), ordinary and logistic regression analysis was used to examine the cross-sectional relationship between the four social isolation/loneliness groups and desire for more social participation and four types of social support (tangible, positive interaction, affection, and emotional support). Prospective logistic regression analysis was possible for psychological distress, which was derived from the Maintaining Contact Questionnaire administered about 18 months after the baseline questionnaire (unweighted N = 28,789).Results
Findings indicate that being socially isolated and lonely was associated with the most social support gaps; this group also had an increased likelihood of psychological distress, relative to those who were neither socially isolated nor lonely. Participants who were only socially isolated, and those only lonely also perceived some social support gaps. In addition, the only lonely group was more likely to be psychologically distressed than the only socially isolated group and the neither isolated nor lonely group.Conclusion
Examining the four social isolation/loneliness was useful, as it provided more nuanced risk profiles than would have been possible had we examined social isolation and loneliness separately. Findings may suggest avenues for interventions tailored to the unique needs of at-risk individuals.
The purpose of this paper is to provide measurement properties evaluation and factor analysis of the Brazilian version of the diabetic foot ulcer scale‐short form (DFS‐SF). This methodological study evaluated the measurement properties of the DFS‐SF by ceiling and floor effect reliability, responsiveness, and structural construct validity. The study included 290 people with diabetic foot under regular follow‐up in a specialised outpatient clinic in inland São Paulo. Reliability was assessed by internal consistency using Cronbach's alpha and composite reliability. Ceiling and floor effects were assessed by the percentage of participants who scored the 15% worst (floor) and 15% best (ceiling) possible scale results. Validity was tested by correlating the instrument values with the domains of the Brazilian version of the Short Form Health Survey (SF‐36). Responsiveness (n = 34) was accessed through the wound area obtained by photography and evaluated by the Image J Features program and the DFS‐SF score at two moments, with a 4‐week interval between them. The instrument had good evidence of reliability, shown by adequate internal consistency (Cronbach's alpha in domains >0.70) and compound reliability (0.84 > CC > 0.92); and of convergent validity, by significant positive correlations of moderate to strong magnitude with SF‐36. Structural construct validity was examined by applying the DFS‐SF confirmatory factor analysis, which indicated that the Brazilian version of the instrument is properly fitted to the original dimensional structure. The ceiling and floor effect analysis showed no ceiling or floor effects. Responsiveness was observed in the wound area, but not in the DFS‐SF scores in the times. The Brazilian version of the DFS‐SF presented evidence of validity and reliability, suggesting that this instrument is a valid tool for assessing the quality of life of people with diabetic foot in the Brazilian population.
Millions of women suffer from the consequences of endometriosis and uterine fibroids, with fibroids the cause for over 50% of hysterectomies in the USA, and direct costs for their treatment estimated at between US$4 and US$9 billion. Endometriosis commonly affects millions of women worldwide predominantly during reproductive age, with severe menstrual and non-menstrual pain and subfertility the main symptoms. Due to the ‘unhappy triad’ of endometriosis—lack of awareness, lack of clinically relevant biomarkers and the unspecific nature of symptoms—women wait on average for 8–12 years before the definitive endometriosis diagnosis is made. Treatment options for both conditions are not satisfactory at the moment, especially with a view to preserving fertility for the women and families affected. In the Fibroids and Endometriosis Oxford (FENOX) study, we combine the investigation of fibroids and endometriosis, and plan to collect high-quality tissue samples and medical data of participants over a time frame of 5 years after surgical intervention.
Biological samples such as blood, saliva, urine, fat, peritoneal fluid and—if found—endometrial tissue or fibroids as well as detailed clinical and intraoperative data will be collected from women undergoing surgery and participating in the study after informed consent. We plan to recruit up to 1200 participants per disease arm (ie, endometriosis and uterine fibroids) over 5 years. Participants will fill in detailed and validated questionnaires on their medical history and quality of life, with follow-ups for 5 years. Enrolment started on 2 April 2018, and FENOX will close on 31 March 2028. We will analyse the biological samples using state-of-the-art molecular biology methods and correlate the findings with the medical records and questionnaire data.
The findings will be published in high-ranking journals in the field and presented at national and international conferences.
To evaluate patient follow-up and complexity in cancer clinical trial delivery, using consensus methods to: (1) identify research professionals’ priorities, (2) understand localised challenges, (3) define study complexity and workloads supporting the development of a trial rating and complexity assessment tool (TRACAT).
A classic eDelphi completed in three rounds, conducted as the launch study to a multiphase national project (evaluating follow-up and complexity in cancer clinical trials).
Multicentre online survey involving professionals at National Health Service secondary care hospital sites in Scotland and England varied in scale, geographical location and patient populations.
Principal investigators at 13 hospitals across nine clinical research networks recruited 33 participants using pre-defined eligibility criteria to form a multidisciplinary panel.
Statements achieving a consensus level of 70% on a 7-point Likert-type scale and ranked trial rating indicators (TRIs) developed by research professionals.
The panel developed 75 consensus statements illustrating factors contributing to complexity, follow-up intensity and operational performance in trial delivery, and specified 14 ranked TRIs. Seven open questions in the first qualitative round generated 531 individual statements. Iterative survey rounds returned rates of 82%, 82% and 93%.
Clinical trials operate within a dynamic, complex healthcare and innovation system where rapid scientific advances present opportunities and challenges for delivery organisations and professionals. Panellists highlighted cultural and organisational factors limiting the profession’s potential to support growing trial complexity and patient follow-up. Enhanced communication, interoperability, funding and capacity have emerged as key priorities. Future operational models should test dialectic Singerian-based approaches respecting open dialogue and shared values. Research capacity building should prioritise innovative, collaborative approaches embedding validated review and evaluation models to understand changing operational needs and challenges. TRACAT provides a mechanism for continual knowledge assimilation to improve decision-making.
On average women retain 5 to 9 kg 1 year after giving birth which can increase the risk of later obesity and chronic diseases. Some previous trials in this population have been effective in reducing weight, but are too intensive and costly to deliver at scale. There is a need for low-cost interventions to facilitate weight loss in this population.
The primary aim is to assess the feasibility of delivering a weight management intervention for overweight/obese postnatal women within child immunisation appointments. We will conduct a randomised controlled cluster feasibility trial with a nested qualitative study to assess study recruitment and acceptability of the intervention. General practitioner practice (cluster) will be the unit of randomisation, with practices randomised to offer usual care plus the intervention or usual care only. Eighty women will be recruited. The intervention group will be offered brief support that encourages self-management of weight when attending child immunisation appointments. Practice nurses will encourage women to weigh themselves weekly and record this, and to make healthy lifestyle choices through using an online weight management programme. Women will be advised to aim for 0.5 to 1 kg/week weight loss. At each child immunisation the nurse will assess progress by weighing women. The comparator group will receive a healthy lifestyle leaflet. Data on weight, body fat, depression, anxiety, body image, eating behaviours and physical activity will be collected at baseline and follow-up. Women and nurses will be interviewed to ascertain their views about the intervention. The decision to proceed to the phase III trial will be based on prespecified stop-go criteria.
Data will be stored securely at the University of Birmingham. Results will be disseminated through academic publications and presentations and will inform a possible phase III trial. The National Research Ethics Committee approved the study protocol.
Given the exponential increase in the use of e-cigarettes among younger age groups and in the growth in research on e-cigarette flavours, we conducted a systematic review examining the impact of non-menthol flavoured e-cigarettes on e-cigarette perceptions and use among youth and adults.
PubMed, Embase, PyscINFO and CINAHL were systematically searched for studies published and indexed through March 2018.
Quantitative observational and experimental studies that assessed the effect of non-menthol flavours in e-cigarettes on perceptions and use behaviours were included. Specific outcome measures assessed are appeal, reasons for use, risk perceptions, susceptibility, intention to try, initiation, preference, current use, quit intentions and cessation.
Three authors independently extracted data related to the impact of flavours in tobacco products. Data from a previous review were then combined with those from the updated review for final analysis. Results were then grouped and analysed by outcome measure.
The review included 51 articles for synthesis, including 17 published up to 2016 and an additional 34 published between 2016 and 2018. Results indicate that non-menthol flavours in e-cigarettes decrease harm perceptions (five studies) and increase willingness to try and initiation of e-cigarettes (six studies). Among adults, e-cigarette flavours increase product appeal (seven studies) and are a primary reason many adults use the product (five studies). The role of flavoured e-cigarettes on smoking cessation remains unclear (six studies).
This review provides summary data on the role of non-menthol flavours in e-cigarette perceptions and use. Consistent evidence shows that flavours attract both youth and adults to use e-cigarettes. Given the clear findings that such flavours increase product appeal, willingness to try and initiation among youth, banning non-menthol flavours in e-cigarettes may reduce youth e-cigarette use. Longitudinal research is needed to examine any role flavours may play in quit behaviours among adults.
Worldwide, 10%–20% of children and adolescents experience mental health conditions. However, most such disorders remain undiagnosed until adolescence or adulthood. Little is known about the factors that influence mental health in children and adolescents, especially in low and middle-income countries (LMIC), where environmental threats, such as poverty and war, may affect optimal neurodevelopment. Cohort studies provide important information on risks and resilience across the life course by enabling tracking of the effects of early life environment on health during childhood and beyond. Large birth cohort studies, including twin cohorts that can be aetiologically informative, have been conducted within high-income countries but are not generalisable to LMIC. There are limited longitudinal birth cohort studies in LMIC.
We sought to enhance the volume of impactful research in Sri Lanka by establishing a Centre of Excellence for cohort studies. The aim is to establish a register of infant, child and adolescent twins, including mothers pregnant with twins, starting in the districts of Colombo (Western Province) and Vavuniya (Northern Province). We will gain consent from twins or parents for future research projects. This register will provide the platform to investigate the aetiology of mental illness and the impact of challenges to early brain development on future mental health. Using this register, we will be able to conduct research that will (1) expand existing research capacity on child and adolescent mental health and twin methods; (2) further consolidate existing partnerships and (3) establish new collaborations. The initiative is underpinned by three pillars: high-quality research, ethics, and patient and public involvement and engagement (PPIE).
Ethical approval for this study was obtained from the Ethics Review Committee of Sri Lanka Medical Association and Keele University’s Ethical Review Panel. In addition to journal publications, a range of PPIE activities have been conducted.
This study aimed to estimate the association of smoking with the direct medical expenditures for chronic disease management in north of Jordan.
Retrospective cohort study using hospital database. Patients who were diagnosed with at least one chronic disease,were aged 18 years or older and had attended King Abdullah University Hospital for disease management and procedures from 1 July 2015 through 30 June 2016 were included in the study.
The outcome of interest was the direct medical expenditures for chronic disease management according to smoking status.
Data were collected from 845 patients having at least one chronic disease (mean age of 61±10.7 years). Smokers formed 22% of total patients. The back transformed mean total expenditure per patient of smokers, former smokers and non-smokers was 875 JD, 928 JD and 774 JD, respectively. Drugs were the most expensive healthcare resource used, accounting for 43% of total expenditure, followed by inpatient-related and outpatient-related services (19%). Smokers and former smokers were associated with the highest inpatient expenditures and inpatient-related and outpatient-related services expenditures. However, smokers were associated with the lowest outpatient and medication expenditures.
Smokers and former smokers presented with higher statistically significant inpatient-related and outpatient-related services expenditures and higher transformed mean total expenditures compared to non-smokers; highlighting this economic burden is useful for promoting tobacco control policies.
Urban transmission patterns of influenza viruses are complex and poorly understood, and multiple factors may play a critical role in modifying transmission. Whole genome sequencing (WGS) allows the description of patient-to-patient transmissions at highest resolution. The aim of this study is to explore urban transmission patterns of influenza viruses in high detail by combining geographical, epidemiological and immunological data with WGS data.
The study is performed at the University Hospital Basel, University Children’s Hospital Basel and a network of paediatricians and family doctors in the Canton of Basel-City, Switzerland. The retrospective study part includes an analysis of PCR-confirmed influenza cases from 2013 to 2018. The prospective study parts include (1) a household survey regarding influenza-like illness (ILI) and vaccination against influenza during the 2015/2016 season; (2) an analysis of influenza viruses collected during the 2016/2017 season using WGS—viral genomic sequences are compared with determine genetic relatedness and transmissions; and (3) measurement of influenza-specific antibody titres against all vaccinated and circulated strains during the 2016/2017 season from healthy individuals, allowing to monitor herd immunity across urban quarters. Survey data and PCR-confirmed cases are linked to data from the Statistics Office of the Canton Basel-City and visualised using geo-information system mapping. WGS data will be analysed in the context of patient epidemiological data using phylodynamic analyses, and the obtained herd immunity for each quarter. Profound knowledge on the key geographical, epidemiological and immunological factors influencing urban influenza transmission will help to develop effective counter measurements.
The study is registered and approved by the regional ethics committee as an observational study (EKNZ project ID 2015–363 and 2016–01735). It is planned to present the results at conferences and publish the data in scientific journals.
Idiopathic nephrotic syndrome (INS) is characterised by a high relapse rate up to 80% after initial response to standard therapy with corticosteroids. Steroid toxicity is common and causes a great burden of disease that negatively influences the health-related quality of life (HRQoL). Recently, studies have shown that levamisole, an anthelminthic drug, significantly improves relapse-free survival in children with frequent relapses or steroid dependency. Compared with other steroid-sparing drugs, levamisole has relatively few side effects. We hypothesise that adding levamisole to standard therapy with corticosteroids in children with a first episode of INS will prevent relapses, decrease cumulative dosage of steroids used and improve HRQoL. This paper presents the study protocol for the LEARNS study (LEvamisole as Adjuvant therapy to Reduce relapses of Nephrotic Syndrome).
An international, double-blind, placebo-controlled randomised trial will be conducted in 20 participating hospitals in the Netherlands and Belgium. Participants (n=92) with a first episode of INS, aged 2–16 years, who achieve remission after 4 weeks of oral prednisolone will be randomly assigned (1:1) to receive either levamisole 2.5 mg/kg alternate day or placebo added to prednisolone (18-week tapering schedule) for a total of 24 weeks. Follow-up will be until 2 years after first presentation. Additionally, parents and/or children will fill out five HRQoL questionnaires. Primary outcome of the LEARNS study is occurrence of relapses within 12 months after first presentation. Secondary outcomes include time to first relapse, cumulative steroid dose after 2 years, safety parameters and quality of life scores.
The trial was approved by the Medical Ethical Committee. Results of the study will be published in a peer-reviewed journal.
To gain a deeper understanding of the differences in patients and staff perspectives in response to aggression and to explore recommendations on prevention.
Qualitative, grounded theory study.
We conducted semi‐structured interviews with patients and nurses involved in an aggressive incident. Data collection was performed from May 2016 ‐ March 2017.
Thirty‐one interviews were conducted concerning 15 aggressive incidents. Patients and nurses generally showed agreement on the factual course of events, there was variation in agreement on the perceived severity (PS). Patients' recommendations on prevention were mostly personally focussed, while nurses suggested general improvements.
Patients are often capable to evaluate aggression and give recommendations on prevention shortly after the incident. Patients and nurses differ in the PS of aggression. Recommendations on prevention of patients and nurses are complementary.
What problem did the study address? Perspectives of patients and nurses differ with respect to aggression, but how is unclear. What were the main findings? Patients and nurses generally described a similar factual course of events concerning the incident, patients often perceive the severity less than nurses. Patients are capable to give recommendations on prevention of aggressive incidents, shortly after the incident. Where and on whom will the research have impact? Factual course of events can be a common ground to start evaluating aggressive incidents and post‐incident review should address the severity of incidents. Asking recommendations from patients on how to improve safety and de‐escalation can lead to innovative and personal de‐escalation strategies and supports patients autonomy.