PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-25 (2495)
 

Clipboard (0)
None
Journals
Year of Publication
Document Types
1.  Incidence and fatality of serious suicide attempts in a predominantly rural population in Shandong, China: a public health surveillance study 
BMJ Open  2015;5(2):e006762.
Objectives
To estimate the incidence of serious suicide attempts (SSAs, defined as suicide attempts resulting in either death or hospitalisation) and to examine factors associated with fatality among these attempters.
Design
A surveillance study of incidence and mortality. Linked data from two public health surveillance systems were analysed.
Setting
Three selected counties in Shandong, China.
Participants
All residents in the three selected counties.
Outcome measures
Incidence rate (per 100 000 person-years) and case fatality rate (%).
Methods
Records of suicide deaths and hospitalisations that occurred among residents in selected counties during 2009–2011 (5 623 323 person-years) were extracted from electronic databases of the Disease Surveillance Points (DSP) system and the Injury Surveillance System (ISS) and were linked by name, sex, residence and time of suicide attempt. A multiple logistic regression model was developed to examine the factors associated with a higher or lower fatality rate.
Results
The incidence of SSAs was estimated to be 46 (95% CI 44 to 48) per 100 000 person-years, which was 1.5 times higher in rural versus urban areas, slightly higher among females, and increased with age. Among all SSAs, 51% were hospitalised and survived, 9% were hospitalised but later died and 40% died with no hospitalisation. Most suicide deaths (81%) were not hospitalised and most hospitalised SSAs (85%) survived. The fatality rate was 49% overall, but was significantly higher among attempters living in rural areas, who were male, older, with lower education or with a farming occupation. With regard to the method of suicide, fatality was lowest for non-pesticide poisons (7%) and highest for hanging (97%).
Conclusions
The incidence of serious suicide attempts is substantially higher in rural areas than in urban areas of China. The risk of death is influenced by the attempter's sex, age, education level, occupation, method used and season of year.
doi:10.1136/bmjopen-2014-006762
PMCID: PMC4325129  PMID: 25673439
Suicide; Incidence; Mortality; Hospitalisation
2.  Assessing the effect of unilateral cerebral revascularisation on the vascular reactivity of the non-intervened hemisphere: a retrospective observational study 
BMJ Open  2015;5(2):e006014.
Objectives
Unilateral haemodynamically significant large-vessel intracranial stenosis may be associated with reduced blood-oxygen-level-dependent (BOLD) cerebrovascular reactivity (CVR), an indicator of autoregulatory reserve. Reduced CVR has been associated with ipsilateral cortical thinning and loss in cognitive function. These effects have been shown to be reversible following revascularisation. Our aim was to study the effects of unilateral revascularisation on CVR in the non-intervened hemisphere in bilateral steno-occlusive or Moyamoya disease.
Study Design
A retrospective observational study.
Setting
A routine follow-up assessment of CVR after a revascularisation procedure at a research teaching hospital in Toronto (Journal wants us to generalise).
Participants
Thirteen patients with bilateral Moyamoya disease (age range 18 to 52 years; 3 males), seven patients with steno-occlusive disease (age range 18 to 78 years; six males) and 27 approximately age-matched normal control subjects (age range 19–71 years; 16 males) with no history or findings suggestive of any neurological or systemic disease.
Intervention
Participants underwent BOLD CVR MRI using computerised prospective targeting of CO2, before and after unilateral revascularisation (extracranial–intracranial bypass, carotid endarterectomy or encephaloduroarteriosynangiosis). Pre-revascularisation and post-revascularisation CVR was assessed in each major arterial vascular territory of both hemispheres.
Results
As expected, surgical revascularisation improved grey matter CVR in the middle cerebral artery (MCA) territory of the intervened hemisphere (0.010±0.023 to 0.143±0.010%BOLD/mm Hg, p<0.01). There was also a significant post-revascularisation improvement in grey matter CVR in the MCA territory of the non-intervened hemisphere (0.101±0.025 to 0.165±0.015%BOLD/mm Hg, p<0.01).
Conclusions
Not only does CVR improve in the hemisphere ipsilateral to a flow restoration procedure, but it also improves in the non-intervened hemisphere. This highlights the potential of CVR mapping for staging and evaluating surgical interventions.
doi:10.1136/bmjopen-2014-006014
PMCID: PMC4325130  PMID: 25673438
NEUROPHYSIOLOGY
3.  Change in paternity, risk of placental abruption and confounding by birth interval: a population-based prospective cohort study in Norway, 1967–2009 
BMJ Open  2015;5(2):e007023.
Objectives
We examined abruption risk in relation to change in paternity, and evaluated if birth interval confounds this association.
Setting
Population-based study of singleton births in Norway between 1967 and 2009.
Participants
Women who had their first two (n=747 566) singleton births in the Norwegian Medical Birth Registry. The associations between partner change between pregnancies and birth interval were examined in relation to abruption in a series of logistic regression models.
Primary outcome measures
Risk, as well as unadjusted and adjusted OR of placental abruption in relation to change in paternity and interval between births.
Results
Among women without abruption in their first pregnancy, the risks of abruption in the second pregnancy were 4.7 and 6.5 per 1000 in women who had the same and different partners, respectively (OR=1.39, 95% CI 1.26 to 1.53). After adjustments for confounders including birth interval and smoking, partner change was not associated with abruption (OR=1.01, 95% CI 0.79 to 1.32). Among women with abruption in the first pregnancy, the association between partner change and abruption in the second pregnancy was 0.98 (95% CI 0.75 to 1.28). Interval <1 year was associated with increased abruption risk in the second pregnancy among women with the same as well as different partners, but interval over 4 years was only associated with increased risk among women with the same partner. No such patterns were seen for recurrent abruption.
Conclusions
We find no evidence that a change in partner is associated with increased abruption risk. Theories supporting an immune maladaptation hypothesis afforded by change in paternity are not supported insofar as abruption is concerned.
doi:10.1136/bmjopen-2014-007023
PMCID: PMC4325127  PMID: 25670732
EPIDEMIOLOGY
4.  Dietary protein-to-carbohydrate ratio and added sugar as determinants of excessive gestational weight gain: a prospective cohort study 
BMJ Open  2015;5(2):e005839.
Objective
To examine the relation between the protein:carbohydrate (P/C) ratio and added sugar intake in pregnancy and gestational weight gain (GWG).
Design
A prebirth cohort including 103 119 pregnancies enrolled between 1996 and 2003.
Setting
All women in Denmark were eligible to participate if they spoke Danish and were planning to carry to term.The pregnant women were recruited and enrolled during their first antenatal visit (6–10 weeks of gestation).
Participants
Participants included women with live-born singletons and complete data on dietary intake and GWG, leaving 46 262 women for the analysis.
Exposure
Macronutrient intake was quantified using a validated food frequency questionnaire administered in the 25th week of gestation. The P/C ratio and added sugar intake were examined in quintiles.
Primary outcome measures
GWG was based on self-reported weight in gestational weeks 12 and 30 and defined as gain in g/week. We used multivariable linear regression, including adjusting for pre-pregnancy body mass index, to calculate relative change in GWG and 95% CI.
Results
Average GWG was 471(224) g/week. The adjusted weight gain was 16 g/week lower (95% CI 9 to 22, p for trend <0.001) in the highest (Q5) versus lowest (Q1) quintile of the P/C ratio (∼3% average reduction across the entire pregnancy). Weight gain for those with >20%E vs <12%E from protein was 36 g/week lower (95% CI 20 to 53, p for trend <0.0001; ∼8% average reduction). A high P/C ratio was inversely related to intake of added sugars. Added sugar consumption was strongly associated with GWG (Q5 vs Q1: 34, 95% CI 28 to 40 g/week, p for trend <0.0001).
Conclusions
A high P/C ratio was associated with reduced GWG. This association appeared to be partly driven by a decrease in intake of added sugar. These results are consistent with randomised trials in non-pregnant participants. A dietary intervention targeting an increased P/C ratio with emphasis on reducing added sugar can contribute to reducing excessive GWG.
doi:10.1136/bmjopen-2014-005839
PMCID: PMC4325128  PMID: 25670731
EPIDEMIOLOGY; NUTRITION & DIETETICS; OBSTETRICS
5.  Patients’ experiences of the choice of GP practice pilot, 2012/2013: a mixed methods evaluation 
BMJ Open  2015;5(2):e006090.
Objectives
To investigate patients’ experiences of the choice of general practitioner (GP) practice pilot.
Design
Mixed-method, cross-sectional study.
Setting
Patients in the UK National Health Service (NHS) register with a general practice responsible for their primary medical care and practices set geographic boundaries. In 2012/2013, 43 volunteer general practices in four English NHS primary care trusts (PCTs) piloted a scheme allowing patients living outside practice boundaries to register as an out of area patient or be seen as a day patient.
Participants
Analysis of routine data for 1108 out of area registered patients and 250 day patients; postal survey of out of area registered (315/886, 36%) and day (64/188, 34%) patients over 18 years of age, with a UK mailing address; comparison with General Practice Patient Survey (GPPS); semistructured interviews with 24 pilot patients.
Results
Pilot patients were younger and more likely to be working than non-pilot patients at the same practices and reported generally more or at least as positive experiences than patients registered at the same practices, practices in the same PCT and nationally, despite belonging to subgroups of the population who typically report poorer than average experiences. Out of area patients who joined a pilot practice did so: after moving house and not wanting to change practice (26.2%); for convenience (32.6%); as newcomers to an area who selected a practice although they lived outside its boundary (23.6%); because of dissatisfaction with their previous practice (13.9%). Day patients attended primarily on grounds of convenience (68.8%); 51.6% of the day patient visits were for acute infections, most commonly upper respiratory infections (20.4%). Sixty-six per cent of day patients received a prescription during their visit.
Conclusions
Though the 12-month pilot was too brief to identify all costs and benefits, the scheme provided a positive experience for participating patients and practices.
doi:10.1136/bmjopen-2014-006090
PMCID: PMC4322193  PMID: 25667149
primary health care; practice boundaries; access; choice
6.  Violence, self-harm and drug or alcohol misuse in adolescents admitted to hospitals in England for injury: a retrospective cohort study 
BMJ Open  2015;5(2):e006079.
Objectives
Of adolescents in the general population in England, we aimed to determine (1) the proportion that has an emergency admission to hospital for injury related to adversity (violence, self-harm or drug or alcohol misuse) and (2) the risk of recurrent emergency admissions for injury in adolescents admitted with adversity-related injury compared with those admitted with accident-related injury only.
Design
We used longitudinally linked administrative hospital data (Hospital Episode Statistics) to identify participants aged 10–19 years with emergency admissions for injury (including day cases lasting more than 4 h) in England in 1998–2011. We used the Office for National Statistics mid-year estimates for population denominators.
Results
Approximately 4.3% (n=141 248) of adolescents in the general population (n=3 254 046) had one or more emergency admissions for adversity-related injury (girls 4.6%, boys 4.1%), accounting for 50% of all emergency admissions for injury in girls and 29.1% in boys. Admissions for self-harm or drug or alcohol misuse commonly occurred in the same girls and boys. Recurrent emergency admissions for injury were more common in adolescents with adversity-related injury (girls 17.3%, boys 16.5%) than in those with accident-related injury only (girls 4.7%, boys 7.4%), particularly for adolescents with adversity-related injury related to multiple types of adversity (girls 21.1%, boys 24.2%).
Conclusions
Hospital-based interventions should be developed to reduce the risk of future injury in adolescents admitted for adversity-related injury.
doi:10.1136/bmjopen-2014-006079
PMCID: PMC4322205  PMID: 25667148
MENTAL HEALTH
7.  Zonal T2* and T1Gd assessment of knee joint cartilage in various histological grades of cartilage degeneration: an observational in vitro study 
BMJ Open  2015;5(2):e006895.
Objectives
Accurate assessment of cartilage status is increasingly becoming important to clinicians for offering joint preservation surgeries versus joint replacements. The goal of this study was to evaluate the validity of three-dimensional (3D), gradient-echo (GRE)-based T2* and T1Gd mapping for the assessment of various histological severities of degeneration in knee joint cartilage with potential implications for clinical management.
Methods
MRI and histological assessment were conducted in 36 ex vivo lateral femoral condyle specimens. The MRI protocol included a 3D GRE multiecho data image combination sequence in order to assess the T2* decay, a 3D double-echo steady-state sequence for assessment of cartilage morphology, and a dual flip angle 3D GRE sequence with volumetric interpolated breathhold examination for the T1Gd assessment. The histological sample analysis was performed according to the Mankin system. The data were then analysed statistically and correlated.
Results
We observed a significant decrease in the T2* and T1Gd values with increasing grades of cartilage degeneration (p<0.001) and a moderate correlation between T2* (r=0.514)/T1Gd (r=0.556) and the histological grading of cartilage degeneration (p<0.001). In addition, we noted a zonal variation in the T2* and T1Gd values reflecting characteristic zonal differences in the biochemical composition of hyaline cartilage.
Conclusions
This study outlines the potential of GRE-based T2* and T1Gd mapping to identify various grades of cartilage damage. Early changes in specific zones may assist clinicians in identifying methods of early intervention involving the targeted joint preservation approach versus moving forward with unicompartmental, bicompartmental or tricompartmental joint replacement procedures.
Trial registration number
DRKS00000729.
doi:10.1136/bmjopen-2014-006895
PMCID: PMC4322206  PMID: 25667150
8.  TElehealth in CHronic disease: mixed-methods study to develop the TECH conceptual model for intervention design and evaluation 
BMJ Open  2015;5(2):e006448.
Objective
To develop a conceptual model for effective use of telehealth in the management of chronic health conditions, and to use this to develop and evaluate an intervention for people with two exemplar conditions: raised cardiovascular disease risk and depression.
Design
The model was based on several strands of evidence: a metareview and realist synthesis of quantitative and qualitative evidence on telehealth for chronic conditions; a qualitative study of patients’ and health professionals’ experience of telehealth; a quantitative survey of patients’ interest in using telehealth; and review of existing models of chronic condition management and evidence-based treatment guidelines. Based on these evidence strands, a model was developed and then refined at a stakeholder workshop. Then a telehealth intervention (‘Healthlines’) was designed by incorporating strategies to address each of the model components. The model also provided a framework for evaluation of this intervention within parallel randomised controlled trials in the two exemplar conditions, and the accompanying process evaluations and economic evaluations.
Setting
Primary care.
Results
The TElehealth in CHronic Disease (TECH) model proposes that attention to four components will offer interventions the best chance of success: (1) engagement of patients and health professionals, (2) effective chronic disease management (including subcomponents of self-management, optimisation of treatment, care coordination), (3) partnership between providers and (4) patient, social and health system context. Key intended outcomes are improved health, access to care, patient experience and cost-effective care.
Conclusions
A conceptual model has been developed based on multiple sources of evidence which articulates how telehealth may best provide benefits for patients with chronic health conditions. It can be used to structure the design and evaluation of telehealth programmes which aim to be acceptable to patients and providers, and cost-effective.
doi:10.1136/bmjopen-2014-006448
PMCID: PMC4322202  PMID: 25659890
PRIMARY CARE
9.  The effect of Chinese herbal medicine Jian Ling Decoction for the treatment of essential hypertension: a systematic review 
BMJ Open  2015;5(2):e006502.
Objectives
Jian Ling Decoction (JLD) is often prescribed to improve hypertension-related symptoms in China. However, this treatment has not been systematically reviewed for its efficacy against essential hypertension (EH). This review aims to assess the current clinical evidence of JLD in the treatment of EH.
Design
Seven electronic databases, including the Cochrane Central Register of Controlled Trials, PubMed, EMBASE, the Chinese National Knowledge Infrastructure (CNKI), the Chinese Scientific Journal Database (VIP), the Chinese Biomedical Literature Database (CBM) and the Wanfang Database, were searched up to March 2014. Randomised control trials (RCTs) comparing JLD or combined with antihypertensive drugs versus antihypertensive drugs were included. We assessed the methodological quality, extracted the valid data and conducted the meta-analysis according to criteria from the Cochrane group. The primary outcome was categorical or continuous blood pressure (BP), and the secondary outcome was quality of life (QOL).
Results
Ten trials (655 patients) with unclear-to-high risk of bias were identified. Meta-analysis showed that JLD used alone showed no BP reduction effect; however, improvement on QOL was found in the JLD group compared to antihypertensive drugs. A significant reduction in systolic and diastolic BP was observed for JLD plus antihypertensive drugs when compared with antihypertensive drugs alone. No serious adverse effects were reported.
Conclusions
Owing to insufficient clinical data, it is difficult to draw a definite conclusion regarding the effectiveness and safety of JLD for EH, and better trials are needed.
doi:10.1136/bmjopen-2014-006502
PMCID: PMC4322192  PMID: 25652798
essential hypertension; Chinese herbal medicine; Jian Ling Decoction; systematic review; blood pressure
10.  Over-reassurance and undersupport after a ‘false alarm’: a systematic review of the impact on subsequent cancer symptom attribution and help seeking 
BMJ Open  2015;5(2):e007002.
Objectives
This literature review examined research into the impact of a previous ‘all-clear’ or non-cancer diagnosis following symptomatic presentation (‘false alarm’) on symptom attribution and delays in help seeking for subsequent possible cancer symptoms.
Design and setting
The comprehensive literature review included original research based on quantitative, qualitative and mixed data collection methods. We used a combination of search strategies, including in-depth searches of electronic databases (PubMed, EMBASE, PsychInfo), searching key authors and articles listed as ‘related’ in PubMed, and reference lists. We performed a narrative synthesis of key themes shared across studies.
Participants
The review included studies published after 1990 and before February 2014 reporting information on adult patients having experienced a false alarm following symptomatic presentation. We excluded false alarms in the context of screening.
Primary and secondary outcome measures
We evaluated the effect of a ‘false alarm’ on symptom attribution and help seeking for new or recurrent possible cancer symptoms.
Results
Overall, 1442 papers were screened and 121 retrieved for full-text evaluation. Among them, 19 reported on false alarms and subsequent symptom attribution or help seeking. They used qualitative (n=14), quantitative (n=3) and mixed methods (n=2). Breast (n=7), gynaecological (n=3), colorectal (n=2), testicular (n=2), and head and neck cancers (n=2) were the most studied. Two broad themes emerged underlying delays in help seeking: (1) over-reassurance from the previous ‘all-clear’ diagnosis leading to subsequent symptoms being interpreted as benign, and (2) unsupportive healthcare experiences in which symptoms were dismissed, leaving patients concerned about appearing hypochondriacal or uncertain about the appropriate next actions. The evidence suggested that the effect of a false alarm can persist for months and even years.
Conclusions
In conclusion, over-reassurance and undersupport of patients after a false alarm can undermine help seeking in the case of new or recurrent potential cancer symptoms, highlighting the need for appropriate patient information when investigations rule out cancer.
doi:10.1136/bmjopen-2014-007002
PMCID: PMC4322204  PMID: 25652803
GENERAL MEDICINE (see Internal Medicine); ONCOLOGY; PRIMARY CARE; PUBLIC HEALTH; QUALITATIVE RESEARCH
11.  Trauma airway management in emergency departments: a multicentre, prospective, observational study in Japan 
BMJ Open  2015;5(2):e006623.
Objectives
Although successful airway management is essential for emergency trauma care, comprehensive studies are limited. We sought to characterise current trauma care practice of airway management in the emergency departments (EDs) in Japan.
Design
Analysis of data from a prospective, observational, multicentre registry—the Japanese Emergency Airway Network (JEAN) registry.
Setting
13 academic and community EDs from different geographic regions across Japan.
Participants
723 trauma patients who underwent emergency intubation from March 2010 through August 2012.
Outcome measures
ED characteristics, patient and operator demographics, methods of airway management, intubation success or failure at each attempt and adverse events.
Results
A total of 723 trauma patients who underwent emergency intubation were eligible for the analysis. Traumatic cardiac arrest comprised 32.6% (95% CI 29.3% to 36.1%) of patients. Rapid sequence intubation (RSI) was the initial method chosen in 23.9% (95% CI 21.0% to 27.2%) of all trauma patients and in 35.5% (95% CI 31.4% to 39.9%) of patients without cardiac arrest. Overall, intubation was successful in ≤3 attempts in 96% of patients (95% CI 94.3% to 97.2%). There was a wide variation in the initial methods of intubation; RSI as the initial method was performed in 0–50.9% of all trauma patients among 12 EDs. Similarly, there was a wide variation in success rates and adverse event rates across the EDs. Success rates varied between 35.5% and 90.5% at the first attempt, and 85.1% and 100% within three attempts across the 12 EDs.
Conclusions
In this multicentre prospective study in Japan, we observed a high overall success rate in airway management during trauma care. However, the methods of intubation and success rates were highly variable among hospitals.
doi:10.1136/bmjopen-2014-006623
PMCID: PMC4322207  PMID: 25652800
TRAUMA MANAGEMENT; ACCIDENT & EMERGENCY MEDICINE; MEDICAL EDUCATION & TRAINING
12.  Loss of GD1-positive Lactobacillus correlates with inflammation in human lungs with COPD 
BMJ Open  2015;5(2):e006677.
Objectives
The present study assesses the relationship between contents of GD1 (glycerol dehydratase)-positive Lactobacillus, presence of Lactobacillus and the inflammatory response measured in host lung tissue in mild to moderate chronic obstructive pulmonary disease (COPD). We hypothesise that there will be a loss of GD1 producing Lactobacillus with increasing severity of COPD and that GD1 has anti-inflammatory properties.
Setting
Secondary care, 1 participating centre in Vancouver, British Columbia, Canada.
Participants
74 individuals who donated non-cancerous portions of their lungs or lobes removed as treatment for lung cancer (normal lung function controls (n=28), persons with mild (GOLD 1) (n=21) and moderate (GOLD 2) COPD (n=25)).
Outcome measures
Primary outcome measure was GD1 positivity within each group and whether or not this impacted quantitative histological measures of lung inflammation. Secondary outcome measures included Lactobacillus presence and quantification, and quantitative histological measurements of inflammation and remodelling in early COPD.
Results
Total bacterial count (p>0.05) and prevalence of Lactobacillus (p>0.05) did not differ between groups. However, the GD1 gene was detected more frequently in the controls (14%) than in either mild (5%) or moderate (0%) COPD (p<0.05) samples. Macrophage and neutrophil volume fractions (0.012±0.005 (mean±SD) vs 0.026±0.017 and 0.005±0.002 vs 0.015±0.014, respectively) in peripheral lung tissue were reduced in samples positive for the GD1 gene (p<0.0035).
Conclusions
A reduction in GD1 positivity is associated with an increased tissue immune inflammatory response in early stage COPD. There is potential for Lactobacillus to be used as a possible therapeutic, however, validation of these results need to be completed before an anti-inflammatory role of Lactobacillus in COPD can be confirmed.
doi:10.1136/bmjopen-2014-006677
PMCID: PMC4322209  PMID: 25652802
13.  Service evaluation of the GOALS family-based childhood obesity treatment intervention during the first 3 years of implementation 
BMJ Open  2015;5(2):e006519.
Objectives
To evaluate the impact of the GOALS (Getting Our Active Lifestyles Started) family-based childhood obesity treatment intervention during the first 3 years of implementation.
Design
Single-group repeated measures with qualitative questionnaires.
Setting
Community venues in a socioeconomically deprived, urban location in the North-West of England.
Participants
70 overweight or obese children (mean age 10.5 years, 46% boys) and their parents/carers who completed GOALS between September 2006 and March 2009.
Interventions
GOALS was a childhood obesity treatment intervention that drew on social cognitive theory to promote whole family lifestyle change. Sessions covered physical activity (PA), diet and behaviour change over 18 2 h weekly group sessions (lasting approximately 6 months). A Template for Intervention Description and Replication (TIDieR) checklist of intervention components is provided.
Primary and secondary outcome measures
The primary outcome measure was child body mass index (BMI) z-score, collected at baseline, post-intervention and 12 months. Secondary outcome measures were child self-perceptions, parent/carer BMI and qualitative changes in family diet and PA (parent/carer questionnaire).
Results
Child BMI z-score reduced by 0.07 from baseline to post-intervention (p<0.001) and was maintained at 12 months (p<0.05). There was no change in parent/carer BMI or child self-perceptions, other than an increase in perceived social acceptance from baseline to post-intervention (p<0.05). Parents/carers reported positive changes to family PA and dietary behaviours after completing GOALS.
Conclusions
GOALS completion was associated with small improvements in child BMI z-score and improved family PA and dietary behaviours. Several intervention modifications were necessary during the implementation period and it is suggested childhood obesity treatment interventions need time to embed before a definitive evaluation is conducted. Researchers are urged to use the TIDieR checklist to ensure transparent reporting of interventions and facilitate the translation of evidence to practice.
doi:10.1136/bmjopen-2014-006519
PMCID: PMC4322210  PMID: 25652799
childhood obesity; behaviour change; evaluation; diet; physical activity; family
14.  Can certified health professionals treat obesity in a community-based programme? A quasi-experimental study 
BMJ Open  2015;5(2):e006650.
Objective
To test the effectiveness of a non-pharmaceutical programme for obese participants in a rural Eastern Canadian Province using certified health professionals.
Design
A prospective quasi-experimental design with repeated premeasure and postmeasure.
Participants
146 participants with obesity (body mass index >30 kg/m2) from rural and urban communities in an Eastern Canadian Province were divided into four groups.
Intervention
A 6-month intensive active community-based lifestyle intervention (InI) delivered by Certified Exercise Physiologists, Certified Personal Trainers and Registered Dietitians, followed by 6 months of self-management. A second intervention (InII) was nested in InI and consisted of group-mediated cognitive–behavioral intervention (GMCBI) delivered by an exercise psychologist to two of the four InI groups.
Outcomes
(1) Improving health outcomes among the participants’ preactive and postactive 6-month intervention and self-management period, (2) Documenting the impact of InII (GMCBI) and location of the intervention (urban vs rural).
Results
The 6-month active InI significantly improved cardiovascular health for participants who completed the intervention. InII (GMCBI) significantly lowered the attrition rate among the participants. The self-management period was challenging for the participants and they did not make further gains; however, most were able to maintain the gains achieved during the active intervention. The location of the intervention, urban or rural, had little impact on outcomes.
Conclusions
A community-based programme utilising healthcare professionals other than physicians to treat obese patients was effective based on premeasure and postmeasure. During the self-management phase, the participants were able to maintain the gains. Psychological support is essential to participant retention.
doi:10.1136/bmjopen-2014-006650
PMCID: PMC4322212  PMID: 25652801
PRIMARY CARE; PUBLIC HEALTH; NUTRITION & DIETETICS
15.  Effect of once-daily indacaterol maleate/mometasone furoate on exacerbation risk in adolescent and adult asthma: a double-blind randomised controlled trial 
BMJ Open  2015;5(2):e006131.
Objective
To investigate the safety and efficacy of QMF149, a once-daily, fixed-dose combination of the long-acting β2-agonist (LABA) indacaterol maleate and inhaled corticosteroid (ICS) mometasone furoate (MF) for the treatment of persistent asthma. The hypothesis was that QMF149 would not increase the risk of serious asthma exacerbations.
Setting
174 research centres in nine countries.
Participants
1519 adolescents and adults with persistent asthma who were treated or qualified for treatment with combination LABA/ICS were randomised, and 1508 were included in the intention-to-treat analysis.
Intervention
Patients were randomised to QMF149 (indacaterol maleate 500 µg/MF 400 µg) or MF (400 µg) once daily via Twisthaler inhalation device in a double-blind, parallel-group study for 6–21 months.
Primary and secondary outcome measures
The primary end point was time to first serious asthma exacerbation (resulting in hospitalisation, intubation or death). The key secondary end point was annual rate of exacerbations requiring systemic corticosteroids.
Results
Treatment with QMF149 resulted in no significant difference in time to first serious exacerbation compared to MF (2 (0.3%) vs 6 events (0.8%); difference −0.52 percentage point; 95% CI −1.25 to 0.21, p=0.160, HR=0.31; 95% CI 0.06 to 1.54, p=0.151). QMF149 significantly reduced the annual rate of exacerbations requiring systemic corticosteroids (rate ratio=0.71; 95% CI 0.55 to 0.90, p=0.005). Proportions of patients experiencing adverse events were similar across groups (74.0% in the QMF149 group and 73.4% in the MF group). Serious adverse events occurred in 4% and 5.8% of patients in the QMF149 and MF groups, respectively.
Conclusions
No significant difference was observed in the primary outcome of time to first serious asthma exacerbation in patients treated with QMF149 compared with patients treated with MF. Long-term treatment with QMF149 once daily had a favourable safety/efficacy profile in adolescent and adult patients with persistent asthma.
Trial registration number
ClinicalTrials.gov; NCT00941798.
doi:10.1136/bmjopen-2014-006131
PMCID: PMC4322191  PMID: 25649209
CLINICAL PHARMACOLOGY
16.  Risk of developing multimorbidity across all ages in an historical cohort study: differences by sex and ethnicity 
BMJ Open  2015;5(2):e006413.
Objective
To study the incidence of de novo multimorbidity across all ages in a geographically defined population with an emphasis on sex and ethnic differences.
Design
Historical cohort study.
Setting
All persons residing in Olmsted County, Minnesota, USA on 1 January 2000 who had granted permission for their records to be used for research (n=123 716).
Participants
We used the Rochester Epidemiology Project medical records-linkage system to identify all of the county residents. We identified and removed from the cohort all persons who had developed multimorbidity before 1 January 2000 (baseline date), and we followed the cohort over 14 years (1 January 2000 through 31 December 2013).
Main outcome measures
Incident multimorbidity was defined as the development of the second of 2 conditions (dyads) from among the 20 chronic conditions selected by the US Department of Health and Human Services. We also studied the incidence of the third of 3 conditions (triads) from among the 20 chronic conditions.
Results
The incidence of multimorbidity increased steeply with older age; however, the number of people with incident multimorbidity was substantially greater in people younger than 65 years compared to people age 65 years or older (28 378 vs 6214). The overall risk was similar in men and women; however, the combinations of conditions (dyads and triads) differed extensively by age and by sex. Compared to Whites, the incidence of multimorbidity was higher in Blacks and lower in Asians.
Conclusions
The risk of developing de novo multimorbidity increases steeply with older age, varies by ethnicity and is similar in men and women overall. However, as expected, the combinations of conditions vary extensively by age and sex. These data represent an important first step toward identifying the causes and the consequences of multimorbidity.
doi:10.1136/bmjopen-2014-006413
PMCID: PMC4322195  PMID: 25649210
EPIDEMIOLOGY; GENERAL MEDICINE (see Internal Medicine); GERIATRIC MEDICINE; PREVENTIVE MEDICINE; PRIMARY CARE
17.  Assessing beliefs and risk perceptions on smoking and smoking cessation in immigrant Chinese adult smokers residing in Vancouver, Canada: a cross-sectional study 
BMJ Open  2015;5(2):e006435.
Objectives
We aimed to conduct culturally-based participatory research to assess cultural and belief contexts for smoking behaviours within Mandarin and Cantonese communities. Outcome variables were smoking-related knowledge, smoking patterns, attitudes and beliefs, and perceived barriers and facilitators to successful cessation.
Design
A community-based approach was applied involving smokers, community key-informants and professionals in study design and implementation. Initially, focus groups were conducted and findings were used to develop study instrument. Participants responded once to study questionnaire after informed consent.
Setting
Community based in the Greater Vancouver Area, Canada.
Participants
16 Chinese smokers participated in focus groups and subsequently, 167 current Chinese immigrant (137 males and 30 females) smokers from Mandarin and Cantonese communities, recruited with the help of community agencies and collaborating physicians, were enrolled in a cross-sectional study.
Results
We found that a majority believed smoking was harmful on their health. Younger smokers (<35 years of age) did not mind smoking in front of young children compared to older smokers (≥35 years of age) (p<0.001). People with high school or lower levels of education believed that they would benefit more from smoking than suffering from withdrawal symptoms compared to better educated smokers (p<0.05). Mandarin smokers were significantly more likely to encourage others to quit than Cantonese smokers (p<0.05). Many indicated not receiving adequate support from care providers and lack of access to culturally and linguistically appropriate cessation programmes impacted on their ability to quit smoking.
Conclusions
Our study highlighted the importance of tobacco beliefs and perceptions among Mandarin and Cantonese speaking immigrants with limited access to healthcare information and for younger smokers whose attention to health consequences of smoking may be limited as well. Study participants were generally aware of the health risks and were willing to quit. Access to appropriate cessation programmes would fulfil their willingness.
doi:10.1136/bmjopen-2014-006435
PMCID: PMC4322197  PMID: 25649211
18.  Tonsillectomy among children with low baseline acute throat infection consultation rates in UK general practices: a cohort study 
BMJ Open  2015;5(2):e006686.
Objective
To investigate the effectiveness of tonsillectomy in reducing acute throat infection (ATI) consultation rates over 6 years’ follow-up among children with low baseline ATI consultation rates.
Design
Retrospective cohort study.
Setting
UK general practices from the Clinical Practice Research Datalink.
Participants
Children aged 4–15 years with ≤3 ATI consultations during the 3 years prior to 2001 (baseline). 450 children who underwent tonsillectomy (tonsillectomy group) and 13 442 other children with an ATI consultation (comparison group) in 2001.
Main outcome measures
Mean differences in ATI consultation rates over the first 3 years’ and subsequent 3 years’ follow-up compared with 3 years prior to 2001 (baseline); odds of ≥3 ATI consultations at the same time points.
Results
Among children in the tonsillectomy group, the 3-year mean ATI consultation rate decreased from 1.31 to 0.66 over the first 3 years’ follow-up and further declined to 0.60 over the subsequent 3 years’ follow-up period. Compared with children who had no operation, those who underwent tonsillectomy experienced a reduction in 3-year mean ATI consultations per child of 2.5 (95% CI 2.3 to 2.6, p<0.001) over the first 3 years’ follow-up, but only 1.2 (95% CI 1.0 to 1.4, p<0.001) over the subsequent 3 years’ follow-up compared with baseline, respectively. This equates to a mean reduction of 3.7 ATI consultations over a 6-year period and approximates to a mean annual reduction of 0.6 ATI consultations per child, per year, over 6 years’ follow-up. Children who underwent tonsillectomy were also much less likely to experience ≥3 ATI consultations during the first 3 years’ follow-up (adjusted OR=0.12, 95% CI 0.08 to 0.17) and the subsequent 3 years’ follow-up (adjusted OR=0.24, 95% CI 0.14 to 0.41).
Conclusions
Among children with low baseline ATI rates, there was a statistically significant reduction in ATI consultation rates over 6 years’ follow-up. However, the relatively modest clinical benefit needs to be weighed against the potential risks and complications associated with surgery.
doi:10.1136/bmjopen-2014-006686
PMCID: PMC4322199  PMID: 25649213
PRIMARY CARE
19.  Older doctors and progression through specialty training in the UK: a cohort analysis of General Medical Council data 
BMJ Open  2015;5(2):e005658.
Objective
To determine whether older age at graduation is associated with any difference in outcomes from the annual specialty training progression assessment.
Design
An open cohort of 38 308 doctors who graduated from a UK medical school with annual assessments of progression in their specialty training programme with data centrally collected by the General Medical Council between 5 August 2009 to 31 July 2012.
Results
Mature junior doctors (≥29 years at graduation) were more likely to have problems with progression on their annual review of competence progression record of in training assessment (ARCP/RITA) than their younger colleagues (OR 1.34, 95% CI 1.22 to 1.49, p<0.001). This association was, if anything, even stronger (OR 1.57, 95% CI 1.41 to 1.74, p<0.001) after adjustment for gender, ethnicity, type of University and specialty. The same was true when only looking at the most extreme ARCP outcome (4) which is being asked to leave their specialist programme (OR 1.81, 95% CI 1.34 to 2.44, p<0.001).
Conclusions
Mature doctors are a growing part of the medical workforce and they are likely to broaden the spectrum of doctors by bring different life experience to the profession. These results suggest that they are more likely to have problems with progressing through their specialist training programme. More research is required to determine the reasons behind these associations and how mature doctors can be supported both in choosing the best training programme and in coping with the complex demands of higher training at a later stage in their lives.
doi:10.1136/bmjopen-2014-005658
PMCID: PMC4322203  PMID: 25649208
MEDICAL EDUCATION & TRAINING
20.  HIV research productivity and structural factors associated with HIV research output in European Union countries: a bibliometric analysis 
BMJ Open  2015;5(2):e006591.
Objectives
To assess HIV/AIDS research productivity in the 27 countries of the European Union (EU), and the structural level factors associated with levels of HIV/AIDS research productivity.
Methods
A bibliometric analysis was conducted with systematic search methods used to locate HIV/AIDS research publications (period of 1 January 2002 to 31 December 2011; search databases: MEDLINE (Ovid, PubMed), EMBASE, ISI-Thomson Web of Science; no language restrictions).
The publication rate (number of HIV/AIDS research publications per million population in 10 years) and the rate of articles published in HIV/AIDS journals and selected journals with moderate to very high (IF ≥3) 5-year impact factors were used as markers for HIV research productivity. A negative binomial regression model was fitted to assess the impact of structural level factors (sociodemographic, health, HIV prevalence and research/development indicators) associated with the variation in HIV research productivity.
Results
The total numbers of HIV/AIDS research publications in 2002–2011 by country ranged from 7 to 9128 (median 319). The median publication rate (per million population in 10 years) was 45 (range 5–150) for all publications. Across all countries, 16% of the HIV/AIDS research was published in HIV/AIDS journals and 7% in selected journals with IF ≥3. Indicators describing economic (gross domestic product), demographic (size of the population) and epidemiological (HIV prevalence) conditions as well as overall scientific activity (total research output) in a country were positively associated with HIV research productivity.
Conclusions
HIV research productivity varies noticeably across EU countries, and this variation is associated with recognisable structural factors.
doi:10.1136/bmjopen-2014-006591
PMCID: PMC4322208  PMID: 25649212
STATISTICS & RESEARCH METHODS; EPIDEMIOLOGY
21.  Association between sense of coherence in adolescence and social benefits later in life: a 12-year follow-up study 
BMJ Open  2015;5(1):e006489.
Objectives
Local government concerns over expenditure on social and healthcare are growing. The aim of the present study was to explore the association between a weak ‘sense of coherence’ (SOC) in teens and their subsequent risk of receiving social and healthcare benefits during young adulthood, and to monitor how SOC developed during this period.
Design
Prospective cohort study.
Setting
North Denmark Region.
Participants
773 Pupils from seventh and eighth forms who answered a questionnaire in 1998.
Outcome measures
Different social benefits (from the Danish DREAM database embracing disbursed public social benefits). Change in SOC score from 1998 to 2010.
Results
722 had answered seven items of the original SOC-13 questionnaire (denoted by SOC-7). Girls with a weak SOC-7 (the lowest 1st quartile) in 1998 had a significantly increased risk of receiving unemployment benefits (RR 1.3 (1.1 to 1.6)), social assistance (RR 1.8 (1.3 to 2.5)) and sickness benefits (RR 1.5 (1.2 to 2.0)) compared with girls with a strong SOC-7. For boys, only minor protective and non-significant differences were found. The SOC answers from 1998 and 2010 were compared (n=394). SOC increased significantly and mostly in girls.
Conclusions
SOC-7 may serve as a predictor for social life event outcomes and hence facilitate an early identification and a selective approach to support teenage girls with a weak SOC. From adolescence to young adulthood, SOC-7 was of a relatively unstable nature.
doi:10.1136/bmjopen-2014-006489
PMCID: PMC4316432  PMID: 25643701
EPIDEMIOLOGY; PUBLIC HEALTH; SOCIAL MEDICINE
22.  Chinese herbal medicine for resistant hypertension: a systematic review 
BMJ Open  2015;5(1):e005355.
Objectives
This study aimed to summarise the current evidence from randomised control trials (RCTs) concerning treatment of patients with resistant hypertension with Chinese herbal medicine (CHM).
Design
Seven databases, including the Cochrane Library, PubMed, EMBASE, CNKI, VIP, CBM and Wanfang, were systematically searched from their inception to March 2014 for RCTs investigating treatment of resistant hypertension in which CHM was used either as a monotherapy or in combination with conventional medicine versus placebo, no intervention or conventional medicine.
Results
Five trials containing 446 hypertensive patients were identified. The methodological quality of most trials was evaluated as generally low. All included trials compared CHM plus antihypertensive drugs with antihypertensive drugs alone for resistant hypertension. Formulations of CHM included tablet, decoction and injection. It was found that, compared with antihypertensive drugs alone, CHM (tablet) plus antihypertensive drugs resulted in clinically, but not statistically, significant reductions in systolic blood pressure (SBP; weighted mean difference (WMD)=−10.32 mm Hg; 95% CI −21.10 to 0.46; p=0.06) and diastolic blood pressure (DBP; WMD=−3.30 mm Hg; 95% CI −7.66 to 1.06; p=0.14). CHM (decoction) plus antihypertensive drugs also produced a clinically meaningful, but not statistically significant, reduction in SBP (WMD=−12.56 mm Hg; 95% CI −26.83 to 1.71; p=0.08), and did significantly decrease DBP (WMD=−7.89 mm Hg; 95% CI −11.74 to −4.04; p<0.0001). There were no significant differences in SBP (WMD=−3.50 mm Hg; 95% CI −8.95 to 1.95; p=0.21) and DBP (WMD=1.00 mm Hg; 95% CI −1.39 to 3.39; p=0.41) between CHM (injection) plus the antihypertensive drugs group and antihypertensive drugs alone. The safety of CHM remained uncertain.
Conclusions
No definite conclusions about the effectiveness and safety of CHM for resistant hypertension could be drawn. More rigorously designed trials are warranted.
doi:10.1136/bmjopen-2014-005355
PMCID: PMC4316421  PMID: 25636788
Chinese herbal medicine; resistant hypertension; systematic review
23.  Methamphetamine and cannabis abuse in adolescence: a quasi-experimental study on specific and long-term neurocognitive effects 
BMJ Open  2015;5(1):e005833.
Objectives
Methamphetamine abuse affects brain structure and function. Although methamphetamine and cannabis are commonly abused together, few studies have investigated the differential neurocognitive consequences of methamphetamine abuse with or without cannabis. Furthermore, the effects of drug use on the developing adolescent brain remain poorly understood. We compared neurocognitive function between adolescents with ‘pure’ methamphetamine abuse, those with comorbid methamphetamine and cannabis abuse, and healthy controls at baseline and follow-up.
Methods
Individuals residing in the greater Cape Town region, between the ages of 13 and 18 years, were recruited into either Methamphetamine only group (Meth-only; n=10), Methamphetamine and cannabis group (Meth-cann; n=10) or healthy control (n=20) groups using a quasi-experimental design. All participants underwent a comprehensive neurocognitive assessment. Substance-use variables and psychiatric symptom counts were also recorded. A portion of the Meth-only and control participants completed 12-month follow-up assessments.
Results
While the Meth-cann group demonstrated widespread neurocognitive deficits at baseline, these deficits were restricted to the self-monitoring domain in the Meth-only group at baseline and at follow-up.
Conclusions
Methamphetamine abuse with cannabis abuse is associated with significantly more neurocognitive impairment than methamphetamine abuse alone, and such deficits may be enduring.
doi:10.1136/bmjopen-2014-005833
PMCID: PMC4316423  PMID: 25636791
methamphetamine; cannabis; neurocognition; adolescence; externalizing
24.  Use of wind-up fetal Doppler versus Pinard for fetal heart rate intermittent monitoring in labour: a randomised clinical trial 
BMJ Open  2015;5(1):e006867.
Objectives
In resource-poor settings, the standard of care to inform labour management is the partograph plus Pinard stethoscope for intermittent fetal heart rate (FHR) monitoring. We compared FHR monitoring in labour using a novel, robust wind-up handheld Doppler with the Pinard as a primary screening tool for abnormal FHR on perinatal outcomes.
Design
Prospective equally randomised clinical trial.
Setting
The labour and delivery unit of a teaching hospital in Kampala, Uganda.
Participants
Of the 2042 eligible antenatal women, 1971 women in active term labour, following uncomplicated pregnancies, were randomised to either the standard of care or not.
Intervention
Intermittent FHR monitoring using Doppler.
Primary outcome measures
Incidence of FHR abnormality detection, intrapartum stillbirth and neonatal mortality prior to discharge.
Results
Age, parity, gestational age, mode of delivery and newborn weight were similar between study groups. In the Doppler group, there was a significantly higher rate of FHR abnormalities detected (incidence rate ratio (IRR)=1.61, 95% CI 1.13 to 2.30). However, in this group, there were also higher though not statistically significant rates of intrapartum stillbirths (IRR=3.94, 0.44 to 35.24) and neonatal deaths (IRR=1.38, 0.44 to 4.34).
Conclusions
Routine monitoring with a handheld Doppler increased the identification of FHR abnormalities in labour; however, our trial did not find evidence that this leads to a decrease in the incidence of intrapartum stillbirth or neonatal death.
Trial registration number
Clinical Trails.gov (1000031587).
doi:10.1136/bmjopen-2014-006867
PMCID: PMC4316429  PMID: 25636792
NEONATOLOGY; PRIMARY CARE
25.  Placebo effects in trials evaluating 12 selected minimally invasive interventions: a systematic review and meta-analysis 
BMJ Open  2015;5(1):e007331.
Objectives
To analyse the impact of placebo effects on outcome in trials of selected minimally invasive procedures and to assess reported adverse events in both trial arms.
Design
A systematic review and meta-analysis.
Data sources and study selection
We searched MEDLINE and Cochrane library to identify systematic reviews of musculoskeletal, neurological and cardiac conditions published between January 2009 and January 2014 comparing selected minimally invasive with placebo (sham) procedures. We searched MEDLINE for additional randomised controlled trials published between January 2000 and January 2014.
Data synthesis
Effect sizes (ES) in the active and placebo arms in the trials’ primary and pooled secondary end points were calculated. Linear regression was used to analyse the association between end points in the active and sham groups. Reported adverse events in both trial arms were registered.
Results
We included 21 trials involving 2519 adult participants. For primary end points, there was a large clinical effect (ES≥0.8) after active treatment in 12 trials and after sham procedures in 11 trials. For secondary end points, 7 and 5 trials showed a large clinical effect. Three trials showed a moderate difference in ES between active treatment and sham on primary end points (ES ≥0.5) but no trials reported a large difference. No trials showed large or moderate differences in ES on pooled secondary end points. Regression analysis of end points in active treatment and sham arms estimated an R2 of 0.78 for primary and 0.84 for secondary end points. Adverse events after sham were in most cases minor and of short duration.
Conclusions
The generally small differences in ES between active treatment and sham suggest that non-specific mechanisms, including placebo, are major predictors of the observed effects. Adverse events related to sham procedures were mainly minor and short-lived. Ethical arguments frequently raised against sham-controlled trials were generally not substantiated.
doi:10.1136/bmjopen-2014-007331
PMCID: PMC4316431  PMID: 25636794

Results 1-25 (2495)