Does Kangaroo Mother Care Reduce Anxiety in Postnatal Mothers of Preterm Babies? - A Descriptive Study from a Tertiary Care Centre in South India

BACKGROUND

To assess anxiety and depression among postnatal mothers of preterm babies and to evaluate whether Kangaroo mother care reduces their anxiety.

METHODS

This descriptive study was conducted in a tertiary care teaching hospital in south India. Anxiety and depression was assessed using Hospital Anxiety and Depression Scale in 2 groups of postnatal mothers (Pre Kangaroo mother care and post Kangaroo mother care) with 50 participants each and compared.

RESULTS

In the pre Kangaroo mother care group, abnormal sub scale scores were noted in 27 (54%) and 21 (42%) for anxiety and depression respectively. The mean Hospital Anxiety and Depression Scale anxiety subscale score was 10.1 (±4.5) and mean depression subscale score was 9.15 (±4.3) in the pre Kangaroo mother care group compared to 7.76 (± 4.8) and 7.24 (± 5.15) respectively in the post Kangaroo mother care group. The mean total Hospital Anxiety and Depression Scale score was significantly less in the post Kangaroo mother care group compared to pre Kangaroo mother care group.

CONCLUSIONS

Mothers of preterm neonates experience significant anxiety and depression during the immediate postnatal period and Kangaroo mother care can reduce their stress.

A novel patient-centered protocol to reduce hospital readmissions for dehydration after ileostomy

Early hospital readmission for dehydration represents a relevant problem among patients with diverting or terminal ileostomy. The aim of the study was to evaluate the efficacy of a new multidisciplinary individualized multistep protocol in terms of reduction of hospital readmission for dehydration. Since January 2016, our institution adopted a new protocol for patients with ileostomy. Protocol key points were: preoperative personalized education in stoma management; early recognition of dehydration symptoms; multidisciplinary counseling; patient autonomy in stoma management through post-operative recall schedule. The study compared a series of consecutive patients treated before (2014-2015) and after (2016-2017) the protocol application. The primary endpoint was hospital readmission rate after protocol use. The secondary endpoint was the identification of possible risk factors for readmission. The entire cohort was composed of 296 patients, 129 in the protocol group and 167 in the control one. The two groups were homogeneous for baseline characteristics. Hospital readmission rate within 30 days post-discharge for dehydration dropped from 9 to 3.9% after protocol application. Specifically, the number of avoided potential readmissions was 29/129 (22.4%). The number needed to treat (NNT) was 20. Univariate analysis identified three relevant variables: patient comorbidities, diuretics use as risk factors and protocol application as the protective one. The multivariate analysis confirmed patient comorbidity as the risk factor. Dehydration related to ileostomy is a potentially avoidable problem, by employing preventive strategies, especially in high-risk patients. Our new protocol could be a simple and cost-saving method, effective in preventing hospital readmissions.

Increasing the use of home medication lists in an outpatient neurorehabilitation clinic

Medication reconciliation in ambulatory care settings helps prevent adverse drug events. Patient involvement in the process is crucial, as clinicians must verify the reported medication history with other sources such as home medication lists or brown-bagged home medications provided by patients. However, only 47.8% of brain injury and stroke adult outpatients at Toronto Rehabilitation Institute, an academic rehabilitation hospital, bring their medications/medication lists to clinic visits. In turn, missing medication information impacts the clinic by causing delays in treatment and interrupted clinic flow. This project aimed to increase the percentage of patients who bring their medications/medication lists to 80% and decrease the impact on clinic visits caused by missing medication information to 10%. This was a controlled before-after study, with the outpatient rehabilitation assessment (OPRA) clinic as the intervention and the spasticity clinic as the control. The model for improvement was used as the project framework. Process mapping, Ishikawa diagrams, driver diagrams and patient surveys generated the change ideas. Verbal reminders during confirmation phone calls, written reminders and medication list templates were implemented. Data were collected on a biweekly basis and analysed using statistical control charts. After six Plan-Do-Study-Act cycles conducted over 49 weeks, both project aims were achieved. The percentage of OPRA clinic patients who brought medications/medication lists was 81.8% and the impact on clinic visits caused by missing medication information was 9.1% of clinic visits. Special cause variation was detected on the statistical control charts. Conversely, there was no special cause variation for the spasticity clinic (the control) for either aim. Lessons learnt include the importance of prolonged data collection when implementing interventions with long lag time, and that verbal reminders may not be effective for patients with cognitive impairments. Future efforts may focus on implementing the bundle of project interventions for the spasticity clinic.

[Efficacy and safety of metformin for Behcet's disease and its effect on Treg/Th17 balance: a single-blinded, before-after study]

OBJECTIVE

Behcet's disease (BD) is an autoimmune disorder that causes most commonly mouth and genital ulcerations and erythema nodules of the skin and currently has limited options of therapeutic medicines. Metformin is recently reported to suppress immune reaction, and we hypothesized that metformin could be an option for treatment of BD.

METHODS

Thirty patients with BD were enrolled in this perspective single-blinded, before-after study. We recorded the changes in the mucocutaneous activity index for BD (MAIBD), relapse frequency, C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR) after metformin treatment to assess the changes in the disease activity. We also analyzed the changes in the protein and mRNA expression levels of Foxp3, interleukin-35 (IL-35), transforming growth factor-β (TGF-β), Ror-γt, IL-17, and tumor necrosis factor-α (TNF-α) in these patients using ELISA and qRT-PCR.

RESULTS

Of the 30 patients enrolled, 26 completed the trial. After the treatment, favorable responses were achieved in 88.46% (23/26) of the patients, and partial remission was obtained in 11.54% (4/26) of them. During the treatment, 8 patients complained of gastrointestinal side effects, for which 4 chose to withdraw from the study in the first week. Our results showed that metformin treatment decreased MAIBD and relapse frequency in the patients, and significantly lowered the clinical inflammatory indexes including CRP and ESR. The results of ELISA and qRT-PCR revealed that metformin treatment obviously increased Foxp3 and TGF-β expressions at both the protein and mRNA levels and significantly decreased the levels of ROR-γt, IL-17 and TNF-α as well as IL-35 level in these patients.

CONCLUSIONS

Metformin treatment relieves the clinical symptoms, reduces the inflammatory reaction indexes and regulates the Treg/Th17 axis in patients with BD, suggesting the potential of metformin as a candidate medicine for treatment of BD.

Impact of patient information leaflets on doctor-patient communication in the context of acute conditions: a prospective, controlled, before-after study in two French emergency departments

OBJECTIVE

In the context of acute conditions seen in an emergency department, where communication may be difficult, patient information leaflets (PILs) could improve doctor-patient communication (DPC) and may have an impact on other outcomes of the consultation. Our objective was to assess the impact of PILs on DPC, patient satisfaction and adherence, and on patient and doctor behaviours.

DESIGN

Prospective, controlled, before-after trial between November 2013 and June 2015.

SETTING

Two French emergency departments.

PARTICIPANTS

Adults and adolescents >15 years diagnosed with ankle sprain or an infection (diverticulitis, infectious colitis, pyelonephritis, pneumonia or prostatitis).

INTERVENTION

Physicians in the intervention group gave patients a PIL about their condition along with an oral explanation.

MAIN OUTCOME MEASURES

7-10 days later, patients were contacted by phone to answer questionnaires. Results were derived from questions scored using a 4-point Likert scale.

MAIN FINDINGS

Analysis of the 324 patients showed that PILs improved the mean DPC score (range: 13-52), with 46 (42-49) for 168 patients with PILs vs 44 (38-48) for 156 patients without PILs (p<0.01). The adjusted OR for good communication (having a score >35/52) was 2.54 (1.27 to 5.06). The overall satisfaction and adherence scores did not show significant differences. In contrast, satisfaction with healthcare professionals and timing of medication intake were improved with PILs. The overall satisfaction score improved significantly on per-protocol analysis. When using PILs, doctors prescribed fewer drugs and more examinations (radiology, biology, appointment with a specialist); the need for a new medical consultation for the same pathology was reduced from 32.1% to 17.9% (OR 0.46 [0.27 to 0.77]), particularly revisiting the emergency department.

CONCLUSION

In emergency departments, PILs given by doctors improve DPC, increase patients' satisfaction with healthcare professionals, reduce the number of emergency reconsultations for the same pathology and modify the doctor's behaviour.

TRIAL REGISTRATION NUMBER

NCT02246361.

Effects of Intervention Program Prev@cib on Traditional Bullying and Cyberbullying

Due to the negative consequences of being bullied and the increase in cyberbullying among adolescents, there is a need for evidence-based programs to prevent and intervene in these types of peer violence. The aim of this study was to evaluate the effectiveness of the Prev@cib bullying and cyberbullying program, drawing on three theoretical frameworks: the ecological model, empowerment theory, and the model of personal and social responsibility. The Prev@cib program was evaluated using a repeated-measures pre-post-test design with an experimental group and a control group. The sample consisted of 660 adolescents between 12 and 17 years old (M = 13.58, SD = 1.26), randomly assigned to the experimental and control groups. Repeated-measures ANOVA of pre-post-test scores were conducted. Results showed a significant decrease in bullying and victimization and cyberbullying and cybervictimization in the experimental group, compared to the control group, indicating that the Prev@cib program is effective in reducing bullying and cyberbullying. Taking into account the harmful effects of these types of violence, the results have important implications in the prevention of these behaviors because they provide scientific evidence of the program’s effectiveness.

Prospective evaluation of a dynamic insulin infusion algorithm for non critically-ill diabetic patients: A before-after study

INTRODUCTION

Insulin infusion is recommended during management of diabetic patients in critical care units to rapidly achieve glycaemic stability and reduce the mortality. The application of an easy-to-use standardized protocol, compatible with the workload is preferred. Glycaemic target must quickly be reached, therefore static algorithms should be replaced by dynamic ones. The dynamic algorithm seems closer to the physiological situation and appreciates insulin sensitivity. However, the protocol must meet both safety and efficiency requirements. Indeed, apprehension from hypoglycaemia is the main deadlock with the dynamic algorithms, thus their application remains limited. In contrary to the critical care units, to date, no prospective study evaluated a dynamic algorithm of insulin infusion in non-critically ill patients.

AIM

This study primarily aimed to evaluate the efficacy of a dynamic algorithm of intravenous insulin therapy in non-critically-ill patients, and addressed its safety and feasibility in different departments of our university hospital.

METHODS

A "before-after" study was conducted in five hospital departments (endocrinology and four "non-expert" units) comparing a dynamic algorithm (during the "after" period-P2) to the static protocol (the "before" period-P1). Static protocol is based on determining insulin infusion according to an instant blood glycaemia (BG) level at a given time. In the dynamic algorithm, insulin infusion rate is determined according to the rate of change of the BG (the previous and actual BG under a specific insulin infusion rate). Additionally, two distinct glycaemic targets were defined according to the patients' profile: 100-180 mg/dl (5.5-10 mmol/l) for vigorous patients and 140-220 mg/dl (7.8-12.2 mmol/l) for frail ones. Different BG measurements for each patient were collected and recorded in a specific database (e-CRF) in order to analyse the rates of hypo- and hyperglycaemia. A satisfaction survey was also performed. A study approval was obtained from the institutional revision board before starting the study.

RESULTS

Over 8 months, 72 and 66 patients during P1 and P2 were respectively included. The dynamic algorithm was more efficient, with reduced time to control hyperglycaemia (P1 vs P2:8.3 vs 5.3 hours; HR: 2.02 [1.27; 3.21]; p<0.01), increased the number of in-target BG measurements (P1 vs P2: 37.0% vs 41.8%; p<0.05), and reduced the glycaemic variability related to each patient (P1 vs P2, %CV: 40.9 vs 38.2;p<0.05, Index Correlation Class:0.30 vs 0.14; p<0.05). In patients after the first event of hypoglycemia after having started the infusion, new events were lower (P1 vs P2: 19.4 vs 11.4; p<0.001) thanks to an earlier reaction to hypoglycaemia (8.3% during P1 vs 44.3% during P2; p = 0.004). With the dynamic algorithm, the percentage of recurrence of mild hypoglycaemia was significantly lower in frail patients (20.5% vs 10.2%; p<0.001), and in patients managed in the non-expert units (18 vs 7.1%, p<0.001). The %CV was significantly improved in frail patients (36.9%). Mean BG measurements for each patient/day were 5.5±1.1 during P1 and 6.0±1.6 during P2 (p = 0.6). The threat from hypoglycaemia and the difficulty in using dynamic algorithm are barriers for nurses' adherence.

CONCLUSIONS

This dynamic algorithm for non-critically-ill patients is more efficient and safe than the static protocol, and adapted for frail patients and non-expert units.

Effects of work conditions on provider mental well-being and quality of care: a mixed-methods intervention study in the emergency department

BACKGROUND

Emergency departments (EDs) are highly dynamic and stressful care environments that affect provider and patient outcomes. Yet, effective interventions are missing. This study evaluated prospective effects of a multi-professional organizational-level intervention on changes in ED providers' work conditions and well-being (primary outcomes) and patient-perceived quality of ED care (secondary outcome).

METHODS

A before and after study including an interrupted time-series (ITS) design over 1 year was established in the multidisciplinary ED of a tertiary referral hospital in Southern Germany. Our mixed-methods approach included standardized provider surveys, expert work observations, patient surveys, and register data. Stakeholder interviews were conducted for qualitative process evaluation. ITS data was available for 20 days pre- and post-intervention (Dec15/Jan16; Dec16/Jan17). The intervention comprised ten multi-professional meetings in which ED physicians and nurses developed solutions to work stressors in a systematic moderated process. Most solutions were consecutively implemented. Changes in study outcomes were assessed with paired t-tests and segmented regression analyses controlling for daily ED workload.

RESULTS

One hundred forty-nine surveys were returned at baseline and follow-up (response at baseline: 76 out of 170; follow-up: 73 out of 157). Forty-one ED providers participated in both waves. One hundred sixty expert work observations comprising 240 observation hours were conducted with 156 subsequent work stress reports. One thousand four hundred eighteen ED patients were surveyed. Considering primary outcomes, respondents reported more job control and less overtime hours at follow-up. Social support, job satisfaction, and depersonalization deteriorated while respondents' turnover intentions and inter-professional interruptions increased. Considering the secondary outcome, patient reports indicated improvements in ED organization and waiting times. Interviews revealed facilitators (e.g., comprehensive approach, employee participation) and barriers (e.g., understaffing, organizational constraints) for intervention implementation.

CONCLUSIONS

To the best of our knowledge, this is the first study to report prospective effects of an ED work system intervention on provider well-being and patient-perceived quality of ED care. We found inconsistent results with partial improvements in work conditions and patient perceptions of care. However, aspects of provider mental well-being deteriorated. Given the lack of organizational-level intervention research in EDs, our findings provide valuable insights into the feasibility and effects of participatory interventions in this highly dynamic hospital setting.

Workplace interventions for reducing sitting at work

BACKGROUND

A large number of people are employed in sedentary occupations. Physical inactivity and excessive sitting at workplaces have been linked to increased risk of cardiovascular disease, obesity, and all-cause mortality.

OBJECTIVES

To evaluate the effectiveness of workplace interventions to reduce sitting at work compared to no intervention or alternative interventions.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, OSH UPDATE, PsycINFO, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal up to 9 August 2017. We also screened reference lists of articles and contacted authors to find more studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cross-over RCTs, cluster-randomised controlled trials (cluster-RCTs), and quasi-RCTs of interventions to reduce sitting at work. For changes of workplace arrangements, we also included controlled before-and-after studies. The primary outcome was time spent sitting at work per day, either self-reported or measured using devices such as an accelerometer-inclinometer and duration and number of sitting bouts lasting 30 minutes or more. We considered energy expenditure, total time spent sitting (including sitting at and outside work), time spent standing at work, work productivity and adverse events as secondary outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and full-text articles for study eligibility. Two review authors independently extracted data and assessed risk of bias. We contacted authors for additional data where required.

MAIN RESULTS

We found 34 studies - including two cross-over RCTs, 17 RCTs, seven cluster-RCTs, and eight controlled before-and-after studies - with a total of 3,397 participants, all from high-income countries. The studies evaluated physical workplace changes (16 studies), workplace policy changes (four studies), information and counselling (11 studies), and multi-component interventions (four studies). One study included both physical workplace changes and information and counselling components. We did not find any studies that specifically investigated the effects of standing meetings or walking meetings on sitting time.Physical workplace changesInterventions using sit-stand desks, either alone or in combination with information and counselling, reduced sitting time at work on average by 100 minutes per workday at short-term follow-up (up to three months) compared to sit-desks (95% confidence interval (CI) -116 to -84, 10 studies, low-quality evidence). The pooled effect of two studies showed sit-stand desks reduced sitting time at medium-term follow-up (3 to 12 months) by an average of 57 minutes per day (95% CI -99 to -15) compared to sit-desks. Total sitting time (including sitting at and outside work) also decreased with sit-stand desks compared to sit-desks (mean difference (MD) -82 minutes/day, 95% CI -124 to -39, two studies) as did the duration of sitting bouts lasting 30 minutes or more (MD -53 minutes/day, 95% CI -79 to -26, two studies, very low-quality evidence).We found no significant difference between the effects of standing desks and sit-stand desks on reducing sitting at work. Active workstations, such as treadmill desks or cycling desks, had unclear or inconsistent effects on sitting time.Workplace policy changesWe found no significant effects for implementing walking strategies on workplace sitting time at short-term (MD -15 minutes per day, 95% CI -50 to 19, low-quality evidence, one study) and medium-term (MD -17 minutes/day, 95% CI -61 to 28, one study) follow-up. Short breaks (one to two minutes every half hour) reduced time spent sitting at work on average by 40 minutes per day (95% CI -66 to -15, one study, low-quality evidence) compared to long breaks (two 15-minute breaks per workday) at short-term follow-up.Information and counsellingProviding information, feedback, counselling, or all of these resulted in no significant change in time spent sitting at work at short-term follow-up (MD -19 minutes per day, 95% CI -57 to 19, two studies, low-quality evidence). However, the reduction was significant at medium-term follow-up (MD -28 minutes per day, 95% CI -51 to -5, two studies, low-quality evidence).Computer prompts combined with information resulted in no significant change in sitting time at work at short-term follow-up (MD -14 minutes per day, 95% CI -39 to 10, three studies, low-quality evidence), but at medium-term follow-up they produced a significant reduction (MD -55 minutes per day, 95% CI -96 to -14, one study). Furthermore, computer prompting resulted in a significant decrease in the average number (MD -1.1, 95% CI -1.9 to -0.3, one study) and duration (MD -74 minutes per day, 95% CI -124 to -24, one study) of sitting bouts lasting 30 minutes or more.Computer prompts with instruction to stand reduced sitting at work on average by 14 minutes per day (95% CI 10 to 19, one study) more than computer prompts with instruction to walk at least 100 steps at short-term follow-up.We found no significant reduction in workplace sitting time at medium-term follow-up following mindfulness training (MD -23 minutes per day, 95% CI -63 to 17, one study, low-quality evidence). Similarly a single study reported no change in sitting time at work following provision of highly personalised or contextualised information and less personalised or contextualised information. One study found no significant effects of activity trackers on sitting time at work.Multi-component interventions Combining multiple interventions had significant but heterogeneous effects on sitting time at work (573 participants, three studies, very low-quality evidence) and on time spent in prolonged sitting bouts (two studies, very low-quality evidence) at short-term follow-up.

AUTHORS' CONCLUSIONS

At present there is low-quality evidence that the use of sit-stand desks reduce workplace sitting at short-term and medium-term follow-ups. However, there is no evidence on their effects on sitting over longer follow-up periods. Effects of other types of interventions, including workplace policy changes, provision of information and counselling, and multi-component interventions, are mostly inconsistent. The quality of evidence is low to very low for most interventions, mainly because of limitations in study protocols and small sample sizes. There is a need for larger cluster-RCTs with longer-term follow-ups to determine the effectiveness of different types of interventions to reduce sitting time at work.

Microscopic evaluation of traffic safety at signal coordinated intersections: A before-after study

OBJECTIVE

This research aims to evaluate the safety impacts of signal coordination on signalized intersections and provide a scientific basis to design and improve signal control and management from a traffic safety perspective.

METHODS

A kernel regression model is adopted to evaluate the safety performance of intersections before and after implementing the signal coordination strategy. By using this statistical method, the authors identify the nonlinear relationship between crash frequency and the crash's spatial location and examine the discrepancy of crash spatial distributions between the coordination and noncoordination conditions at disaggregated levels, such as time of day and crash type. A case study is presented with the use of Michigan crash data (2003-2007).

RESULTS

The study finds that the (1) crash distribution on arterials tends to be spatially disperse when the signal coordination is in operation and (2) crash frequency at the approaches of intersections is increased with the use of signal coordination under the following conditions: Nonpeak hours, rear-end and sideswipe crashes, intersections with low speed limits, and both injury and property damage-only crashes.

CONCLUSION

Signal coordination poses safety concerns in addition to its operational benefits for intersections.

Organisation of health services for preventing and treating pressure ulcers

BACKGROUND

Pressure ulcers, which are a localised injury to the skin, or underlying tissue, or both, occur when people are unable to reposition themselves to relieve pressure on bony prominences. Pressure ulcers are often difficult to heal, painful, expensive to manage and have a negative impact on quality of life. While individual patient safety and quality care stem largely from direct healthcare practitioner-patient interactions, each practitioner-patient wound-care contact may be constrained or enhanced by healthcare organisation of services. Research is needed to demonstrate clearly the effect of different provider-orientated approaches to pressure ulcer prevention and treatment.

OBJECTIVES

To assess the effects of different provider-orientated interventions targeted at the organisation of health services, on the prevention and treatment of pressure ulcers.

SEARCH METHODS

In April 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched three clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs, non-RCTs, controlled before-and-after studies and interrupted time series, which enrolled people at risk of, or people with existing pressure ulcers, were eligible for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment, data extraction and GRADE assessment of the certainty of evidence.

MAIN RESULTS

The search yielded a total of 3172 citations and, following screening and application of the inclusion and exclusion criteria, we deemed four studies eligible for inclusion. These studies reported the primary outcome of pressure ulcer incidence or pressure ulcer healing, or both.One controlled before-and-after study explored the impact of transmural care (a care model that provided activities to support patients and their family/partners and activities to promote continuity of care), among 62 participants with spinal cord injury. It is unclear whether transmural care leads to a difference in pressure ulcer incidence compared with usual care (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.53 to 1.64; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision).One RCT explored the impact of hospital-in-the-home care, among 100 older adults. It is unclear whether hospital-in-the-home care leads to a difference in pressure ulcer incidence risk compared with hospital admission (RR 0.32, 95% CI 0.03 to 2.98; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision).A third study (cluster-randomised stepped-wedge trial), explored the impact of being cared for by enhanced multidisciplinary teams (EMDT), among 161 long-term-care residents. The analyses of the primary outcome used measurements of 201 pressure ulcers from 119 residents. It is unclear if EMDT reduces the pressure ulcer incidence rate compared with usual care (hazard ratio (HR) 1.12, 95% CI 0.74 to 1.68; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear whether there is a difference in the number of wounds healed (RR 1.69, 95% CI 1.00 to 2.87; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear whether there is a difference in the reduction in surface area, with and without EMDT, (healing rate 1.006; 95% CI 0.99 to 1.03; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear if EMDT leads to a difference in time to complete healing (HR 1.48, 95% CI 0.79 to 2.78, very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision).The final study (quasi-experimental cluster trial), explored the impact of multidisciplinary wound care among 176 nursing home residents. It is unclear whether there is a difference in the number of pressure ulcers healed between multidisciplinary care, or usual care (RR 1.18, 95% CI 0.98 to 1.42; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear if this type of care leads to a difference in time to complete healing compared with usual care (HR 1.73, 95% CI 1.20 to 2.50; very low-certainty evidence; downgraded twice for very serious study limitations and twice for very serious imprecision).In all studies the certainty of the evidence is very low due to high risk of bias and imprecision. We downgraded the evidence due to study limitations, which included selection and attrition bias, and sample size. Secondary outcomes, such as adverse events were not reported in all studies. Where they were reported it was unclear if there was a difference as the certainty of evidence was very low.

AUTHORS' CONCLUSIONS

Evidence for the impact of organisation of health services for preventing and treating pressure ulcers remains unclear. Overall, GRADE assessments of the evidence resulted in judgements of very low-certainty evidence. The studies were at high risk of bias, and outcome measures were imprecise due to wide confidence intervals and small sample sizes, meaning that additional research is required to confirm these results. The secondary outcomes reported varied across the studies and some were not reported. We judged the evidence from those that were reported (including adverse events), to be of very low certainty.

Knowledge of health professional students on waterpipe tobacco smoking: curricula implications

BACKGROUND

Tobacco prevention research traditionally focuses upon cigarette smoking, but there is also a need to implement and evaluate the usefulness of waterpipe tobacco smoking (WTS) interventions since it is considered less harmful than cigarettes. This study aimed to assess the impact of an educational intervention on WTS knowledge of health professional students in three academic health institutions in Bahrain.

METHODS

A quasi-experimental design was used to include medical students from the Arabian Gulf University, medical and nursing students from the Royal College of Surgeons in Ireland-Bahrain and nursing students from the University of Bahrain. Two hundred fifty students participated in the three phases of the study during October 2015-June 2016 from an original sample of 335. The participants answered knowledge questions on WTS before and after an intervention, which included a lecture by an expert and a video on the awareness about the health hazards of WTS.

RESULTS

The mean age of starting cigarette and WTS was 16.8 ± 2.8 and 17.5 ± 1.7 years, respectively. The prevalence of ever smoking any type of tobacco among students was 22.4% (medical 25.8% and nursing 37.5%) and that of WTS, 17.7% (medical 20.0%, nursing 13.6%). The prevalence of current cigarette smoking was 9.6% among medical and nursing students combined with 10.3 and 8.5% for medical and nursing students, respectively. WTS was prevalent at a proportion of 6.8% among medical and nursing students combined with 6.5% in medical and 14.8% in nursing students. The university curriculum as the main source of knowledge on WTS increased from 14.2 to 33.3% after the intervention (p < 0.005). Knowledge about the hazards of WTS increased in 16 of the 20 statements. The difference in overall knowledge score was significant (p < 0.05) for nursing (77. 5 ± 1.5 vs 85.8 ± 2.2) compared to medical students (85.3 ± 1.0 vs 87.3 ± 0.9) after the intervention.

CONCLUSIONS

Our educational intervention with health professional students improved their knowledge about the health effects of WTS. Medical and nursing institutions may consider using various methods such as informative videos and expert lectures to include in their teaching curricula as part of WTS prevention strategies.

Evaluation of the effectiveness and safety of a daily dose of 5 mg of tadalafil, over an 8-week period, for improving quality of life among Korean men with andropause symptoms, including erectile dysfunction: A pilot study

BACKGROUND

The primary aim of this study was to evaluate the effects of a once-a-day 5 mg dose of tadalafil, prescribed for 8 weeks, on the quality of life (QoL) of South Korean men with andropause symptoms, including erectile dysfunction (ED), using a single group, open-labeled, before-and-after preliminary trial. The secondary objective was to evaluate the effectiveness and safety of tadalafil for ED.

METHODS

Forty South Korean men (>35 years of age) with andropause symptoms including ED were enrolled into our trial. Andropause syndrome was defined using the androgen deficiency in aging males (ADAM) questionnaire and other screening tests, including testosterone levels. The following outcome measures were obtained at baseline and at 4 and 8 weeks of tadalafil treatment: physical examination, adverse effects, Short Form 12 Health Survey (SF-12) score, International Index of Erectile Function (IIEF-5) score, bioelectrical impedance analysis (BIA), and free radical testing.

RESULTS

Treatment increased the SF-12 Mental component score, used as a proxy measure of quality of life, from baseline to at 4 and 8 weeks (P < .05). In addition, the mean IIEF-5 score, which assesses sexual function, increased from baseline at 4 and 8 weeks (P < .05), with this increase being significant at both time points. No adverse effects were noted.

CONCLUSION

Tadalafil (5 mg dose, once daily) is a safe and effective treatment to improve ED, and overall QoL, among Korean men with andropause symptoms, including ED.

Effectiveness and efficiency of tele-expertise for improving access to retinopathy screening among 351 neonates in a secondary care center: An observational, controlled before-after study

In France, secondary care hospitals encounter difficulties to adhere to retinopathy of prematurity (ROP) screening guidelines. Our objective was to assess the effectiveness and efficacy of a tele-expertise program for ROP screening in neonatal intensive care units without on-site ophthalmologists. We evaluated the impact of a tele-expertise program funded by the Paris Region Health Authority in a secondary care center general hospital of the Paris Region (CHSF), where there was previously no on-site ophthalmologist. We performed an observational, controlled before-after study, with a university tertiary care center with on-site ophthalmologists (Port-Royal) as the control group. Recruitment and data collection for both periods took place from 1 January 2012 to 31 December 31 2012, and from 1 January 2014 to 31 March 2015. The primary endpoint was the percentage of compliance with screening guidelines, secondary endpoints included pain scores and costs. Over the two periods, at total of 351 infants were recruited in the CHSF. Implementation of the tele-expertise resulted in an absolute +57.3% increase in the proportion of examinations realized in accordance with guidelines (3.8% during the "before" period and 61.1% during the "after" period, p<0.001). As compared with the control group, the proportion of infants appropriately screened improved (57.5% versus 43.1%, p = 0.002); median pain score on the acute pain rating scale for neonates during examination was significantly higher (median score 5.5/10, range [2.5-5.7] versus 2.0/10, range [1.0-3.1], p = 0.002). Screening rates in the control group remained unchanged. The average cost per examination increased from €337 in the "before" period to €353 in the "after period" in the tele-expertise group. The implementation of tele-expertise for ROP screening in the CHSF medical center resulted in a major improvement of access to care with a small cost increase. The issue of pain control during examination with tele-expertise should be further addressed.

A Before and After Analysis of Health Care Utilization by Patients Enrolled in Opioid Controlled Substance Agreements for Chronic Noncancer Pain

OBJECTIVE

To evaluate the impact of opioid controlled substance agreements (CSAs) enrollment on health care utilization.

PATIENTS AND METHODS

We retrospectively evaluated health care utilization changes among 772 patients receiving long-term opioid therapy for chronic noncancer pain enrolled in a CSA between July 1, 2015, and December 31, 2015. We ascertained patient characteristics and utilization 12 months before and after CSA enrollment. Decreased utilization was defined as a decrease of 1 or more hospitalizations or emergency department visits and 3 or more outpatient primary and specialty care visits. Multivariate modeling assessed demographic characteristics associated with utilization changes.

RESULTS

The 772 patients enrolled in an opioid CSA during the study period had a mean ± SD age of 63.5±14.9 years and were predominantly female, white, and married. The CSA enrollment was associated with decreased outpatient primary care visits (odds ratio [OR], 0.16; 95% CI, 0.14-0.19) and increased diagnostic radiology services (OR, 1.22; 95% CI, 1.02-1.47). After CSA enrollment, patients with greater comorbidity (Charlson Comorbidity Index score >3) were more likely to have reduced hospitalizations (adjusted OR, 2.8; 95% CI, 1.3-6.0; P=.008), reduced outpatient primary care visits (adjusted OR, 2.0; 95% CI, 1.2-3.2; P=.005), and reduced specialty care visits (adjusted OR, 2.0; 95% CI, 1.2-3.3; P=.006).

CONCLUSION

For patients receiving long-term opioid therapy for chronic noncancer pain, CSA enrollment is associated with reductions in primary care visits and increased radiologic service utilization. Patients with greater comorbidity were more likely to have reductions in hospitalizations, outpatient primary care visits, and outpatient specialty clinic visits after CSA enrollment. The observational nature of the study does not allow the conclusion that CSA implementation is the primary reason for these observed changes.

Non-clinical interventions for reducing unnecessary caesarean section

BACKGROUND

Caesarean section rates are increasing globally. The factors contributing to this increase are complex, and identifying interventions to address them is challenging. Non-clinical interventions are applied independently of a clinical encounter between a health provider and a patient. Such interventions may target women, health professionals or organisations. They address the determinants of caesarean births and could have a role in reducing unnecessary caesarean sections. This review was first published in 2011. This review update will inform a new WHO guideline, and the scope of the update was informed by WHO's Guideline Development Group for this guideline.

OBJECTIVES

To evaluate the effectiveness and safety of non-clinical interventions intended to reduce unnecessary caesarean section.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers in March 2018. We also searched websites of relevant organisations and reference lists of related reviews.

SELECTION CRITERIA

Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series studies and repeated measures studies were eligible for inclusion. The primary outcome measures were: caesarean section, spontaneous vaginal birth and instrumental birth.

DATA COLLECTION AND ANALYSIS

We followed standard methodological procedures recommended by Cochrane. We narratively described results of individual studies (drawing summarised evidence from single studies assessing distinct interventions).

MAIN RESULTS

We included 29 studies in this review (19 randomised trials, 1 controlled before-after study and 9 interrupted time series studies). Most of the studies (20 studies) were conducted in high-income countries and none took place in low-income countries. The studies enrolled a mixed population of pregnant women, including nulliparous women, multiparous women, women with a fear of childbirth, women with high levels of anxiety and women having undergone a previous caesarean section.Overall, we found low-, moderate- or high-certainty evidence that the following interventions have a beneficial effect on at least one primary outcome measure and no moderate- or high-certainty evidence of adverse effects.Interventions targeted at women or familiesChildbirth training workshops for mothers alone may reduce caesarean section (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.33 to 0.89) and may increase spontaneous vaginal birth (RR 2.25, 95% CI 1.16 to 4.36). Childbirth training workshops for couples may reduce caesarean section (RR 0.59, 95% CI 0.37 to 0.94) and may increase spontaneous vaginal birth (RR 2.13, 95% CI 1.09 to 4.16). We judged this one study with 60 participants to have low-certainty evidence for the outcomes above.Nurse-led applied relaxation training programmes (RR 0.22, 95% CI 0.11 to 0.43; 104 participants, low-certainty evidence) and psychosocial couple-based prevention programmes (RR 0.53, 95% CI 0.32 to 0.90; 147 participants, low-certainty evidence) may reduce caesarean section. Psychoeducation may increase spontaneous vaginal birth (RR 1.33, 95% CI 1.11 to 1.61; 371 participants, low-certainty evidence). The control group received routine maternity care in all studies.There were insufficient data on the effect of the four interventions on maternal and neonatal mortality or morbidity.Interventions targeted at healthcare professionalsImplementation of clinical practice guidelines combined with mandatory second opinion for caesarean section indication slightly reduces the risk of overall caesarean section (mean difference in rate change -1.9%, 95% CI -3.8 to -0.1; 149,223 participants). Implementation of clinical practice guidelines combined with audit and feedback also slightly reduces the risk of caesarean section (risk difference (RD) -1.8%, 95% CI -3.8 to -0.2; 105,351 participants). Physician education by local opinion leader (obstetrician-gynaecologist) reduced the risk of elective caesarean section to 53.7% from 66.8% (opinion leader education: 53.7%, 95% CI 46.5 to 61.0%; control: 66.8%, 95% CI 61.7 to 72.0%; 2496 participants). Healthcare professionals in the control groups received routine care in the studies. There was little or no difference in maternal and neonatal mortality or morbidity between study groups. We judged the certainty of evidence to be high.Interventions targeted at healthcare organisations or facilitiesCollaborative midwifery-labourist care (in which the obstetrician provides in-house labour and delivery coverage, 24 hours a day, without competing clinical duties), versus a private practice model of care, may reduce the primary caesarean section rate. In one interrupted time series study, the caesarean section rate decreased by 7% in the year after the intervention, and by 1.7% per year thereafter (1722 participants); the vaginal birth rate after caesarean section increased from 13.3% before to 22.4% after the intervention (684 participants). Maternal and neonatal mortality were not reported. We judged the certainty of evidence to be low.We studied the following interventions, and they either made little or no difference to caesarean section rates or had uncertain effects.Moderate-certainty evidence suggests little or no difference in caesarean section rates between usual care and: antenatal education programmes for physiologic childbirth; antenatal education on natural childbirth preparation with training in breathing and relaxation techniques; computer-based decision aids; individualised prenatal education and support programmes (versus written information in pamphlet).Low-certainty evidence suggests little or no difference in caesarean section rates between usual care and: psychoeducation; pelvic floor muscle training exercises with telephone follow-up (versus pelvic floor muscle training without telephone follow-up); intensive group therapy (cognitive behavioural therapy and childbirth psychotherapy); education of public health nurses on childbirth classes; role play (versus standard education using lectures); interactive decision aids (versus educational brochures); labourist model of obstetric care (versus traditional model of obstetric care).We are very uncertain as to the effect of other interventions identified on caesarean section rates as the certainty of the evidence is very low.

AUTHORS' CONCLUSIONS

We evaluated a wide range of non-clinical interventions to reduce unnecessary caesarean section, mostly in high-income settings. Few interventions with moderate- or high-certainty evidence, mainly targeting healthcare professionals (implementation of guidelines combined with mandatory second opinion, implementation of guidelines combined with audit and feedback, physician education by local opinion leader) have been shown to safely reduce caesarean section rates. There are uncertainties in existing evidence related to very-low or low-certainty evidence, applicability of interventions and lack of studies, particularly around interventions targeted at women or families and healthcare organisations or facilities.

Interventions to improve the appropriate use of polypharmacy for older people

BACKGROUND

Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing. This is the second update of this Cochrane Review.

OBJECTIVES

To determine which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older people.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 7 February 2018, together with handsearching of reference lists to identify additional studies.

SELECTION CRITERIA

We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people aged 65 years and older, prescribed polypharmacy (four or more medicines), which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people).

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We identified 32 studies, 20 from this update. Included studies consisted of 18 randomised trials, 10 cluster randomised trials (one of which was a stepped-wedge design), two non-randomised trials and two controlled before-after studies. One intervention consisted of computerised decision support (CDS); and 31 were complex, multi-faceted pharmaceutical-care based approaches (i.e. the responsible provision of medicines to improve patient's outcomes), one of which incorporated a CDS component as part of their multi-faceted intervention. Interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists and geriatricians, and all were conducted in high-income countries. Assessments using the Cochrane 'Risk of bias' tool, found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low.It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool), mean difference (MD) -4.76, 95% CI -9.20 to -0.33; 5 studies, N = 517; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs), (standardised mean difference (SMD) -0.22, 95% CI -0.38 to -0.05; 7 studies; N = 1832; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIMs, (risk ratio (RR) 0.79, 95% CI 0.61 to 1.02; 11 studies; N = 3079; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.81, 95% CI -0.98 to -0.64; 2 studies; N = 569; low-certainty evidence), however it must be noted that this effect estimate is based on only two studies, which had serious limitations in terms of risk bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPOs (RR 0.40, 95% CI 0.18 to 0.85; 5 studies; N = 1310; very low-certainty evidence). Pharmaceutical care may make little or no difference in hospital admissions (data not pooled; 12 studies; N = 4052; low-certainty evidence). Pharmaceutical care may make little or no difference in quality of life (data not pooled; 12 studies; N = 3211; low-certainty evidence). Medication-related problems were reported in eight studies (N = 10,087) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies.

AUTHORS' CONCLUSIONS

It is unclear whether interventions to improve appropriate polypharmacy, such as reviews of patients' prescriptions, resulted in clinically significant improvement; however, they may be slightly beneficial in terms of reducing potential prescribing omissions (PPOs); but this effect estimate is based on only two studies, which had serious limitations in terms of risk bias.

Magnesium sulfate therapy after cardiac surgery: a before-and-after study comparing strategies involving bolus and continuous infusion

BACKGROUND

Magnesium therapy may reduce the risk of atrial fibrillation after cardiac surgery. However, studies are heterogeneous in relation to dosage and method of delivery and no studies have directly compared the biochemical effect of different delivery strategies.

AIMS

We conducted a before-and-after study to compare the effects of two strategies of magnesium delivery after cardiac surgery.

METHODS

We conducted a prospective interventional before-and-after study. We enrolled patients admitted to the intensive care unit (ICU) after cardiac surgery and with no history of renal failure. The before period consisted of a single 20 mmol of magnesium sulfate bolus administered over one hour. The after period comprised a 10 mmol magnesium loading dose over one hour followed by a continuous infusion at 3 mmol/h for 12 hours. We measured serum and urine magnesium levels at baseline (T0), at the end of loading dose (T1), 6 (T2) and 12 hours after the intervention (T3).

RESULTS

We enrolled 60 patients (30 in each group) with similar baseline characteristics. In the before period, patients had a higher peak serum magnesium level at T1 (1.88 ± 0.06 v 1.59 ± 0.04 mmo/L; P < 0.001) compared with the after period. However, at 6 hours, patients in the after period had a significantly higher magnesium level (1.61 ± 0.04 v 1.29 ± 0.26 mmol/L; P < 0.001) and this level remained higher at 12 hours (1.70 ± 0.05 v 1.17 ± 0.02; P < 0.001), leading to increased time-weighted magnesaemia (P < 0.001). These changes occurred despite a significantly increased urinary magnesium concentration, fractional excretion of magnesium, and magnesium clearance, which paralleled changes in magnesaemia (P < 0.001).

CONCLUSIONS

The strategy of a 10 mmol magnesium bolus followed by a continuous infusion over 12 hours achieved a more sustained and moderately elevated magnesium concentration in comparison to a single 20 mmol bolus, despite increased urinary losses of magnesium. Further studies are required to assess a more extended continuous infusion.

The efficacy of a brief hazard perception interventional program for child bicyclists to improve perceptive standards

INTRODUCTION

Even though child bicyclists are highly vulnerable in traffic only few studies focused on providing child bicyclists with means to enhance their abilities to deal with the complexity of dynamic traffic situations. The current study therefore evaluated whether a brief hazard perception intervention might be effective to improve hazard perception skills in child bicyclists towards a level more comparable to adult bicyclists.

METHODS

Eighty children of the fourth grade (9.03 ± 0.43 years; 34 girls) and forty-six adults (34.67 ± 14.25 years age; 24 woman) first performed a Hazard Perception test for bicyclists. Response rate, reaction times, first fixation, duration of the first fixation, dwell time and total number of fixations on the events were measured. Next, the children took part in the HP intervention in which video clips of dangerous traffic situations were presented. The intervention comprised two classroom sessions of one hour (1/week). A post-test was performed one day after and the retention-test three weeks after the intervention.

RESULTS

Children responded to more covert hazards immediately after the intervention (p < 0.05), but did not improve their response rate for overt hazards. Reaction times for the covert hazards improved on the post-test (p < 0.001) compared to the pre-test but this effect was reduced on the retention test. There was no effect of the intervention for entry time of the first fixation but the duration of the first fixation increased for the covert hazards (p < 0.05). Children made fewer fixations on the event compared to adults (p < 0.001), except for the covert hazards on the retention-test. The training also increased the number of fixations for the overt hazards on the post-test (p < 0.001) and the retention-test (p < 0.001) but only increased on the retention test for the covert hazards (p < 0.001).

CONCLUSION

The results demonstrated that a brief intervention for training hazard perception skills in child bicyclists is able to improve children's situation awareness and hazard perception for potential dangerous situations. The training, however, was too short to improve children to higher adult levels.

Workplace interventions for reducing sitting at work

BACKGROUND

A large number of people are employed in sedentary occupations. Physical inactivity and excessive sitting at workplaces have been linked to increased risk of cardiovascular disease, obesity, and all-cause mortality.

OBJECTIVES

To evaluate the effectiveness of workplace interventions to reduce sitting at work compared to no intervention or alternative interventions.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, OSH UPDATE, PsycINFO, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal up to 9 August 2017. We also screened reference lists of articles and contacted authors to find more studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cross-over RCTs, cluster-randomised controlled trials (cluster-RCTs), and quasi-RCTs of interventions to reduce sitting at work. For changes of workplace arrangements, we also included controlled before-and-after studies. The primary outcome was time spent sitting at work per day, either self-reported or measured using devices such as an accelerometer-inclinometer and duration and number of sitting bouts lasting 30 minutes or more. We considered energy expenditure, total time spent sitting (including sitting at and outside work), time spent standing at work, work productivity and adverse events as secondary outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and full-text articles for study eligibility. Two review authors independently extracted data and assessed risk of bias. We contacted authors for additional data where required.

MAIN RESULTS

We found 34 studies - including two cross-over RCTs, 17 RCTs, seven cluster-RCTs, and eight controlled before-and-after studies - with a total of 3,397 participants, all from high-income countries. The studies evaluated physical workplace changes (16 studies), workplace policy changes (four studies), information and counselling (11 studies), and multi-component interventions (four studies). One study included both physical workplace changes and information and counselling components. We did not find any studies that specifically investigated the effects of standing meetings or walking meetings on sitting time.Physical workplace changesInterventions using sit-stand desks, either alone or in combination with information and counselling, reduced sitting time at work on average by 100 minutes per workday at short-term follow-up (up to three months) compared to sit-desks (95% confidence interval (CI) -116 to -84, 10 studies, low-quality evidence). The pooled effect of two studies showed sit-stand desks reduced sitting time at medium-term follow-up (3 to 12 months) by an average of 57 minutes per day (95% CI -99 to -15) compared to sit-desks. Total sitting time (including sitting at and outside work) also decreased with sit-stand desks compared to sit-desks (mean difference (MD) -82 minutes/day, 95% CI -124 to -39, two studies) as did the duration of sitting bouts lasting 30 minutes or more (MD -53 minutes/day, 95% CI -79 to -26, two studies, very low-quality evidence).We found no significant difference between the effects of standing desks and sit-stand desks on reducing sitting at work. Active workstations, such as treadmill desks or cycling desks, had unclear or inconsistent effects on sitting time.Workplace policy changesWe found no significant effects for implementing walking strategies on workplace sitting time at short-term (MD -15 minutes per day, 95% CI -50 to 19, low-quality evidence, one study) and medium-term (MD -17 minutes/day, 95% CI -61 to 28, one study) follow-up. Short breaks (one to two minutes every half hour) reduced time spent sitting at work on average by 40 minutes per day (95% CI -66 to -15, one study, low-quality evidence) compared to long breaks (two 15-minute breaks per workday) at short-term follow-up.Information and counsellingProviding information, feedback, counselling, or all of these resulted in no significant change in time spent sitting at work at short-term follow-up (MD -19 minutes per day, 95% CI -57 to 19, two studies, low-quality evidence). However, the reduction was significant at medium-term follow-up (MD -28 minutes per day, 95% CI -51 to -5, two studies, low-quality evidence).Computer prompts combined with information resulted in no significant change in sitting time at work at short-term follow-up (MD -10 minutes per day, 95% CI -45 to 24, two studies, low-quality evidence), but at medium-term follow-up they produced a significant reduction (MD -55 minutes per day, 95% CI -96 to -14, one study). Furthermore, computer prompting resulted in a significant decrease in the average number (MD -1.1, 95% CI -1.9 to -0.3, one study) and duration (MD -74 minutes per day, 95% CI -124 to -24, one study) of sitting bouts lasting 30 minutes or more.Computer prompts with instruction to stand reduced sitting at work on average by 14 minutes per day (95% CI 10 to 19, one study) more than computer prompts with instruction to walk at least 100 steps at short-term follow-up.We found no significant reduction in workplace sitting time at medium-term follow-up following mindfulness training (MD -23 minutes per day, 95% CI -63 to 17, one study, low-quality evidence). Similarly a single study reported no change in sitting time at work following provision of highly personalised or contextualised information and less personalised or contextualised information. One study found no significant effects of activity trackers on sitting time at work.Multi-component interventions Combining multiple interventions had significant but heterogeneous effects on sitting time at work (573 participants, three studies, very low-quality evidence) and on time spent in prolonged sitting bouts (two studies, very low-quality evidence) at short-term follow-up.

AUTHORS' CONCLUSIONS

At present there is low-quality evidence that the use of sit-stand desks reduce workplace sitting at short-term and medium-term follow-ups. However, there is no evidence on their effects on sitting over longer follow-up periods. Effects of other types of interventions, including workplace policy changes, provision of information and counselling, and multi-component interventions, are mostly inconsistent. The quality of evidence is low to very low for most interventions, mainly because of limitations in study protocols and small sample sizes. There is a need for larger cluster-RCTs with longer-term follow-ups to determine the effectiveness of different types of interventions to reduce sitting time at work.

Treatment of cutaneous leishmaniasis with thermotherapy in Brazil: an efficacy and safety study

BACKGROUND

Pentavalent antimonials remain as the standard drugs in the treatment of cutaneous leishmaniosis. The high cost, difficult administration, long treatment time, toxicity and increasing morbidity are factors that limit the use of these drugs.

OBJECTIVES

To describe the response to radiofrequency thermotherapy in the treatment of localized cutaneous leishmaniasis in Brazil, and to evaluate its safety and tolerability.

METHODS

We conducted a non-comparative open trial with a total of 15 patients confirmed to have cutaneous leishmaniasis on parasitological examination. A single radiofrequency thermotherapy session at 50ºC for 30 seconds was applied to the lesion and its edges. In patients with more than one lesion, only the largest one was treated initially. If after 30 days there was no evidence of healing, the smaller lesion was also treated with thermotherapy. Clinical cure was defined as visible healing for three months after treatment. The patients were followed-up for six months and there was no follow-up loss.

RESULTS

Of all 23 lesions, only two evolved to complete healing without the need of treatment. Of 21 lesions, 18 (85.7%) achieved full healing. The main observed side effects were itching, burning sensation, pain and blisters.

STUDY LIMITATIONS

Sample with a small number of patients and short follow-up.

CONCLUSION

Thermotherapy can be considered a therapeutic alternative in localized cutaneous leishmaniasis, especially in cases of single cutaneous lesions and with formal contraindications to conventional treatment with pentavalent antimonials.

Contracting out to improve the use of clinical health services and health outcomes in low- and middle-income countries

BACKGROUND

Contracting out of governmental health services is a financing strategy that governs the way in which public sector funds are used to have services delivered by non-governmental health service providers (NGPs). It represents a contract between the government and an NGP, detailing the mechanisms and conditions by which the latter should provide health care on behalf of the government. Contracting out is intended to improve the delivery and use of healthcare services. This Review updates a Cochrane Review first published in 2009.

OBJECTIVES

To assess effects of contracting out governmental clinical health services to non-governmental service provider/s, on (i) utilisation of clinical health services; (ii) improvement in population health outcomes; (iii) improvement in equity of utilisation of these services; (iv) costs and cost-effectiveness of delivering the services; and (v) improvement in health systems performance.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, NHS Economic Evaluation Database, EconLit, ProQuest, and Global Health on 07 April 2017, along with two trials registers - ClinicalTrials.gov and the International Clinical Trials Registry Platform - on 17 November 2017.

SELECTION CRITERIA

Individually randomised and cluster-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies, comparing government-delivered clinical health services versus those contracted out to NGPs, or comparing different models of non-governmental-delivered clinical health services.

DATA COLLECTION AND ANALYSIS

Two authors independently screened all records, extracted data from the included studies and assessed the risk of bias. We calculated the net effect for all outcomes. A positive value favours the intervention whilst a negative value favours the control. Effect estimates are presented with 95% confidence intervals. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence and we prepared a Summary of Findings table.

MAIN RESULTS

We included two studies, a cluster-randomised trial conducted in Cambodia, and a controlled before-after study conducted in Guatemala. Both studies reported that contracting out over 12 months probably makes little or no difference in (i) immunisation uptake of children 12 to 24 months old (moderate-certainty evidence), (ii) the number of women who had more than two antenatal care visits (moderate-certainty evidence), and (iii) female use of contraceptives (moderate-certainty evidence).The Cambodia trial reported that contracting out may make little or no difference in the mortality over 12 months of children younger than one year of age (net effect = -4.3%, intervention effect P = 0.36, clustered standard error (SE) = 3.0%; low-certainty evidence), nor to the incidence of childhood diarrhoea (net effect = -16.2%, intervention effect P = 0.07, clustered SE = 19.0%; low-certainty evidence). The Cambodia study found that contracting out probably reduces individual out-of-pocket spending over 12 months on curative care (net effect = $ -19.25 (2003 USD), intervention effect P = 0.01, clustered SE = $ 5.12; moderate-certainty evidence). The included studies did not report equity in the use of clinical health services and in adverse effects.

AUTHORS' CONCLUSIONS

This update confirms the findings of the original review. Contracting out probably reduces individual out-of-pocket spending on curative care (moderate-certainty evidence), but probably makes little or no difference in other health utilisation or service delivery outcomes (moderate- to low-certainty evidence). Therefore, contracting out programmes may be no better or worse than government-provided services, although additional rigorously designed studies may change this result. The literature provides many examples of contracting out programmes, which implies that this is a feasible response when governments fail to provide good clinical health care. Future contracting out programmes should be framed within a rigorous study design to allow valid and reliable measures of their effects. Such studies should include qualitative research that assesses the views of programme implementers and beneficiaries, and records implementation mechanisms. This approach may reveal enablers for, and barriers to, successful implementation of such programmes.

Multifaceted intervention to curb in-hospital over-prescription of proton pump inhibitors: A longitudinal multicenter quasi-experimental before-and-after study

BACKGROUND

Proton pump inhibitors (PPIs) are indicated for a restricted number of clinical conditions, and their misuse can lead to several adverse effects. Despite that, the proportion of overuse is alarmingly high.

OBJECTIVE

To test the efficacy of a multifaceted strategy in order to achieve a significant reduction of new PPI prescriptions at discharge in hospitalized patients.

DESIGN

Multicenter longitudinal quasi-experimental before-and-after study conducted from July 1st, 2014 to June 30th, 2017.

PARTICIPANTS

44,973 admissions in a network of 5 public teaching hospitals of the Italian-speaking region of Switzerland.

INTERVENTION

Multifaceted strategy consisting in a continuous transparent monitoring-benchmarking and in capillary educational interventions applied in the internal medicine departments. To confirm the causality of the results we monitored the trend of new PPI prescriptions in the, not exposed to the intervention, surgery departments of the same hospital network.

MAIN MEASURES

New PPI prescriptions at hospital discharge.

KEY RESULTS

Over the 36month study period 44,973 patient files were analyzed. At admission, comparing internal medicine vs. surgery departments, 44.9% vs. 23.3% of patients were already being treated with a PPI. The annual rate of new PPI prescriptions, for internal medicine showed a decreasing trend: 19, 19, 18, 16% in years 2014, 2015, 2016, 2017, respectively (p<0.001, 2014 vs. 2017; p-for-trend <0.001), while an increasing rate was found in the surgery departments in the same years: 30, 29, 36, 36%, respectively (p<0.001, 2014 vs. 2017; p-for-trend <0.001). The case mix was significantly associated with the probability of new PPI prescriptions in both departments (OR1.35, 95% CI 1.26-1.44 for internal medicine and 1.24, 95% CI 1.19-1.30 for surgery).

CONCLUSIONS

The introduction of a multifaceted intervention significantly reduced the time trend of PPI prescriptions at hospital discharge in internal medicine departments. Further studies are needed to confirm whether the strategy proposed could contribute to optimize the in-hospital drug prescription behavior in other healthcare settings as well.

Implementation of a seven-day hospitalist program to improve the outcomes of the weekend admission: A retrospective before-after study in Taiwan

Objective

Patients admitted during weekends may have worse outcomes than those during weekdays. Adjusting the practice of senior physicians over weekends may reduce the weekend effect.

Design

A controlled before-after study, with propensity score matching (PSM) for potential confounding variables, to compare outcomes between weekday and weekend admissions.

Setting

A 2000-bed medical centre in Taiwan

Participants

Hospitalised general medicine patients cared for by traditional internal medicine teams (pre-intervention cohort) and those cared for by hospitalists after introducing a seven-day hospitalist program in the first six-month (post-intervention cohort) and following three-year periods.

Main outcome measures

Proportion of intensive care unit (ICU) admissions, cardiopulmonary resuscitation (CPR) events, and in-hospital mortality.

Results

The pre-intervention cohort included 982 patients. Significantly higher mortality rates (11.3% vs. 6.2%, p = 0.032) were recorded in the case of weekend admissions, with similar proportions of ICU admission and CPR events. The post-intervention cohort included 601 patients. No significant difference was recorded in any of the main outcomes between weekday and weekend admissions. PSM for pre-intervention and post-intervention cohort showed shorter LOS after intervention, with no difference in ICU admission, CPR, and morality for the weekday and weekend admissions, respectively. The three-year cohort that followed, consisting of 3315 patients, showed no difference of outcomes between weekday and weekend admissions. After PSM, there were no significant differences in ICU admission rates (1.0% vs. 1.8%), CPR (0.3% vs. 0.2%) events and hospital mortality rates (8.1% vs. 8.5%), when weekday and weekend admissions were compared.

Conclusions

The seven-day hospitalist program shows potential in providing equally safe care for both weekday and weekend general medicine admissions with sustainable development.

Fluvastatin for lowering lipids

BACKGROUND

Fluvastatin is thought to be the least potent statin on the market, however, the dose-related magnitude of effect of fluvastatin on blood lipids is not known.

OBJECTIVES

Primary objectiveTo quantify the effects of various doses of fluvastatin on blood total cholesterol, low-density lipoprotein (LDL cholesterol), high-density lipoprotein (HDL cholesterol), and triglycerides in participants with and without evidence of cardiovascular disease.Secondary objectivesTo quantify the variability of the effect of various doses of fluvastatin.To quantify withdrawals due to adverse effects (WDAEs) in randomised placebo-controlled trials.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to February 2017: the Cochrane Central Register of Controlled Trials (CENTRAL) (2017, Issue 1), MEDLINE (1946 to February Week 2 2017), MEDLINE In-Process, MEDLINE Epub Ahead of Print, Embase (1974 to February Week 2 2017), the World Health Organization International Clinical Trials Registry Platform, CDSR, DARE, Epistemonikos and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. No language restrictions were applied.

SELECTION CRITERIA

Randomised placebo-controlled and uncontrolled before and after trials evaluating the dose response of different fixed doses of fluvastatin on blood lipids over a duration of three to 12 weeks in participants of any age with and without evidence of cardiovascular disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility criteria for studies to be included, and extracted data. We entered data from placebo-controlled and uncontrolled before and after trials into Review Manager 5 as continuous and generic inverse variance data, respectively. WDAEs information was collected from the placebo-controlled trials. We assessed all trials using the 'Risk of bias' tool under the categories of sequence generation, allocation concealment, blinding, incomplete outcome data, selective reporting, and other potential biases.

MAIN RESULTS

One-hundred and forty-five trials (36 placebo controlled and 109 before and after) evaluated the dose-related efficacy of fluvastatin in 18,846 participants. The participants were of any age with and without evidence of cardiovascular disease, and fluvastatin effects were studied within a treatment period of three to 12 weeks. Log dose-response data over doses of 2.5 mg to 80 mg revealed strong linear dose-related effects on blood total cholesterol and LDL cholesterol and a weak linear dose-related effect on blood triglycerides. There was no dose-related effect of fluvastatin on blood HDL cholesterol. Fluvastatin 10 mg/day to 80 mg/day reduced LDL cholesterol by 15% to 33%, total cholesterol by 11% to 25% and triglycerides by 3% to 17.5%. For every two-fold dose increase there was a 6.0% (95% CI 5.4 to 6.6) decrease in blood LDL cholesterol, a 4.2% (95% CI 3.7 to 4.8) decrease in blood total cholesterol and a 4.2% (95% CI 2.0 to 6.3) decrease in blood triglycerides. The quality of evidence for these effects was judged to be high. When compared to atorvastatin and rosuvastatin, fluvastatin was about 12-fold less potent than atorvastatin and 46-fold less potent than rosuvastatin at reducing LDL cholesterol. Very low quality of evidence showed no difference in WDAEs between fluvastatin and placebo in 16 of 36 of these short-term trials (risk ratio 1.52 (95% CI 0.94 to 2.45).

AUTHORS' CONCLUSIONS

Fluvastatin lowers blood total cholesterol, LDL cholesterol and triglyceride in a dose-dependent linear fashion. Based on the effect on LDL cholesterol, fluvastatin is 12-fold less potent than atorvastatin and 46-fold less potent than rosuvastatin. This review did not provide a good estimate of the incidence of harms associated with fluvastatin because of the short duration of the trials and the lack of reporting of adverse effects in 56% of the placebo-controlled trials.