Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

Spleen Volume Reduction Is a Reliable and Independent Biomarker for Long-Term Risk of Leukopenia Development in Peptide Receptor Radionuclide Therapy

177Lu-DOTATATE therapy is an effective treatment for advanced neuroendocrine tumors, despite its dose-limiting hematotoxicity. Herein, the significance of off-target splenic irradiation is unknown. Our study aims to identify predictive markers of peptide receptor radionuclide therapy-induced leukopenia. Methods: We retrospectively analyzed blood counts and imaging data of 88 patients with histologically confirmed, unresectable metastatic neuroendocrine tumors who received 177Lu-DOTATATE treatment at our institution from February 2009 to July 2021. Inclusion criterium was a tumor uptake equivalent to or greater than that in the liver on baseline receptor imaging. We excluded patients with less than 24 mo of follow-up and those patients who received fewer than 4 treatment cycles, additional therapies, or blood transfusions during follow-up. Results: Our study revealed absolute and relative white blood cell counts and relative spleen volume reduction as independent predictors of radiation-induced leukopenia at 24 mo. However, a 30% decline in spleen volume 12 mo after treatment most accurately predicted patients proceeding to leukopenia at 24 mo (receiver operating characteristic area under the curve of 0.91, sensitivity of 0.93, and specificity of 0.90), outperforming all other parameters by far. Conclusion: Automated splenic volume assessments demonstrated superior predictive capabilities for the development of leukopenia in patients undergoing 177Lu-DOTATATE treatment compared with conventional laboratory parameters. The reduction in spleen size proves to be a valuable, routinely available, and quantitative imaging-based biomarker for predicting radiation-induced leukopenia. This suggests potential clinical applications for risk assessment and management.

Acute Appendicitis After COVID-19 Vaccines in Italy: A Self-Controlled Case Series Study

BACKGROUND AND OBJECTIVE

Cases of appendicitis were identified in the pivotal randomized clinical trial on BNT162b2 mRNA vaccine and reported from coronavirus disease 2019 (COVID-19) vaccine pharmacovigilance systems. Three cohort studies and two self-controlled case series (SCCS) studies evaluating the association between mRNA vaccines and appendicitis reported discordant results. To address this uncertainty, the present study examines in a large population, with a SCCS design, the association between mRNA (BNT162b2 and mRNA-1273) and, for the first time, viral vector (ChAdOx1-S and Ad26.COV2-S) COVID-19 vaccines and acute appendicitis.

METHODS

The SCCS study design was used to evaluate the association between COVID-19 vaccination and subsequent onset of acute appendicitis. The study was based on record linkage of health archives through TheShinISS application, a statistical tool that locally processes data from regional health care databases according to ad hoc, study-tailored and common data model. The study population included all vaccinated subjects ≥ 12 years old between 27 December 2020 and 30 September 2021. The acute appendicitis was identified through discharge diagnoses of hospital admissions or emergency department visits. Incident cases were defined as those who experienced a first event of acute appendicitis in the study period, excluding subjects with a diagnosis of appendicitis in the previous 5 years. Exposure was defined as the first or second dose of BNT162b2, mRNA-1273 and ChAdOx1-S and the single dose of Ad26.COV2-S. The risk interval was defined as 42 days from the first or second vaccination dose and divided into pre-specified risk subperiods; the reference period was the observation time outside the risk interval. Relative incidences (RI) and 95% confidence intervals (95% CI) were estimated with the SCCS method 'modified for event-dependent exposures', through unbiased estimating equations. The seasonal component was considered as a time-dependent covariate.

RESULTS

In the 42-day risk interval 1285 incident cases of acute appendicitis occurred: 727 cases after the first dose and 558 cases after the second dose. In the main analysis, no increased risks of acute appendicitis were observed in subjects vaccinated with BNT162b, mRNA-1273, ChAdOx1-S and Ad26.COV2-S. The subgroup analyses by sex showed an increased risk in the 14-27 day risk interval, in males after the first dose of mRNA-1273 (RI of 1.71; 95% CI 1.08-2.70, p = 0.02) and in females after the single dose of Ad26.COV2-S (RI of 4.40; 95% CI 1.29-15.01, p = 0.02).

CONCLUSIONS

There was no evidence of association of BNT162b, ChAdOx1-S, mRNA-1273 and Ad26.COV2-S with acute appendicitis in the general population. The results of the subgroup analyses by sex needs to be considered with caution. The multiplicity issue cannot be excluded being these hypotheses two of several hypotheses tested. In addition, relevant literature on the biological mechanism of the disease and evidence of similar effects with other vaccines or with the same vaccines are still lacking to provide strong support for a conclusion that there is an harmful effect in males and females with mRNA-1273 and Ad26.COV2-S.

How age and sex affect treatment outcomes for children with severe malnutrition: A multi-country secondary data analysis

Age and sex influence the risk of childhood wasting. We aimed to determine if wasting treatment outcomes differ by age and sex in children under 5 years, enroled in therapeutic and supplementary feeding programmes. Utilising data from stage 1 of the ComPAS trial, we used logistic regression to assess the association between age, sex and wasting treatment outcomes (recovery, death, default, non-response, and transfer), modelling the likelihood of recovery versus all other outcomes. We used linear regression to calculate differences in mean length of stay (LOS) and mean daily weight gain by age and sex. Data from 6929 children from Kenya, Chad, Yemen and South Sudan was analysed. Girls in therapeutic feeding programmes were less likely to recover than boys (pooled odds ratio [OR]: 0.84, 95% confidence interval [CI]: 0.72-0.97, p = 0.018). This association was statistically significant in Chad (OR: 0.61, 95% CI: 0.39-0.95, p = 0.030) and Yemen (OR: 0.47, 95% CI: 0.27-0.81, p = 0.006), but not in Kenya and South Sudan. Multinomial analysis, however, showed no difference in recovery between sexes. There was no difference between sexes for LOS, but older children (24-59 months) had a shorter mean LOS than younger children (6-23 months). Mean daily weight gain was consistently lower in boys compared with girls. We found few differences in wasting treatment outcomes by sex and age. The results do not indicate a need to change current programme inclusion requirements or treatment protocols on the basis of sex or age, but future research in other settings should continue to investigate the aetiology of differences in recovery and implications for treatment protocols.

Overnight Monitoring Criteria for Children with Obstructive Sleep-Disordered Breathing After Tonsillectomy: Revisited

OBJECTIVES

Previous studies indicate children who pass an Asleep Room Air Challenge (AsRAC) do not have significant postoperative adverse respiratory events after adenotonsillectomy (T&A). Subsequently, we revised our overnight monitoring (OM) criteria, allowing patients with an obstructive apnea/hypopnea index (OAHI) ≤20 or nonsevere obesity (Class I) to be considered for same-day surgery (SDS) if they passed an AsRAC. Our hypothesis is that our modified OM criteria would not increase the return visits or readmission rates for patients undergoing SDS within 48 h or 15 days of T&A.

METHODS

A retrospective review of all children aged ≥3 and <21 years who underwent T&A at a tertiary children's hospital and its satellite locations was performed from January 2017 to September 2022. Descriptive statistics and outcome measures were compared using a 3% margin noninferiority test before and after the new criteria implementation.

RESULTS

Before intervention, 3,266 (58%) T&As were performed as SDS. Afterward, 74% of T&As were performed as SDS (p-value <0.05). There was no difference in the ED revisit rate for SDS within the 3% noninferiority margin. Following intervention, 29% more children with Class I obesity (62% vs. 33%) underwent SDS (p-value <0.001). Afterward, 19% more children with polysomnography underwent SDS (39% vs. 20%), p-value <0.001. After intervention, within 48 h of SDS, six (0.9%) children had revisits for bleeding and seven (1.2%) for vomiting. There were no perioperative respiratory events.

CONCLUSION

Our revised monitoring criteria did not demonstrate an increase in ED visit or readmissions rates within 48 h or 15 days of T&A. Additionally, we found a 29% increase in Class I obese children undergoing SDS T&A.

LEVEL OF EVIDENCE

3 Laryngoscope, 2024.

Pilot study of relationship between prenatal stress during the COVID-19 pandemic and social-emotional development of 12-month-old children: the mediation effects of home environment

There is increasing evidence that prenatal stress elevates the risk of children's social-emotional development, but the mechanisms underlying this association are unclear. Home environment provides learning opportunities and stimulation required for children's early development and can be influenced by prenatal maternal stress. This study aimed to examine whether home environment can mediate the association between prenatal stress during the pandemic of coronavirus disease 2019 (COVID-19) and their offspring's social-emotional problems thereafter. A pilot sample was derived from 2020 to 2021 Maternal and Child Health Cohort study (N = 82) with the pregnant women recruited during the COVID-19 lockdown period in 2020. Prenatal stress was assessed using the Perceived Stress Scale. Home environment was measured using the Child Home Nurture Environment Scales. Mother-reported toddler social-emotional problems were assessed at 12 months of age. The mediation model was used for data analysis. The mean scores of social-emotional problems, which include externalizing, internalizing, dysregulation, and competence, were 10.98 (5.08), 14.72 (6.49), 15.15 (6.31), and 36.73 (10.26), respectively. Prenatal stress, home environment, and social-emotional problems were significantly related (P < 0.05). Home environment significantly mediated the association between prenatal stress and social-emotional problems with the indirect effect [95% CI] of 0.06 [0.01, 0.14] for externalizing behaviors, 0.10 [0.00, 0.24] for internalizing behaviors, - 0.15 [- 0.31, - 0.01] for competence, 0.08 [0.01, 0.17] and 0.08 [0.01, 0.21] for dysregulation. These findings suggest that prenatal stress may affect offspring's social-emotional problems through the home environment. Screening for prenatal stress and promoting supportive home environment may be potential strategies for social-emotional problems interventions in children.

Modified dietary fat intake for treatment of gallstone disease in people of any age

BACKGROUND

The prevalence of gallstones varies between less than 1% and 64% in different populations and is thought to be increasing in response to changes in nutritional intake and increasing obesity. Some people with gallstones have no symptoms but approximately 2% to 4% develop them each year, predominantly including severe abdominal pain. People who experience symptoms have a greater risk of developing complications. The main treatment for symptomatic gallstones is cholecystectomy. Traditionally, a low-fat diet has also been advised to manage gallstone symptoms, but there is uncertainty over the evidence to support this.

OBJECTIVES

To evaluate the benefits and harms of modified dietary fat intake in the treatment of gallstone disease in people of any age.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials in the Cochrane Library, MEDLINE ALL Ovid, Embase Ovid, and three other databases to 17 February 2023 to identify randomised clinical trials in people with gallstones. We also searched online trial registries and pharmaceutical company sources, for ongoing or unpublished trials to March 2023.

SELECTION CRITERIA

We included randomised clinical trials (irrespective of language, blinding, or status) in people with gallstones diagnosed using ultrasonography or conclusive imaging methods. We excluded participants diagnosed with another condition that may compromise dietary fat tolerance. We excluded trials where data from participants with gallstones were not reported separately from data from participants who did not have gallstones. We included trials that investigated other interventions (e.g. trials of drugs or other dietary (non-fat) components) providing that the trial groups had received the same proportion of drug or other dietary (non-fat) components in the intervention.

DATA COLLECTION AND ANALYSIS

We intended to undertake meta-analysis and present the findings according to Cochrane recommendations. However, as we identified only five trials, with data unsuitable and insufficient for analyses, we described the data narratively.

MAIN RESULTS

We included five trials but only one randomised clinical trial (69 adults), published in 1986, reported outcomes of interest to the review. The trial had four dietary intervention groups, three of which were relevant to this review. We assessed the trial at high risk of bias. The dietary fat modifications included a modified cholesterol intake and medium-chain triglyceride supplementation. The control treatment was a standard diet. The trial did not report on any of the primary outcomes in this review (i.e. all-cause mortality, serious adverse events, and health-related quality of life). The trial reported on gallstone dissolution, one of our secondary outcomes. We were unable to apply the GRADE approach to determine certainty of evidence because the included trial did not provide data that could be used to generate an estimate of the effect on this or any other outcome. The trial expressed its finding as "no significant effect of a low-cholesterol diet in the presence of ursodeoxycholic acid on gallstone dissolution." There were no serious adverse events reported. The included trial reported that they received no funding that could bias the trial results through conflicts of interest. We found no ongoing trials.

AUTHORS' CONCLUSIONS

The evidence about the effects of modifying dietary fat on gallstone disease versus standard diet is scant. We lack results from high-quality randomised clinical trials which investigate the effects of modification of dietary fat and other nutrient intakes with adequate follow-up. There is a need for well-designed trials that should include important clinical outcomes such as mortality, quality of life, impact on dissolution of gallstones, hospital admissions, surgical intervention, and adverse events.

Quantitative sensory testing, psychological profiles and clinical pain in patients with psoriatic arthritis and hand osteoarthritis experiencing pain of at least moderate intensity

BACKGROUND

Chronic pain is the hallmark symptom of joint diseases. This study examined the differences in quantitative sensory testing between patients with psoriatic arthritis (PsA), hand osteoarthritis (hand-OA) and a pain-free control group and differences between patients with and without concomitant fibromyalgia (cFM).

METHODS

All patients and pain-free controls were assessed using pressure pain thresholds (PPT), temporal summation of pain (TSP), conditioned pain modulation (CPM) and clinical pain intensities. Psychological distress was assessed with the Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, and Pittsburgh Sleep Quality Index. Disability was assessed with the Health Assessment Questionnaire and pain quality with the painDETECT questionnaire. cFM was identified using the revised 2016 American College of Rheumatology diagnostic criteria.

RESULTS

Patients with hand-OA (n = 75) or PsA (n = 58) had statistically significant lower PPTs and CPM, greater TSP, and higher scores of psychological distress (p < 0.05) than controls (n = 20). Patients with cFM (58%) had higher scores of depression (p = 0.001), anxiety (p = 0.004), catastrophizing (p = 0.012), disability (p < 0.001), higher painDETECT score (p = 0.001), TSP (p = 0.027), and reduced sleep quality (p = 0.021) when compared to patients without cFM.

CONCLUSION

Patients with hand-OA and PsA exhibited signs of pain sensitization and a higher degree of psychological distress and disability than pain-free individuals. Patients with cFM had greater TSP, painDETECT score, disability, catastrophizing, and reduced sleep quality, than patients without, indicating greater degree of pain sensitization, psychological burden, and disability.

STATEMENT OF SIGNIFICANCE

This paper shows that a significant proportion of patients with hand osteoarthritis and psoriatic arthritis with moderate pain intensity have significantly increased signs of pain sensitization and markers of psychological distress. A large proportion of these patients fulfil the criteria for concomitant fibromyalgia and these patients show even greater propensity towards pain sensitization and psychological distress.

Evaluating health systems' efficiency towards universal health coverage: A data envelopment analysis

To estimate the technical efficiency of health systems toward achieving universal health coverage (UHC) in 191 countries. We applied an output-oriented data envelopment analysis approach to estimate the technical efficiency of the health systems, including the UHC index (a summary measure that captures both service coverage and financial protection) as the output variable and per capita health expenditure, doctors, nurses, and hospital bed density as input variables. We used a Tobit simple-censored regression with bootstrap analysis to observe the socioeconomic and environmental factors associated with efficiency estimates. The global UHC index improved from the 2019 estimates, ranged from 48.4 (Somalia) to 94.8 (Canada), with a mean of 76.9 (std. dev.: ±12.0). Approximately 78.5% (150 of 191) of the studied countries were inefficient (ϕ < 1.0) with respect to using health system resources toward achieving UHC. By improving health system efficiency, low-income, lower-middle-income, upper-middle-income, and high-income countries can improve their UHC indices by 4.6%, 5.5%, 6.8%, and 4.1%, respectively, by using their current resource levels. The percentage of health expenditure spent on primary health care (PHC), governance quality, and the passage of UHC legislation significantly influenced efficiency estimates. Our findings suggests health systems inefficiency toward achieving UHC persists across countries, regardless of their income classifications and WHO regions, as well as indicating that using current level of resources, most countries could boost their progress toward UHC by improving their health system efficiency by increasing investments in PHC, improving health system governance, and where applicable, enacting/implementing UHC legislation.

The general public's attitude towards accepting payment for kidney donation

Introduction

Kidney transplantation has become the most cost-effective treatment for patients with end-stage kidney disease (ESKD) and offers them the highest quality of life. Yet, kidney donation is often inaccessible due to cultural and traditional beliefs about organ donation. The goal of our study is to assess the value of kidney donation using the Willingness to Accept (WTA) technique. We also aim to understand the factors influencing an individual's willingness to donate an organ.

Methods

A self-administered survey was completed by 985 participants from the general public. The quantitative method and survey design that were chosen used descriptive, correlational, nonparametric, and multivariate statistical tests.

Results

Most of the respondents, 895 (90.9%) are not willing to donate a kidney while alive. Four hundred and five (41.1%) of the respondents are not willing to donate a kidney after their death, while the rest are willing to donate their kidney after their death without financial compensation. The same attitude applies to the donation of a kidney from their relatives. Significant predictors from the results of the logistic regression model in predicting the lowest (minimal) amount that will encourage donation of one kidney after death were: Marital status; Nationality; Adi card holder; Knowing people who need a kidney donation; confidence in the medical staff; and consideration of the family's opinions regarding organ donation.

Discussion

Using cost benefit analysis (CBA), with the aim of evaluating the willingness of individuals to accept payment for innovative medical procedures, such as kidney donation, allows an assessment of the perceived value of the medical procedure and enables policymakers to decide whether to allocate funds or offer subsidies for kidney donation, given the limited healthcare resources available. During our research, we found that most participants did not support the commercialization of organs. Our recommendation for policymakers and health professionals is to continue providing adequate funding for kidney donations and to implement educational programs aimed at improving attitudes towards organ donation.

REVISE: re-evaluating the inhibition of stress erosions in the ICU-statistical analysis plan for a randomized trial

BACKGROUND

The REVISE (Re-Evaluating the Inhibition of Stress Erosions in the ICU) trial will evaluate the impact of the proton pump inhibitor pantoprazole compared to placebo in invasively ventilated critically ill patients.

OBJECTIVE

To outline the statistical analysis plan for the REVISE trial.

METHODS

REVISE is a randomized clinical trial ongoing in intensive care units (ICUs) internationally. Patients ≥ 18 years old, receiving invasive mechanical ventilation, and expected to remain ventilated beyond the calendar day after randomization are allocated to either 40 mg pantoprazole intravenously or placebo while mechanically ventilated.

RESULTS

The primary efficacy outcome is clinically important upper GI bleeding; the primary safety outcome is 90-day mortality. Secondary outcomes are ventilator-associated pneumonia, Clostridioides difficile infection, new renal replacement therapy, ICU and hospital mortality, and patient-important GI bleeding. Tertiary outcomes are total red blood cells transfused, peak serum creatinine concentration, and duration of mechanical ventilation, ICU, and hospital length of stay. Following an interim analysis of results from 2400 patients (50% of 4800 target sample size), the data monitoring committee recommended continuing enrolment.

CONCLUSIONS

This statistical analysis plan outlines the statistical analyses of all outcomes, sensitivity analyses, and subgroup analyses. REVISE will inform clinical practice and guidelines worldwide.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov NCT03374800. November 21, 2017.

Diet-driven microbiome changes and physical activity in cancer patients

Exploring the role of the gut microbiome in oncology is gaining more attention, mainly due to its ability to shape the immune system in cancer patients. A well-balanced microbial composition forms a symbiotic relationship with the host organism. Mounting evidence supports the potential of modifiable lifestyle factors, such as diet and physical activity, in restoring intestinal dysbiosis related to cancer development and treatment. In this Minireview, we describe the host-microbiome interplay following different dietary patterns, including a high-fat diet, fiber-rich diet, diet rich in rice and beans, Mediterranean diet, ketogenic diet, and physical activity in preclinical findings and clinical settings. According to the results, nutrition is a critical factor influencing the composition of gut microbial communities. Therefore, knowledge about the patient's nutritional status in pre-treatment and treatment becomes crucial for further management. A combination of individualized dietary habits and professional training plans might help to maintain gut homeostasis, potentially improving the response to anti-cancer therapy and the quality of life in cancer survivors. However, a deep understanding of underlying mechanisms and large clinical trials are needed to uncover clinically relevant correlations for personalized treatment approaches leading to better outcomes for cancer patients.

Insights into the pathological basis of dementia from population-based neuropathology studies

The epidemiological neuropathology perspective of population and community-based studies allows unbiased assessment of the prevalence of various pathologies and their relationships to late-life dementia. In addition, this approach provides complementary insights to conventional case-control studies, which tend to be more representative of a younger clinical cohort. The Cognitive Function and Ageing Study (CFAS) is a longitudinal study of cognitive impairment and frailty in the general United Kingdom population. In this review, we provide an overview of the major findings from CFAS, alongside other studies, which have demonstrated a high prevalence of pathology in the ageing brain, particularly Alzheimer's disease neuropathological change and vascular pathology. Increasing burdens of these pathologies are the major correlates of dementia, especially neurofibrillary tangles, but there is substantial overlap in pathology between those with and without dementia, particularly at intermediate burdens of pathology and also at the oldest ages. Furthermore, additional pathologies such as limbic-predominant age-related TDP-43 encephalopathy, ageing-related tau astrogliopathy and primary age-related tauopathies contribute to late-life dementia. Findings from ageing population-representative studies have implications for the understanding of dementia pathology in the community. The high prevalence of pathology and variable relationship to dementia status has implications for disease definition and indicate a role for modulating factors on cognitive outcome. The complexity of late-life dementia, with mixed pathologies, indicates a need for a better understanding of these processes across the life-course to direct the best research for reducing risk in later life of avoidable clinical dementia syndromes.

The genetic approach to stillbirth: A »systematic review«

Unexplained stillbirth is defined as a stillbirth with no known cause after the exclusion of common causes, including obstetric complications, infections, placental insufficiency or abruption, umbilical cord complications, and congenital abnormalities with or without known genetic cause. More than 60% of stillbirth cases remain unexplained. The aim of this systematic review was to investigate the known genetic causes of unexplained stillbirth cases and to evaluate the current position and future directions for the use of genetic and genomic testing in expanding the knowledge in this field. A systematic search through several databases was performed using the keywords genetics and stillbirths in humans. Different methods to detect various types of causal genetic aberrations have been used in the past decades, from standard karyotyping to novel methods such as chromosomal microarray analysis and next generation sequencing technologies. Apart from common chromosomal aneuploidies, a promising hypothesis about genetic causes included genes related to cardiomyopathies and channelopathies. However, these were tested in the research settings, since molecular karyotyping is currently the standard approach in the routine evaluation of genetic causes of stillbirth. Hereby, we provide evidence that expanding knowledge using novel genetic and genomic testing might uncover new genetic causes of unexplained stillbirth.

War trauma and strategies for coping with stress among Ukrainian refugees staying in Poland

Objectives

The Russian military aggression against Ukraine resulted in a humanitarian crisis. There was a mass exodus of war refugees. More than 17 million people have left Ukraine since the war broke out. The refugees who came to Poland and other countries have experienced war trauma. The study aims to assess mental health of Ukrainian war refugees in Poland.

Population and methods

At the time of the study, that is, in April and May 2022, between 1,5 million and 2 million Ukrainian refugees were staying in Poland. They were mainly young women with their children. The CAWI (Computer-Assisted Web Interview) technique was used in the study. The research sample was selected using purposive sampling. The invitation to take part in the survey was posted on social media for Ukrainians in Poland, and also sent to the participants of a Polish as a Foreign Language course. The study utilizes the RHS-15 and a nominal scale measuring the strategies for coping with stress.

Results

The research sample consists of 737 respondents. The results of the screening tests indicate that depression, anxiety disorders and PTSD may be observed among 73% of respondents, whereas 66% of the respondents display psychological distress. The analyses have shown that higher levels of mental health disorders were observed among women and refugees who do not speak Polish. Younger respondents experienced a higher psychological distress. The results of the study also indicate that the refugees more often implemented problem-focused strategies. The analysis has shown that the respondents who followed active strategies scored the lowest on RHS-15. The emotion-focused strategies, such as praying, diverting attention by becoming involved in different activities or taking sedatives were not effective. The highest levels of disorders were present among the refugees who indicated resignation.

Conclusions

The collected observations indicate that the main problem which might hinder their adaptation could be mental health issues, which in turn impact the general deterioration of health and the quality of life.

Learning from cancer to address COVID-19

Patients with cancer have been disproportionately affected by the novel coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Knowledge collected during the last three decades of cancer research has helped the medical research community worldwide to respond to many of the challenges raised by COVID-19, during the pandemic. The review, briefly summarizes the underlying biology and risk factors of COVID-19 and cancer, and aims to present recent evidence on cellular and molecular relationship between the two diseases, with a focus on those that are related to the hallmarks of cancer and uncovered in the first less than three years of the pandemic (2020-2022). This may not only help answer the question "Why cancer patients are considered to be at a particularly high risk of developing severe COVID-19 illness?", but also helped treatments of patients during the COVID-19 pandemic. The last session highlights the pioneering mRNA studies and the breakthrough discovery on nucleoside-modifications of mRNA by Katalin Karikó, which led to the innovation and development of the mRNA-based SARSCoV-2 vaccines saving lives of millions and also opened the door for a new era of vaccines and a new class of therapeutics.

Evaluation of Risk-Based Approaches to the Registration of Medicines: Current Status Among African Regulatory Authorities

BACKGROUND

Despite the worldwide need for increased access to safe and effective medicines, there is a lack of innovative medicines in many low- to middle-income countries. On the African continent, this is partly due to capacity limitations of National Regulatory Authorities (NRAs). One important approach to address this issue is work sharing and regulatory reliance. Therefore, the aim of this study of regulatory authorities on the African continent was to identify which risk-based approaches are being used as well as their foreseen role in the future.

METHODS

The study employed a questionnaire to identify which risk-based models are used for the regulatory approval of medicines and to determine which frameworks are in place to enable a risk-based approach, as well as to provide insight into the future direction for risk-based models. The questionnaire was sent electronically to 26 NRAs in the African Continent.

RESULTS

Twenty-one authorities (80%) completed the questionnaire. Work sharing was the most commonly used model, followed closely by unilaterial reliance, information sharing, and collaborative review. These methods were perceived to be an effective and efficient use of resources, enabling faster medicine availability for patients. The unilateral reliance approach by the authorities included abridged (85%), verification (70%) and recognition (50%) models for a range of products. However, challenges included a lack of guidelines to undertake a reliance review together with resource constraints, while access to assessment reports was the most common barrier to using a unilateral reliance model.

CONCLUSIONS

Many authorities in Africa have adopted a risk-based approach to medicines registration and created work sharing, unilateral reliance pathways and regionalisation models to facilitate the availability of medicines. The authorities believe that in future, assessment routes should move from stand-alone reviews to risk-based models. However, this study indicated that there would be challenges to implement this approach in practice, which would include improving resource capacity and the number of expert reviewers as well as implementing electronic tracking systems.

A genetically modified Plasmodium berghei parasite as a surrogate for whole-sporozoite vaccination against P. vivax malaria

Two malaria parasite species, Plasmodium falciparum (Pf) and P. vivax (Pv) are responsible for most of the disease burden caused by malaria. Vaccine development against this disease has focused mainly on Pf. Whole-sporozoite (WSp) vaccination, targeting pre-erythrocytic (PE) parasite stages, is a promising strategy for immunization against malaria and several PfWSp-based vaccine candidates are currently undergoing clinical evaluation. In contrast, no WSp candidates have been developed for Pv, mainly due to constraints in the production of Pv sporozoites in the laboratory. Recently, we developed a novel approach for WSp vaccination against Pf based on the use of transgenic rodent P. berghei (Pb) sporozoites expressing immunogens of this human-infective parasite. We showed that this platform can be used to deliver PE Pf antigens, eliciting both targeted humoral responses and cross-species cellular immune responses against Pf. Here we explored this WSp platform for the delivery of Pv antigens. As the Pv circumsporozoite protein (CSP) is a leading vaccine candidate antigen, we generated a transgenic Pb parasite, PbviVac, that, in addition to its endogenous PbCSP, expresses PvCSP under the control of a strictly PE promoter. Immunofluorescence microscopy analyses confirmed that both the PbCSP and the PvCSP antigens are expressed in PbviVac sporozoites and liver stages and that PbviVac sporozoite infectivity of hepatic cells is similar to that of its wild-type Pb counterpart. Immunization of mice with PbviVac sporozoites elicits the production of anti-PvCSP antibodies that efficiently recognize and bind to Pv sporozoites. Our results warrant further development and evaluation of PbviVac as a surrogate for WSp vaccination against Pv malaria.

Modeling the impact of precautionary measures and sanitation practices broadcasted through media on the dynamics of bacterial diseases

The media has a significant contribution in spreading awareness by broadcasting various programs about prevalent diseases in the society along with the role of providing information, feeding news and educating a large mass. In this paper, the effect of media programs promoting precautionary measures and sanitation practices to control the bacterial infection in the community is modeled and analyzed considering the number of media programs as a dynamical variable. In the modeling phenomena, human population is partitioned into three classes; susceptible, infected and recovered. The disease is supposed to spread by direct contact of susceptible with infected individuals and indirectly by the ingestion of bacteria present in the environment. The growth in the media programs is considered proportional to the size of infected population and the impact of these programs on the indirect disease transmission rate and bacteria shedding rate by infected individuals is also considered. The feasibility of equilibria and their stability conditions are obtained. Model analysis reveals that broadcasting media programs and increasing its effectiveness shrink the size of infected class and control the spread of disease to a large extent.

Evaluation of efficacy and safety of intradermal delivery of vaccines through microneedle(s) in human beings: a protocol for a systematic review

BACKGROUND

Microneedles are defined as micron-sized projections with an insertion length ranging from 20 to 1500 μm and an external diameter up to 300 μm. Medications administered through microneedles diffuse through the deeper layers of the skin, into the systemic circulation, with minimal stimulation of pain-sensitive nerve endings. The rich presence of dendritic cells in the dermis makes microneedle-based vaccine delivery an attractive option. This systematic review will evaluate the efficacy and safety of intradermal delivery of vaccines using microneedles, in human beings.

METHODS

We will search the following databases for studies reporting the efficacy and/or safety of intradermal delivery of vaccines using microneedles: Epistemonikos and the Cochrane Library for systematic reviews and MEDLINE (through PubMed), EMBASE, Cochrane CENTRAL, LIVIVO, Web of Science, Scopus and CINAHL databases for primary studies. We will also search grey literature databases and hand search reference lists of relevant studies. We will include randomised and quasi-randomised trials in human beings (any age), using microneedles (any material, length or bore) to deliver vaccines intradermally, wherein outcomes reflecting efficacy, safety, pain responses, participant satisfaction or cost are reported. We will additionally include non-randomised observational studies for long-term safety outcomes that are not reported in trials. Eligibility for inclusion will be independently determined by two reviewers. The risk of bias of the included studies will be assessed using the Cochrane RoB2 Tool (for randomised trials) and Newcastle-Ottawa Scale (for other study designs). Data on efficacy and safety will be pooled through meta-analysis (where feasible). We will explore the heterogeneity amongst randomised trials, using the Higgins and Thompson I2 method. We will undertake sensitivity analysis to explore the impact of study quality and subgroup analysis based on the age of participants, length of microneedle and vaccine dosage. The GRADE approach will be used to estimate the confidence in the evidence.

RESULTS

This is a protocol for a systematic review; hence, there are no results at this stage.

DISCUSSION

The proposed systematic review will provide evidence on efficacy, safety, pain responses, participant acceptability and cost in human beings (adults and children) for vaccines administered through the intradermal route using microneedles. Since intradermal injections using microneedles are associated with less pain due to their short lengths and narrow bores, we anticipate that delivery of vaccine antigens using this method could be a safe, efficacious and less painful alternative compared with conventional injections using hypodermic needles. The evidence in this review will be useful for policymakers, vaccine manufacturers and healthcare providers to consider this approach for the vaccination of infants and children in routine immunisation programmes. Therefore, we plan to disseminate the review through a peer-reviewed journal publication and will also provide data that cannot be included in the published version to anyone upon reasonable request.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020213608.

Should systemic antibiotics be prescribed in periodontal abscesses and pericoronitis? A systematic review of the literature

This study assessed whether systemic antibiotics are beneficial or harmful in patients who present with an acute periodontal abscess or pericoronitis, with or without systemic involvement, and, if antibiotics are beneficial, which type, dosage, and duration are the most effective. Medline, Embase, and the Cochrane Library were screened from 1948 up to 1 April 2022 for systematic reviews, randomised clinical trials (RCTs), and other studies. Dedicated websites were consulted for systematic reviews, clinical practice guidelines, and health technology assessments on the topic. Outcomes of interest comprised tooth survival, swelling, pain, tooth mobility, periodontal probing depth, suppuration, adverse effects, quality of life measurements, and medication required for pain relief. Overall, five guidelines, seven systematic reviews, 15 RCTs, and 34 other studies were identified and selected for full-text assessment, but none of them fulfilled the inclusion criteria. At present there is no single randomised or non-randomised controlled trial assessing the harms and clinical effectiveness of systemic antibiotics in adults with a periodontal abscess or pericoronitis.

Trait Anxiety in Individuals on the Autism Spectrum: a Systematic Review

Although anxiety is commonly researched in autism, the focus has predominantly been on anxiety disorders and not upon general levels of anxiousness or trait anxiety. This review summarises research investigating trait anxiety in autism. Systematic searches yielded 1099 records, with 23 studies meeting inclusion criteria. Study participants were mainly males from Western countries, with no representation of older adults or individuals with intellectual disability. All articles used self-report questionnaire trait anxiety measures. Anxiety measure psychometric details were absent in most studies, with 21 using subjective measures that are not validated for use in autism. Results showed higher trait anxiety scores in autism versus control groups, and correlations between trait anxiety scores and other study outcomes.

The nursing care of people with class III obesity in an acute care setting: a scoping review

BACKGROUND

Patients with Class III obesity pose unique challenges to health care staff and organisations. Care requirements of this population are unique and require specialised equipment and knowledge to meet these needs, maintain the quality of care, as well as the safety of patients and staff.

AIM

To synthesise the evidence on the nursing care of Class III obese patients in acute care settings.

METHODS

A scoping review informed by JBI. CINAHL Plus, Medline, Scopus, Proquest Central, Web of Science and Embase were searched for primary research articles about the nursing management of people classified as Class III obese in acute care. Methodological quality of included studies was assessed; data extracted and synthesised into themes.

RESULTS

Fourteen studies were included in the review. The synthesis generated three themes: Access to equipment, knowledge and training, patient care, and opportunities to improve care.

CONCLUSIONS

A paucity of high-quality evidence informs the nursing care of people with Class III obesity in acute care. Access to appropriate equipment dominated the findings of this review. Adequate provision of equipment and education on its use are required. Education to promote engagement with patients, adapting clinical practice and promotion of self-care could improve care and outcomes.

The impact of sleep apnea syndrome on the altered lipid metabolism and the redox balance

Background

Obstructive sleep apnea (OSA) is a disorder with a significant risk for cardiovascular diseases. Dyslipidemia and redox imbalance belong to potential mechanisms linking OSA with the development of vascular diseases. The main aim of this study was the evaluation of the presence of lipid abnormalities in OSA patients, focusing on small dense low-density lipoprotein (LDL) and high-density lipoprotein (HDL) subfractions and determination of the redox imbalance by evaluating the marker of oxidative damage to plasma lipids - lipoperoxides.

Methods

The study included 15 male subjects with polysomnographically confirmed OSA and 16 male healthy controls. Plasma levels of total cholesterol, LDL and HDL and their subfractions, triacylglycerols and lipoperoxides were determined in all study individuals. Plasma LDL and HDL subfractions were separated by the Lipoprint system which is a polyacrylamide gel electrophoresis. Lipoperoxide levels were determined spectrophotometrically.

Results

OSA patients had significantly higher triacylglycerols, total cholesterol and LDL-cholesterol compared to healthy controls. HDL cholesterol was not significantly different. Of the LDL and HDL subfractions, OSA patients had significantly lower levels of atheroprotective LDL1 and large HDL subfractions and significantly higher levels of atherogenic small dense LDL3–7 and HDL8–10 subfractions. Lipoperoxide levels in patients with OSA were significantly elevated compared to healthy individuals.

Conclusion

The lipoprotein pro-atherogenic phenotype was found in individuals with OSA characterized by increased levels of atherogenic lipoprotein subfractions and reduced levels of atheroprotective subfractions. In addition, a plasma redox imbalance was found in patients with OSA compared to controls by detecting higher oxidative damage to lipids. Abnormalities in lipoprotein levels in patients with OSA, as well as the redox imbalance, could lead to an acceleration of the atherosclerotic process in predisposed individuals and thus represent a significant risk factor for vasular diseases.

Can Individualized-Targeted Computerized Cognitive Training Benefit Adults with HIV-Associated Neurocognitive Disorder? The Training on Purpose Study (TOPS)

Half of people with HIV (PWH) have HIV-associated neurocognitive disorder (HAND). This study examined whether cognition can be improved using a framework targeting impaired individual cognitive domains in PWH with HAND. In this two-group pre-post experimental design study, 88 adults with HAND were randomized to either: (1) a no-contact control group (n = 40) or (2) the Individualized-Targeted Cognitive Training group (n = 48). Baseline cognitive performance was assessed on eight cognitive domains. A theoretical framework was used to determine the two cognitive domains selected for training. With priority on speed of processing (SOP) and attention impairments, participants received SOP and/or attention training if such impairments were detected; if not, participants were assigned to cognitive training in one/two of the least impaired cognitive domains contributing to their HAND diagnosis. Global cognitive score was slightly improved following training (p = 0.256; d = - 0.21), but it was not significant. Significant improvements were observed on SOP following training in that domain (SOP; d = - 0.88; p = 0.011). SOP training also improved functioning in other cognitive domains. This individualized cognitive intervention did not change HAND status, but it did result in improved SOP, in turn yielding improvement in other cognitive domains.

Cognitive-Behavioral Interventions Targeting Alcohol or Other Drug Use and Co-Occurring Mental Health Disorders: A Meta-Analysis

AIMS

This meta-analysis reviewed 15 clinical trials (18 study sites/arms), examining the efficacy of an integrated cognitive-behavioral intervention (CBI) delivered to individuals with an alcohol or other drug use disorder and a co-occurring mental health disorder (AOD/MHD). Outcomes were alcohol or other drug use and mental health symptoms at post-treatment through follow-up.

METHODS

The inverse-variance weighted effect size was calculated for each study and pooled under random effects assumptions.

RESULTS

Integrated CBI showed a small effect size for AOD (g = 0.188, P = 0.061; I2 = 86%, τ2 = 0.126, k = 18) and MHD (g = 0.169, P = 0.024; I2 = 58%, τ2 = 0.052, k = 18) outcomes, although only MHD outcomes were statistically significant. Analysis by subgroup suggested that effect magnitude varied by type of contrast condition (integrated CBI + usual care vs. usual care only; integrated CBI vs. a single-disorder intervention), follow-up time point (post-treatment vs. 3-6 months) and primary AOD/MHD diagnosis, although these sub-groups often contained significant residual heterogeneity. In a series of mixed effects, meta-regression models, demographic factors were non-significant predictors of between-study heterogeneity. For AOD outcomes, greater effects were observed in higher quality studies, but study quality was not related to effect size variability for MHD outcomes.

CONCLUSIONS

The current meta-analysis shows a small and variable effect for integrated CBI with the most promising effect sizes observed for integrated CBI compared with a single disorder intervention (typically an AOD-only intervention) for follow-up outcomes, and for interventions targeting alcohol use and/or post-traumatic stress disorder. Given the clinical and methodological variability within the sample, results should be considered a preliminary, but important step forward in our understanding of treatment for co-occurring AOD/MHD.

A cultural experience to support mental health in people aged 16-24 during the COVID-19 pandemic compared to a typical museum website: study protocol of an online randomised controlled trial

Background

Despite the high prevalence of common mental disorders in adolescents and young adults, and their association with poor health and socio-economic outcomes throughout the lifespan, many young people do not seek or receive help for such disorders. There is growing interest in the community sector in supporting mental health in young people; however, there is little by way of experimental research in this area. During the COVID-19 pandemic and lockdown, we designed an online cultural experience to reduce anxiety and depression and support mental health in people aged 16–24.

Methods/design

The O-ACE POP (Online Active Community Engagement Proof of Principle) study is a UK-based online randomised controlled trial of an online cultural experience named Ways of Being, involving human centred narratives and viewpoints, compared with a typical museum website (the Ashmolean Museum). We aim to compare efficacy on  affect,  symptoms of epression and anxiety, flourishing and loneliness as well as investigating potential mechanisms of action.

Discussion

The COVID-19 pandemic has provided a unique opportunity to design an innovative approach to supporting mental health in young adults. Findings derived from this study will allow us to evaluate the efficacy of this intervention and will inform the design of studies to further refine the resource and test it further.

Trial registration

ClinicalTrials.gov NCT04663594. Registered on 11 December 2020 (submitted in same form 27 November 2020). Protocol v1.0: 27 November 2020. Date recruitment began: 4 December 2020. Recruitment complete (estimate): February 2021

What factors promote vaccine hesitancy or acceptance during pandemics? A systematic review and thematic analysis

Examine the factors that promote vaccine hesitancy or acceptance during pandemics, major epidemics and global outbreaks. A systematic review and thematic analysis of 28 studies on the Influenza A/H1N1 pandemic and the global spread of Ebola Virus Disease. We found seven major factors that promote vaccine hesitancy or acceptance: demographic factors influencing vaccination (ethnicity, age, sex, pregnancy, education, and employment), accessibility and cost, personal responsibility and risk perceptions, precautionary measures taken based on the decision to vaccinate, trust in health authorities and vaccines, the safety and efficacy of a new vaccine, and lack of information or vaccine misinformation. An understanding of participant experiences and perspectives toward vaccines from previous pandemics will greatly inform the development of strategies to address the present situation with the COVID-19 pandemic. We discuss the impact vaccine hesitancy might have for the introduction and effectiveness of a potential COVID-19 vaccine. In particular, we believe that skepticism toward vaccines can still exist when there are no vaccines available, which is contrary to contemporary conceptualizations of vaccine hesitancy. We recommend conducting further research assessing the relationship between the accessibility and cost of vaccines, and vaccine hesitancy.

Comparison of hospitalized patients with COVID-19 who did and did not live in residential care facilities in Montréal: a retrospective case series

BACKGROUND

As in other jurisdictions, the demographics of people infected with SARS-CoV-2 changed in Quebec over the course of the first COVID-19 pandemic wave, and affected those living in residential care facilities (RCFs) disproportionately. We evaluated the association between clinical characteristics and outcomes of hospitalized patients with COVID-19, comparing those did or did not live in RCFs.

METHODS

We conducted a retrospective case series of all consecutive adults (≥ 18 yr) admitted to the Jewish General Hospital in Montréal with laboratory-confirmed SARS-CoV-2 infection from Mar. 4 to June 30, 2020, with in-hospital follow-up until Aug. 6, 2020. We collected patient demographics, comorbidities and outcomes (i.e., admission to the intensive care unit, mechanical ventilation and death) from medical and laboratory records and compared patients who did or did not live in public and private RCFs. We evaluated factors associated with the risk of in-hospital death with a Cox proportional hazard model.

RESULTS

In total, 656 patients were hospitalized between March and June 2020, including 303 patients who lived in RCFs and 353 patients who did not. The mean age was 72.9 (standard deviation 18.3) years (range 21 to 106 yr); 349 (53.2%) were female and 118 (18.0%) were admitted to the intensive care unit. The overall mortality rate was 23.8% (156/656), but was higher among patients living in RCFs (36.6% [111/303]) compared with those not living in RCFs (12.7% [45/353]). Increased risk of death was associated with age 80 years and older (hazard ratio [HR] 2.39, 95% confidence interval [CI] 1.35-4.24), male sex (HR 1.74, 95% CI 1.25-2.41), the presence of 4 or more comorbidities (HR 2.01, 95% CI 1.18-3.42) and living in an RCF (HR 1.62, 95% CI 1.09-2.39).

INTERPRETATION

During the first wave of the COVID-19 epidemic in Montréal, more than one-third of RCF residents hospitalized with SARS-CoV-2 infection died during hospitalization. Policies and practices that prevent future outbreaks of SARS-CoV-2 infection in this setting must be implemented to prevent high mortality in this vulnerable population.

Neuroenhancement: State of the Art and Future Perspectives

Pharmacological neuroenhancement refers to the non-medical use of prescription drugs, alcohol, illegal drugs, or the so-called soft enhancers for the purpose of improving cognition, mood, pro-social behavior, or work and academic performance. This phenomenon is undoubtedly more frequent than previously supposed especially amongst university students. The aim of the present paper was to carefully review and comment on the available literature on neuroenhancement, according to Prisma guidelines. The results showed a great use of all prescribed drugs (benzodiazepines, antidepressants, antipsychotics, nootropic compounds, and especially stimulants) as neuroenhancers amongst healthy subjects, although probably the real prevalence is underestimated. The use of illicit drugs and soft enhancers is similarly quite common. Data on the improvement of cognition by other compounds, such as oxytocin and pheromones, or non-pharmacological techniques, specifically deep brain stimulation and transcranial magnetic stimulation, are still limited. In any case, if it is true that human beings are embedded by the desire to overcome the limits of their intrinsic nature, neuroenhancement practices put into question the concept of authenticity. Therefore, the problem appears quite complex and requires to be deepened and analyzed with no prejudice, although within an ethical conceptual frame.

Impact of the Covid-19 pandemic on perinatal mental health (Riseup-PPD-COVID-19): protocol for an international prospective cohort study

BACKGROUND

Corona Virus Disease 19 (COVID-19) is a new pandemic, declared a public health emergency by the World Health Organization, which could have negative consequences for pregnant and postpartum women. The scarce evidence published to date suggests that perinatal mental health has deteriorated since the COVID-19 outbreak. However, the few studies published so far have some limitations, such as a cross-sectional design and the omission of important factors for the understanding of perinatal mental health, including governmental restriction measures and healthcare practices implemented at the maternity hospitals. Within the Riseup-PPD COST Action, a study is underway to assess the impact of COVID-19 in perinatal mental health. The primary objectives are to (1) evaluate changes in perinatal mental health outcomes; and (2) determine the risk and protective factors for perinatal mental health during the COVID-19 pandemic. Additionally, we will compare the results between the countries participating in the study.

METHODS

This is an international prospective cohort study, with a baseline and three follow-up assessments over a six-month period. It is being carried out in 11 European countries (Albania, Bulgaria, Cyprus, France, Greece, Israel, Malta, Portugal, Spain, Turkey, and the United Kingdom), Argentina, Brazil and Chile. The sample consists of adult pregnant and postpartum women (with infants up to 6 months of age). The assessment includes measures on COVID-19 epidemiology and public health measures (Oxford COVID-19 Government Response Tracker dataset), Coronavirus Perinatal Experiences (COPE questionnaires), psychological distress (BSI-18), depression (EPDS), anxiety (GAD-7) and post-traumatic stress symptoms (PTSD checklist for DSM-V).

DISCUSSION

This study will provide important information for understanding the impact of the COVID-19 pandemic on perinatal mental health and well-being, including the identification of potential risk and protective factors by implementing predictive models using machine learning techniques. The findings will help policymakers develop suitable guidelines and prevention strategies for perinatal mental health and contribute to designing tailored mental health interventions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04595123 .

Risk of common infections in people with inflammatory bowel disease in primary care: a population-based cohort study

OBJECTIVE

To evaluate the risk of common infections in individuals with inflammatory bowel disease (IBD) [ulcerative colitis and Crohn's disease] compared with matched controls in a contemporary UK primary care population.

DESIGN

Matched cohort analysis (2014-2019) using the Royal College of General Practitioners Research and Surveillance Centre primary care database. Risk of common infections, viral infections and gastrointestinal infections (including a subset of culture-confirmed infections), and predictors of common infections, were evaluated using multivariable Cox proportional hazards models.

RESULTS

18 829 people with IBD were matched to 73 316 controls. People with IBD were more likely to present to primary care with a common infection over the study period (46% vs 37% of controls). Risks of common infections, viral infections and gastrointestinal infections (including stool culture-confirmed infections) were increased for people with ulcerative colitis and Crohn's disease compared with matched controls (HR range 1.12-1.83, all p<0.001). Treatment with oral glucocorticoid therapy, immunotherapies and biologic therapy, but not with aminosalicylates, was associated with increased infection risk in people with IBD. Despite mild lymphopenia and neutropenia being more common in people with IBD (18.4% and 1.9%, respectively) than in controls (6.5% and 1.5%, respectively), these factors were not associated with significantly increased infection risk in people with IBD.

CONCLUSION

People with IBD are more likely to present with a wide range of common infections. Health professionals and people with IBD should remain vigilant for infections, particularly when using systemic corticosteroids, immunotherapies or biologic agents.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov (NCT03835780).

Effectiveness of Community-Based Health Promotion Interventions in Urban Areas: A Systematic Review

Over the past few decades, a community-based approach was seen to be the "gold standard" for health promotion and disease prevention, especially in the field of socially deprived neighborhoods in urban areas. Up to the beginning of the 2000s, earlier reviews provide valuable information on activities in this context. However, in their conclusions they were limited to North America and Europe. Therefore, we conducted a systematic literature review on community-based health promotion and prevention programs worldwide. The Pubmed and PsycINFO databases were screened for relevant articles published between January 2002 and December 2018, revealing 101 potentially eligible publications out of 3646 hits. After a systematic review process including searching the reference lists, 32 papers met the inclusion criteria and were included in the review. Twenty-four (75.0%) articles reported improvements in at least one health behavior, health service access, health literacy, and/or a range of health status outcomes. Large-scale community-based health promotion programs, however, often resulted in limited or missing population-wide changes. Possible reasons are methodological limitations, concurrent context effects, and limitations of the interventions used. Our results confirm that community-based interventions are promising for health promotion and disease prevention but so far their potential is not fully realized. For the future, such interventions should aim at proximal outcomes and invest in community capacity building.

Inclusion of Other in the Self and Couple's Sexuality: A Scoping Review

To better understand the effect relationship closeness has on couple's sexuality a scoping review was conducted, that focused on the inclusion of other in the self scale (IOS). Authors reviewed quantitative journal articles published between 2000 and 2020 by searching PsychInfo, Medline, and PubMed, resulting in 24 studies. Results suggest positive associations between IOS and sexual well-being, functioning, desire, frequency and satisfaction, and negatively related to sexual distress. Also, the benefits of positive sexual experiences expand well beyond the sexual domain onto different personal and relational factors of health and well-being. Sampling designs considerably limit the generalizability of results.

Association Between Aspartate Aminotransferase to Alanine Aminotransferase Ratio and Incidence of Type 2 Diabetes Mellitus in the Japanese Population: A Secondary Analysis of a Retrospective Cohort Study

BACKGROUND

The study on the association between aspartate aminotransferase to alanine aminotransferase (AST/ALT) ratio and the risk of type 2 diabetes mellitus (T2DM) was limited. Therefore, we conducted a secondary analysis based on online data to explore whether there was an association between the AST/ALT ratio and incident T2DM among a large number of Japanese people.

METHODS

The study was a retrospective cohort study. We downloaded the NAGALA (NAfld in Gifu area) data from DATADRYAD website between 2004 and 2015. This present study included 15,291 participants. Cox proportional-hazards regression, generalized additive models and subgroup analyses were used to find out the association between the AST/ALT ratio and T2DM events.

RESULTS

The negative relationship was shown between AST/ALT ratio and incident T2DM (HR = 0.617, 95% CI: 0.405-0.938) in our study. A non-linear relationship and saturation effect were found between them, and the inflection point was 0.882. It indicated that the AST/ALT ratio was negatively correlated with incident T2DM when the AST/ALT ratio was less than the inflection point (HR = 0.287, 95% CI: 0.126-0.655, p = 0.0030). We found that exercise modified their relationship (P for interaction = 0.0024), and people who did not exercise associated strongly (HR = 0.464 95% CI: 0.290-0.741).

CONCLUSION

AST/ALT ratio was negatively associated with T2DM risk, and their relationship was non-linear and had a saturation effect. When the AST/ALT ratio was less than 0.882, they showed a significant negative correlation.

Dietary oleic acid supplementation and blood inflammatory markers: a systematic review and meta-analysis of randomized controlled trials

The aim of this systematic review and meta-analysis was to analyze data from randomized controlled trials (RCTs) assessing the effects of oleic acid (OA) supplementation on blood inflammatory markers in adults. PubMed, EMBASE and Cochrane Library databases were systematically searched from 1950 to 2019, with adults and a minimum intervention duration of 4 weeks. The effect size was estimated, adopting standardized mean difference (SMD) and 95% confidence interval (CI). Of the 719 identified studies, thirty-one RCTs involving 1634 subjects were eligible. The results of this study revealed that increasing OA supplementation significantly reduced C-reactive protein (CRP) (SMD: -0.11, 95% CI: -0.21, -0.01, P = 0.038). However, dietary OA consumption did not significantly affect tumor necrosis factor (TNF) (SMD: -0.05, 95% CI: -0.19, 0.10, P = 0.534), interleukin 6 (IL-6) (SMD: 0.01, 95% CI: -0.10, 0.13, P = 0.849), fibrinogen (SMD: 0.08, 95% CI: -0.16, 0.31, P = 0.520), plasminogen activator inhibitor type 1 (PAI-1) activity (SMD: -0.11, 95% CI: -0.34, 0.12, P = 0.355), soluble intercellular adhesion molecule-1 (sICAM-1) (SMD: -0.06, 95% CI: -0.26, 0.13, P = 0.595) or soluble vascular cell adhesion molecule-1 (sVCAM-1) (SMD: -0.04, 95% CI: -0.27, 0.18, P = 0.701). Overall, the meta-analysis demonstrated that dietary OA supplementation significantly reduced CRP, yet did not affect other inflammatory markers including TNF, IL-6, fibrinogen, PAI-1 activity, sICAM-1or sVCAM-1.

The Public Health Impact of Coronavirus Disease on Human Trafficking

The global pandemic of severe acute respiratory syndrome coronavirus 2 exacerbates major risk factors for global human trafficking. Social isolation of families and severe economic distress amplify the risk of interpersonal violence, unemployment and homelessness, as well as increased internet use by under-supervised children. Aggravating the situation are overwhelmed health systems, severe limitations in activities of social service organizations, and decreased contact of healthcare professionals with children. Healthcare professionals have a duty to be alert to possible indicators of trafficking, and aware of available victim resources which can be offered to at-risk patients. Healthcare facilities should take steps to increase public awareness of trafficking and community resources.

Self-Monitoring and Management of Blood Pressure in Patients with Stroke or TIA: An Economic Evaluation of TEST-BP, A Randomised Controlled Trial

BACKGROUND

Prevention of secondary stroke following initial ictus is an important focus of after-stroke care. Blood pressure (BP) is a key risk factor, so usual care following stroke or transient ischaemic attack includes regular BP checks and monitoring of anti-hypertensive medication. This is traditionally carried out in primary care, but the evidence supporting self-monitoring and self-guided management of BP in the general population with hypertension is growing.

OBJECTIVE

Our objective was to estimate the cost effectiveness of treatment as usual (TAU) versus (1) self-monitoring of BP (S-MON) and (2) self-monitoring and guided self-management of anti-hypertensive medication (S-MAN).

METHODS

This was a within-trial economic evaluation of a randomised controlled trial estimating the incremental cost per 1 mmHg BP reduction and per quality-adjusted life-year (QALY) gained over a 6-month time horizon from the perspective of the UK National Health Service (NHS).

RESULTS

Data were evaluable for 140 participants. Costs per patient were £473, £853 and £1035; mean reduction in systolic BP (SBP) was 3.6, 6.7 and 6.1 mmHg, and QALYs accrued were 0.427, 0.422 and 0.423 for TAU, S-MON and S-MAN, respectively. No statistically significant differences in incremental costs or outcomes were detected. On average, S-MAN was dominated or extended dominated. The incremental cost per 1 mmHg BP reduction from S-MON versus TAU was £137.

CONCLUSION

On average, S-MAN is an inefficient intervention. S-MON may be cost effective, depending on the willingness to pay for a 1 mmHg BP reduction, although it yielded fewer QALYs over the within-trial time horizon. Decision modelling is required to explore the longer-term costs and outcomes.

Integrating untargeted metabolomics, genetically informed causal inference, and pathway enrichment to define the obesity metabolome

BACKGROUND

Obesity and its associated diseases are major health problems characterized by extensive metabolic disturbances. Understanding the causal connections between these phenotypes and variation in metabolite levels can uncover relevant biology and inform novel intervention strategies. Recent studies have combined metabolite profiling with genetic instrumental variable (IV) analysis (Mendelian randomization) to infer the direction of causality between metabolites and obesity, but often omitted a large portion of untargeted profiling data consisting of unknown, unidentified metabolite signals.

METHODS

We expanded upon previous research by identifying body mass index (BMI)-associated metabolites in multiple untargeted metabolomics datasets, and then performing bidirectional IV analysis to classify metabolites based on their inferred causal relationships with BMI. Meta-analysis and pathway analysis of both known and unknown metabolites across datasets were enabled by our recently developed bioinformatics suite, PAIRUP-MS.

RESULTS

We identified ten known metabolites that are more likely to be causes (e.g., alpha-hydroxybutyrate) or effects (e.g., valine) of BMI, or may have more complex bidirectional cause-effect relationships with BMI (e.g., glycine). Importantly, we also identified about five times more unknown than known metabolites in each of these three categories. Pathway analysis incorporating both known and unknown metabolites prioritized 40 enriched (p < 0.05) metabolite sets for the cause versus effect groups, providing further support that these two metabolite groups are linked to obesity via distinct biological mechanisms.

CONCLUSIONS

These findings demonstrate the potential utility of our approach to uncover causal connections with obesity from untargeted metabolomics datasets. Combining genetically informed causal inference with the ability to map unknown metabolites across datasets provides a path to jointly analyze many untargeted datasets with obesity or other phenotypes. This approach, applied to larger datasets with genotype and untargeted metabolite data, should generate sufficient power for robust discovery and replication of causal biological connections between metabolites and various human diseases.

Big data, privacy and COVID-19 - learning from humanitarian expertise in data protection

The COVID-19 pandemic leads governments around the world to resort to tracking technology and other data-driven tools in order to monitor and curb the spread of SARS-CoV-2. Such large-scale incursion into privacy and data protection is unthinkable during times of normalcy. However, in times of a pandemic the use of location data provided by telecom operators and/or technology companies becomes a viable option. Importantly, legal regulations hardly protect people's privacy against governmental and corporate misuse. Established privacy regimes are focused on individual consent, and most human rights treaties know derogations from privacy and data protection norms for states of emergency. This leaves little safeguards nor remedies to guarantee individual and collective autonomy. However, the challenge of responsible data use during a crisis is not novel. The humanitarian sector has more than a decade of experience to offer. International organisations and humanitarian actors have developed detailed guidelines on how to use data responsibly under extreme circumstances. This article briefly addresses the legal gap of data protection and privacy during this global crisis. Then it outlines the state of the art in humanitarian practice and academia on data protection and data responsibility during crisis.

A qualitative study of the factors influencing recruitment to a pilot trial on the prevention of striae gravidarum

Background

Striae gravidarum are a common occurrence in pregnancy and many women use a topical product to prevent their development or lessen their appearance if they do develop. There is a lack of evidence on the effectiveness of many of the products used by women. This study arose from challenges in recruitment to a pilot randomised trial (ISRCTN trial registration number:76992326) designed to evaluate the feasibility of a definitive trial to compare a moisturising oil to no treatment in the prevention and reduction in severity of striae gravidarum. The study reported here explored the factors influencing recruitment to that pilot trial.

Methods

A qualitative descriptive study was undertaken involving primigravid women attending an Irish maternity hospital. Data were collected by semi-structured telephone interviews over a four-week period and analysed using the framework method of analysis. Fifteen interview transcripts were included in the analysis.

Results

Four main themes consisting of twelve categories were identified from the interview data. The themes focused on women’s prevention of stretch marks and their choice of anti-stretch mark product, who and what influenced that choice and influences on trial participation. In relation to influences on trial participation, the possibility of being randomised to the non- intervention or control group was a deterrent for many women.

Conclusions

The prevention of stretch marks is important to pregnant women, as is their choice of product to prevent them. Offering women the opportunity to be part of a trial that would be of low burden and would test a well-known product may optimise recruitment. However, reluctance to be randomised because of the possibility of being allocated to the non-intervention control group suggests that further work is needed in this field on how best to communicate uncertainty to potential participants.

Pharmacologic labour analgesia and its relationship to postpartum psychiatric disorders: a scoping review

PURPOSE

This scoping review aimed to summarize the current literature on postpartum psychiatric disorders (e.g., postpartum depression, postpartum anxiety, postpartum post-traumatic stress disorder) and the possible relationship of these disorders to the use of pharmacologic labour analgesia (e.g., epidural analgesia, nitrous oxide, parenteral opioids) to identify knowledge gaps that may aid in the planning of future research.

SOURCES

PubMed, PsycINFO, CINAHL, and EMBASE were searched from inception to November 9, 2018 for studies that included both labour analgesia and the postpartum psychiatric disorders specified above.

PRINCIPAL FINDINGS

Two reviewers assessed the studies and extracted the data. Of the 990 identified citations, 17 studies were included for analysis. Existing studies have small sample sizes and are observational cohorts in design. Patient psychiatric risk factors, method of delivery, and type of labour analgesia received were inconsistent among studies. Most studies relied on screening tests for diagnosing postpartum psychiatric illness and did not assess the impact of labour analgesia on postpartum psychiatric illness as the primary study objective.

CONCLUSIONS

Future studies should correlate screen-positive findings with clinical diagnosis; consider adjusting the timing of screening to include the antepartum period, early postpartum, and late postpartum periods; and consider the degree of labour pain relief and the specific pharmacologic labour analgesia used when evaluating postpartum psychiatric disorders.

Early life cognitive development trajectories and intelligence quotient in middle childhood and early adolescence in rural western China

The relationship of cognitive developmental trajectories during the dynamic first years with later life development outcomes remains unclear in low- and middle-income countries. 1388 Children born to women who participated in a randomized trial of antenatal micronutrient supplementation in rural China were prospectively followed. Cognitive development was assessed six times between 3 and 30 months of age using Bayley Scales of Infant Development, and then in mid-childhood (7-9 years) and early adolescence (10-12 years) using Wechsler Intelligence Scale for Children. We identified four distinct infant cognitive development trajectory subgroups using group-based trajectory modeling: (i) consistently above average, (ii) consistently average, (iii) started below average and then improved, and (iv) started below average and then declined. LBW infants (<2500 g) were 10.60 times (95% CI 3.57, 31.49) more likely to be in the trajectory group that started below average and then declined, while each grade increase in maternal education decreased the risk of being in this group by 73% (95% CI 54%, 84%). Infants who performed consistently above average had 8.02 (95% CI 1.46, 14.59) points higher IQ in adolescence versus the declining trajectory group. These findings suggest that interventions to improve early child development trajectories may produce long-term human capital benefits.

Treatment failure definitions for non-purulent skin and soft tissue infections: a systematic review

OBJECTIVE

There is currently no uniform definition for antimicrobial treatment failure for adults with non-purulent skin and soft tissue infections (SSTIs). The objective of this systematic review was to identify treatment failure definitions and their common components in the literature.

METHODS

Five electronic databases were searched from inception to March 2019. Two independent reviewers identified studies involving adults (age ≥ 18 years) with non-purulent SSTIs in which antimicrobial treatment failure was a defined outcome. There were no language restrictions. Only randomized trials or observational studies were included.

RESULTS

After screening 4953 abstracts, 26 studies (N = 6629 patients) met full inclusion criteria. Reported treatment failure ranged from 0 to 29.5%. The most common definition components were hospital admission (78.9%), change in antibiotics (65.4%), and persistent or worsening signs and symptoms of infection (34.6%). Only one study listed specific criteria for persistent or worsening signs and symptoms of infection.

CONCLUSIONS

For studies involving non-purulent SSTIs, the outcome of treatment failure is inconsistently defined and reported failure rates are highly variable. This systematic review has highlighted the need for more robust treatment failure definitions for non-purulent SSTIs. Research should focus on the development of a uniform treatment failure definition that should be used in future studies.

Re-orienting health systems through a commissioning approach: finding solutions for improved consumer engagement

As many developed health systems grapple with the reorientation of their systems to those that are commissioning led, consumer engagement has emerged as an important theme. Despite many governments asserting the importance of consumer engagement in commissioning, an evidence base is yet to be developed to support this approach. This paper identifies the challenges and gaps in the literature relating to consumer engagement and commissioning, before setting out five potential solutions to these challenges. Ultimately, consumer engagement needs clarity of purpose and any approach should be tailored to context. Effective client involvement needs time and investment. To embark on such a process without this effort can be counterproductive.

External validation of molecular subtype classifications of colorectal cancer based on microsatellite instability, CIMP, BRAF and KRAS

Background

Competing molecular classification systems have been proposed to complement the TNM staging system for a better prediction of survival in colorectal cancer (CRC). However, validation studies are so far lacking. The aim of this study was to validate and extend previously published molecular classifications of CRC in a large independent cohort of CRC patients.

Methods

CRC patients were recruited into a population-based cohort study (DACHS). Molecular subtypes were categorized based on three previously published classifications. Cox-proportional hazard models, based on the same set of patients and using the same confounders as reported by the original studies, were used to determine overall, cancer-specific, or relapse-free survival for each subtype. Hazard ratios and confidence intervals, as well as Kaplan-Meier plots were compared to those reported by the original studies.

Results

We observed similar patterns of worse survival for the microsatellite stable (MSS)/BRAF-mutated and MSS/KRAS-mutated subtypes in our validation analyses, which were included in two of the validated classifications. Of the two MSI subtypes, one defined by additional presence of CIMP-high and BRAF-mutation and the other by tumors negative for CIMP, BRAF and KRAS-mutations, we could not confirm associations with better prognosis as suggested by one of the classifications. For two of the published classifications, we were able to provide results for additional subgroups not included in the original studies (men, other disease stages, other locations).

Conclusions

External validation of three previously proposed classifications confirmed findings of worse survival for CRC patients with MSS subtypes and BRAF or KRAS mutations. Regarding MSI subtypes, other patient characteristics such as stage of the tumor, may influence the potential survival benefit. Further integration of methylation, genetic, and immunological information is needed to develop and validate a comprehensive classification that will have relevance for use in clinical practice.

Trends in benzodiazepine anxiolytics and z-hypnotics use among French drivers involved in road traffic crashes from 2005 to 2015: a responsibility case-control study

Background

In France, benzodiazepine anxiolytics and z-hypnotics (zolpidem and zopiclone) account for the largest share of road traffic crash risk attributable to exposure to prescription drugs. The aim of this study was to monitor the evolution of the use of these prescription drugs and their association with crash risk over a period that began before the implementation of a color-graded pictogram system printed on prescription drug boxes.

Methods

Data from three French national databases were extracted and linked: the national health care insurance database, police reports, and the national police database of injurious crashes. Drivers involved in an injurious crash in France, from July 2005 to December 2015, and identified by their national identifier were included. The association with crash risk was estimated using a responsibility analysis comparing the use of benzodiazepines and z-hypnotics among drivers responsible or not for the crash.

Results

A total of 97,936 responsible and 103,522 non-responsible drivers involved in an injurious crash were included. The proportion of drivers exposed to benzodiazepine anxiolytics or z-hypnotics remained stable among responsible and non-responsible drivers. Among controls from the general population, the proportion of exposed individuals tended to increase. The association with crash risk remained almost constant over the study period. The odds-ratio for benzodiazepines ranged between 1.42 [1.24–1.62] at the beginning of the study period and 1.27 [1.09–1.47] at the end.

Conclusion

Given the increase in exposure in the control group from the general population, the stability of exposure for responsible and non-responsible drivers can be interpreted as a relative effectiveness of the pictogram on driver exposure levels. On the other hand, while the intrinsic effect of a prescription drug cannot be modified, a decrease in risk could have been expected if drivers adapted their behavior as promoted by the pictogram. Our results therefore suggest that no significant change occurred in driving behaviors or consumption patterns.

A discourse network analysis of UK newspaper coverage of the "sugar tax" debate before and after the announcement of the Soft Drinks Industry Levy

BACKGROUND

On 6th April 2018, the UK Government introduced the Soft Drinks Industry Levy (SDIL) as a mechanism designed to address increasing prevalence of obesity and associated ill health by reducing sugar consumption. Given that the successful introduction of upstream food and nutrition policies is a highly political enterprise involving multiple interested parties, understanding the complex network of stakeholders seeking to influence such policy decisions is imperative.

METHODS

Media content analysis was used to build a dataset of relevant newspaper articles, which were analysed to identify stakeholder agreement or disagreement with defined concept statements. We used discourse network analysis to produce visual representations of the network of stakeholders and coalitions evident in the debate as it was presented in UK newspapers, in the lead up to and following the announcement of the Soft Drinks Industry Levy in the UK, from May 2015 to November 2016.

RESULTS

Coding identified 3883 statements made by 214 individuals from 176 organisations, relating to 47 concepts. Network visualisations revealed a complex network of stakeholders with clear sceptical and supportive coalitions. Industry stakeholders appeared less united in the network than anticipated, particularly before the SDIL announcement. Some key industry actors appeared in the supportive coalition, possibly due to the use of corporate social responsibility rhetoric. Jamie Oliver appeared as a dominant stakeholder, firmly embedded with public health advocates.

CONCLUSION

This study highlights the complexity of the network of stakeholders involved in the public debate on food policies such as sugar tax and the SDIL. Polarisation of stakeholders arose from differences in ideology, focus on a specific policy and statements about the weight of evidence. Vocal celebrity policy entrepreneurs may be instrumental in gaining public and policy makers' support for future upstream regulation to promote population health, to facilitate alignment around a clear ideology.

Moderators of treatment outcomes in a partial hospitalization and intensive outpatient program for eating disorders

Eating disorders cause a number of severely impairing symptoms that may require more intensive intervention that is available through outpatient therapy services. The PHP/IOP level of care may be an effective mode of treatment in these cases, but few studies have examined overall outcomes or treatment moderators for this level of care. Using a large sample from a PHP/IOP specifically designed for the treatment of eating disorders, the current study examines a variety of symptoms (eating disorder severity, quality of life, depression, etc.) from admission to discharge, as well as potential moderators of treatment, including demographic and clinical factors. Overall, the PHP/IOP level of care was found to improve treatment outcomes. Age, race, gender, and depression were found to moderate the change in quality of life and functional impairment. Additionally, patients diagnosed with anorexia nervosa had significantly lowered quality of life and greater eating disorder symptomatology than all other diagnoses. The results of this study can help to inform clinical practice and help guide in treatment decisions at the partial hospitalization level of care.

Combining mirtazapine with SSRIs or SNRIs for treatment-resistant depression: the MIR RCT

BACKGROUND

Depression is usually managed in primary care and antidepressants are often the first-line treatment, but only half of those treated respond to a single antidepressant.

OBJECTIVES

To investigate whether or not combining mirtazapine with serotonin-noradrenaline reuptake inhibitor (SNRI) or selective serotonin reuptake inhibitor (SSRI) antidepressants results in better patient outcomes and more efficient NHS care than SNRI or SSRI therapy alone in treatment-resistant depression (TRD).

DESIGN

The MIR trial was a two-parallel-group, multicentre, pragmatic, placebo-controlled randomised trial with allocation at the level of the individual.

SETTING

Participants were recruited from primary care in Bristol, Exeter, Hull/York and Manchester/Keele.

PARTICIPANTS

Eligible participants were aged ≥ 18 years; were taking a SSRI or a SNRI antidepressant for at least 6 weeks at an adequate dose; scored ≥ 14 points on the Beck Depression Inventory-II (BDI-II); were adherent to medication; and met the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, criteria for depression.

INTERVENTIONS

Participants were randomised using a computer-generated code to either oral mirtazapine or a matched placebo, starting at a dose of 15 mg daily for 2 weeks and increasing to 30 mg daily for up to 12 months, in addition to their usual antidepressant. Participants, their general practitioners (GPs) and the research team were blind to the allocation.

MAIN OUTCOME MEASURES

The primary outcome was depression symptoms at 12 weeks post randomisation compared with baseline, measured as a continuous variable using the BDI-II. Secondary outcomes (at 12, 24 and 52 weeks) included response, remission of depression, change in anxiety symptoms, adverse events (AEs), quality of life, adherence to medication, health and social care use and cost-effectiveness. Outcomes were analysed on an intention-to-treat basis. A qualitative study explored patients' views and experiences of managing depression and GPs' views on prescribing a second antidepressant.

RESULTS

There were 480 patients randomised to the trial (mirtazapine and usual care, n = 241; placebo and usual care, n = 239), of whom 431 patients (89.8%) were followed up at 12 weeks. BDI-II scores at 12 weeks were lower in the mirtazapine group than the placebo group after adjustment for baseline BDI-II score and minimisation and stratification variables [difference -1.83 points, 95% confidence interval (CI) -3.92 to 0.27 points; p = 0.087]. This was smaller than the minimum clinically important difference and the CI included the null. The difference became smaller at subsequent time points (24 weeks: -0.85 points, 95% CI -3.12 to 1.43 points; 12 months: 0.17 points, 95% CI -2.13 to 2.46 points). More participants in the mirtazapine group withdrew from the trial medication, citing mild AEs (46 vs. 9 participants).

CONCLUSIONS

This study did not find convincing evidence of a clinically important benefit for mirtazapine in addition to a SSRI or a SNRI antidepressant over placebo in primary care patients with TRD. There was no evidence that the addition of mirtazapine was a cost-effective use of NHS resources. GPs and patients were concerned about adding an additional antidepressant.

LIMITATIONS

Voluntary unblinding for participants after the primary outcome at 12 weeks made interpretation of longer-term outcomes more difficult.

FUTURE WORK

Treatment-resistant depression remains an area of important, unmet need, with limited evidence of effective treatments. Promising interventions include augmentation with atypical antipsychotics and treatment using transcranial magnetic stimulation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN06653773; EudraCT number 2012-000090-23.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 63. See the NIHR Journals Library website for further project information.