Mortality associated with Metabolic Syndrome in people with COPD managed in primary care

Objective

The prevalence of metabolic syndrome (MetS) has been reported to be higher in selected populations of people with COPD. The impact of MetS on mortality in COPD is unknown. We used routinely collected healthcare data to estimate the prevalence of MetS in people with COPD managed in primary care and determine its impact on 5-year mortality.

Methods

Records from 103 955 patients with COPD from the Clinical Practice Research Datalink (CPRD-GOLD) between 2009 to 2017 were scrutinised. MetS was defined as the presence of three or more of: obesity, hypertension, lowered high-density lipoprotein cholesterol, elevated triglycerides or type 2 diabetes mellitus (T2DM). Univariate and multivariable Cox regression models were constructed to determine the prognostic impact of MetS on 5-year mortality. Similar univariate models were constructed for individual components of the definition of MetS.

Results

The prevalence of MetS in the COPD cohort was 10.1%. Univariate analyses showed the presence of MetS increased mortality (hazard ratio (HR) 1.19, 95% CI: 1.12–1.27, p<0.001), but this risk was substantially attenuated in the multivariable analysis (HR 1.06, 95% CI: 0.99–1.13, p=0.085). The presence of hypertension (HR 1.70, 95% CI: 1.63–1.77, p<0.001) and T2DM (HR 1.41, 95% CI: 1.34–1.48, p<0.001) increased and obesity (HR 0.74, 95% CI: 0.71–0.78, p<0.001) reduced mortality risk.

Conclusion

MetS in patients with COPD is associated with higher 5-year mortality, but this impact was minimal when adjusted for indices of COPD disease severity and other comorbidities. Individual components of the MetS definition exerted differential impacts on mortality suggesting limitation to the use of MetS as a multicomponent condition in predicting outcome in COPD.

The presence of MetS in COPD is not significantly associated with increased mortality over 5 years. The individual components of MetS exert differential effects on mortality, limiting the utility of the syndrome in predicting outcome.https://bit.ly/3PooGQd

Testing the Institute of Medicine (IOM) recommendations on maternal reproductive health and associated neonatal characteristics in a transitional, Mediterranean population

BACKGROUND

High pre-pregnancy body mass index (BMI) and excessive gestational weight gain (GWG) are significant risk factors for maternal and neonatal health.

AIM

To assess pre-pregnancy BMI and GWG during pregnancy and their association with different maternal and neonatal characteristics in the transitional Mediterranean population from the Eastern Adriatic islands.

SUBJECTS AND METHODS

262 mother-child dyads from the CRoatian Islands' Birth Cohort Study (CRIBS) were included in the study. Chi-square test, ANOVA and regression analysis were used to test the association between selected characteristics.

RESULTS

22% of women entered pregnancy with overweight/obesity and 46.6% had excessive GWG. Pre-pregnancy overweight and obesity were significantly associated with elevated triglycerides uric acid levels, and decreased HDL cholesterol in pregnancy. Excessive GWG was associated with elevated fibrinogen and lipoprotein A levels. Women with high pre-pregnancy BMI and GWG values were more likely to give birth to babies that were large for gestational age (LGA), additionally confirmed in the multiple logistic regression model.

CONCLUSION

High maternal pre-pregnancy BMI and excessive GWG were both significantly associated with deviated biochemical parameters and neonatal size. More careful monitoring of maternal nutritional status can lead to better pre- and perinatal maternal health care.

How well do covariates perform when adjusting for sampling bias in online COVID-19 research? Insights from multiverse analyses

COVID-19 research has relied heavily on convenience-based samples, which-though often necessary-are susceptible to important sampling biases. We begin with a theoretical overview and introduction to the dynamics that underlie sampling bias. We then empirically examine sampling bias in online COVID-19 surveys and evaluate the degree to which common statistical adjustments for demographic covariates successfully attenuate such bias. This registered study analysed responses to identical questions from three convenience and three largely representative samples (total N = 13,731) collected online in Canada within the International COVID-19 Awareness and Responses Evaluation Study ( www.icarestudy.com ). We compared samples on 11 behavioural and psychological outcomes (e.g., adherence to COVID-19 prevention measures, vaccine intentions) across three time points and employed multiverse-style analyses to examine how 512 combinations of demographic covariates (e.g., sex, age, education, income, ethnicity) impacted sampling discrepancies on these outcomes. Significant discrepancies emerged between samples on 73% of outcomes. Participants in the convenience samples held more positive thoughts towards and engaged in more COVID-19 prevention behaviours. Covariates attenuated sampling differences in only 55% of cases and increased differences in 45%. No covariate performed reliably well. Our results suggest that online convenience samples may display more positive dispositions towards COVID-19 prevention behaviours being studied than would samples drawn using more representative means. Adjusting results for demographic covariates frequently increased rather than decreased bias, suggesting that researchers should be cautious when interpreting adjusted findings. Using multiverse-style analyses as extended sensitivity analyses is recommended.

Evidence for causal associations between prenatal and postnatal antibiotic exposure and asthma in children, England

BACKGROUND

Higher risks of asthma have been observed in children with prenatal exposure to antibiotics and during early life compared with those who have not. However, the causality of such associations is unclear.

OBJECTIVE

To assess whether exposure to antibiotics in early life had a causal effect in increasing the risk of asthma in children diagnosed at 5-8 years of life, and the impact in the target population.

METHODS

Data were from electronic health records and questionnaires for children and their mothers in the Born in Bradford birth cohort. Exposure variables were prescriptions of systemic antibiotics to the mother during pregnancy (prenatal) and to the children at 0-24 months of life (postnatal). We assessed the association in 12,476 children with several approaches to deal with different sources of bias (triangulation): the interactions with mother's ethnicity, mode of delivery, and between prenatal and postnatal exposures; dose-response; and estimated the population attributable risk.

RESULTS

There was an association between prenatal exposure at 7-27 days before the child's birth and asthma (adjusted OR = 1.40; 1.05, 1.87), but no association with the negative control exposure (before pregnancy) (adjusted OR = 0.99 (0.88, 1.12)). For postnatal exposure, the adjusted OR was 2.00 (1.71, 2.34), and for sibling analysis, it was 1.99 (1.00, 3.93). For postnatal exposure, the risk of asthma increased with the number of prescriptions. The observed effect of both exposures was lower among children with mothers of Pakistani ethnicity, but inconclusive (p > .25). The interaction between prenatal and postnatal exposures was also inconclusive (p = .287). The population attributable risk of postnatal exposure for asthma was 4.6% (0.1% for prenatal).

CONCLUSIONS

We conclude that the associations between both late-pregnancy prenatal exposure to antibiotics and postnatal exposure to antibiotics and an increased risk of asthma are plausible and consistent with a causal effect.

Incidence of bone stress injury is greater in competitive female distance runners with menstrual disturbances independent of participation in plyometric training

Bone stress injury (BSI) is prevalent in female distance runners. Menstrual disturbances are associated with impaired bone health in endurance athletes. This study aimed to investigate the association between menstrual function and BSI and explore whether plyometric training may protect against BSI in individuals with menstrual disturbances. Competitive female distance runners (n = 183) aged 18-40 years were surveyed for training habits, menstrual function, and BSI, during the previous 12 months. Oligo/amenorrhoea during the previous 12 months (<9 menses) was deemed to indicate menstrual disturbance; hormonal contraceptive users and those previously diagnosed with a pathology that impacted menstrual function were excluded. BSI incidence rate was 2.25 (p = 0.02, 95% CI: 1.14-4.41) times greater in oligo/amenorrhoeic than eumenorrhoeic runners. BSI incidence rate was similar in oligo/amenorrhoeic and eumenorrhoeic runners that did plyometric training, but 3.78 (p = 0.001, 95% CI: 1.68-8.5) times greater in oligo/amenorrhoeic versus eumenorrhoeic runners that did not. However, the effect of plyometrics was non-significant (menstrual function × plyometric training interaction, p = 0.06; main effect, p = 0.89). Conventional plyometric training may not reduce BSI incidence in female distance runners, but menstrual disturbances and prolonged periods of low energy availability should be avoided.

4 Relationship between childhood overweight/obesity indicators and vigorous physical activity among NHANSE III boys (8 to 11 years old): different interpretation between body mass index and subcutaneous adiposity size and shape

Aim

The aim of this study was to investigate whether the relationship between BMI and vigorous physical activity (VPA) differs when both the overall and regional distribution of subcutaneous adiposity (SA) are considered as alternative fatness indicators of BMI.

Methods

The sample data were obtained from the third National Health and Nutrition Examination Survey (NHANES III). Four skinfolds (triceps, subscapular, supraspinal, thigh), BMI, age, race/ethnicity, height, and VPA (i.e., times per week exercise made you sweat) data of 1,028 boys (8–11 yrs) were extracted. The overall and regional distribution of the four skinfolds were calculated into Subcutaneous Adiposity Size and Shape (SASS) variables based on the description provided in Healy and Tanner’s method (1): transform all four skinfolds into logarithms, 2) calculate average (SA-size estimation), 3) calculate difference between the average and each log-transformed skinfold, 4) run principal component analysis (SA-shape estimation). The samples were categorized into three groups based on participants’ VPA levels (very-active: VPA>5 times, active: 2<VPA<4 times, non-active: VPA<1 time). Then, MANCOVA/ANCOVA (BMI) were conducted separately to ascertain whether the fatness indicators provide consistent interpretations of the relationship with VPA.

Results

The MANCOVA showed significant interaction between the SASS and VPA (p<0.05). The MANCOVA Bonferroni-adjustment results indicated that SA-size (F(2,938)=5.528, p<0.005; partial η2=0.012) and subscapular-to-thigh SA-shape was significantly associated with VPA (F(2,938)=9.587,p<0.0005; partial η2=0.020), but not triceps-supraspinal SA-shape (F(2,938)=1.485,p=0.227; partial η2=0.003). This means that the very active and active boys had significantly larger SA-size and larger thigh and smaller subscapular SA-shape than the non-active boys. The ANCOVA result showed no BMI difference between the VPA groups (F(2,1024)=1.296, p=0.274).

Conclusion

It was concluded that the interpretations made via SASS and BMI when associated with VPA are different. Future studies need to further investigate whether tackling childhood obesity by focusing on BMI-based obesity is affective approach to reduce body fat.

Reference

Healy MJR, Tanner JM. Size and shape in relation to growth and form. Symp Zool Soc Lond 1981;46:19–35.

Investigating the relationship between fetal growth and academic attainment: secondary analysis of the Born in Bradford (BiB) cohort

Background

The relationship between ultrasongraphically derived estimates of fetal growth and educational attainment in the postnatal period is unknown. Results from previous studies focusing on cognitive ability, however, suggest there may be gestation-specific associations. Our objective was to model growth in fetal weight (EFW) and head circumference (HC) and identify whether growth variation in different periods was related to academic attainment in middle childhood.

Methods

Data come from the Born in Bradford (BiB) cohort study, which has performed data linkage to both routine antenatal scans and national academic attainment tests at age 6-7 years. Multilevel linear spline models were used to model EFW and HC. Random effects from these were related to Key Stage 1 (KS1) results in reading, writing, mathematics, science and a composite of all four (age 6-7 years), using ordinal logistic and logistic regression. Associations were adjusted for potential confounders, facilitated by directed acyclic graphs. Missing covariate data were imputed using multiple imputation.

Results

In all, 6995 and 8438 children had complete KS1, and EFW and HC data, respectively. Positive associations were observed between both fetal weight in early pregnancy (14 weeks) and EFW growth in mid-pregnancy (14-26 weeks) and the individual KS1 outcomes. Furthermore, after adjustment for previous size and confounders, a 1-z score increase in growth in mid-pregnancy was associated with an 8% increased odds of achieving the expected standard for all KS1 outcomes [odds ratio (OR): 1.08, 95% confidence interval (CI): 1.02; 1.13]. Similar results were observed for HC, with generally larger effect sizes. Smaller associations were observed with growth in the early-third trimester, with no associations observed with growth in the later-third trimester.

Conclusions

We observed consistent positive associations between fetal size and growth in early and mid-gestation and academic attainment in childhood. The smaller and null associations with growth in the early-third and later-third trimester, respectively, suggests that early-mid gestation may be a sensitive period for future cognitive development.

Overprescribing antibiotics for asymptomatic bacteriuria in older adults: a case series review of admissions in two UK hospitals

Background

Overdiagnosis and overtreatment of urinary tract infection (UTI) with antibiotics is a concern. In older adults, diagnosis of UTI using near-patient urine tests (reagent strip tests, dipsticks) is advised against because the age-related increase in asymptomatic bacteriuria can cause false-positive results. Instead, UTI diagnosis should be based on a full clinical assessment. Previous research lacks systematic information on urine dipstick use in hospitals. The aim of this study was to examine the use of urine dipstick tests and microbiology among older adult hospital admissions in relation to recommended UTI diagnostic criteria. A further aim was to assess factors associated with the use of dipsticks.

Methods

A case series review of patients aged ≥70 years admitted to two NHS Trust hospitals in England. Records from 312 patients admitted in 2015 meeting inclusion criteria were selected at random.

Results

Of 298 complete patient records, 54% had at least one urine dipstick test recorded. 13% (21/161) of patients who received a urine dipstick test were diagnosed as having a UTI, only 2 out of these 21 cases had two or more clinical signs and symptoms. 60 patients received a second dipstick test, leading to 13 additional cases of UTI diagnosis. Dipstick tests were more likely to be performed on patients with a history of falls (OR 1.93, 95% CI:1.21, 3.07, p < 0.01), and less likely on those with dementia (OR 0.44, 95% CI: 0.22, 0.87, p < 0.05). The most common reason for testing was routine admissions policy (49.1% of cases), but these cases were predominantly in one hospital.

Conclusions

Use of urine dipstick tests was high among older adults admitted to hospitals. Most cases were asymptomatic and therefore received inappropriate antibiotic therapy. This paper highlights the need to implement new Public Health England diagnostic guidelines to hospital admission and emergency departments.

Infant deaths from congenital anomalies: novel use of Child Death Overview Panel data

OBJECTIVE

We aimed to assess Child Death Overview Panel (CDOP) data validity, and cause of death classification, by comparison with information from a local birth cohort study (Born in Bradford, BiB), and another cause of death coding system (causes of death and associated conditions-CODAC). We then aimed to use CDOP data to calculate ethnic-specific infant mortality rates (IMRs), and compare characteristics of infants who died of congenital anomalies (CA) with those who died from other causes (non-CA).

DESIGN

Retrospective cohort study.

SETTING

Bradford Metropolitan District.

PATIENTS

All infant deaths, 2008 to 2013.

MAIN OUTCOME MEASURES

Infant mortality rates from CA and non-CA causes.

RESULTS

315 infant deaths were included, 56 of whom were BiB recruits. Agreement between CDOP and BiB was moderate to perfect for all characteristics except ethnicity, which showed weak agreement (kappa=0.58). The same deaths (27/56) were classified as CA by CDOP and CODAC. IMRs (per 1000 live births, 2009-2013) were highest in Pakistani infants (all causes 9.8, CA cause 5.5) compared with white British (all causes 4.3, CA cause 1.3) and other infants (all causes 5.1, CA cause 1.4). In multivariate analysis, infants who died of CA cause were more likely to have been born at term (OR 3.18) and to consanguineous parents (OR 3.28) than infants who died of non-CA cause.

CONCLUSIONS

Excess Pakistani mortality appears to be partly explained by an excess of deaths from CA, which in this population appears associated with a greater prevalence of consanguinity.

Identifying MAIS 3+ injury severity collisions in UK police collision records

OBJECTIVE

This study represents the first stage of a project to identify serious injury, at the level of Maximum Abbreviated Injury Scale (MAIS) 3 + (excluding fatal collisions) from within the police collision data. The resulting data will then be used to identify the vehicle drivers concerned and in later studies these will be culpability scored and profiled to allow targeting of interventions.

METHOD

UK police collision data known as STATS19 for the county of Cambridgeshire were linked using Stata with Trauma Audit and Research Network (TARN) hospital trauma patient data for the same geographical area for the period April 2012 to March 2017. Linking was 2-stage: A deterministic process followed by a probabilistic process.

RESULTS

The linked records represent an individual trauma patient from TARN data linked to an individual trauma casualty from STATS19 data. Full collision data for the incident resulting in the trauma casualty were extracted. The resulting subset of collisions has the MAIS 3+ injury criteria applied. From the 10,498 recorded collisions, the deterministic linking process was successful in linking 257 MAIS 3+ trauma patients to collision injury subjects from 232 separate collisions with the probabilistic process linking a further 22 MAIS 3+ subjects from 21 collision events. The combined collision data for the 253 collisions involved 434 motor vehicle drivers.

CONCLUSIONS

We produced viable results from the available data to identify MAIS 3+ collisions from the overall collision data.

Influence of muscle mass in the assessment of lower limb strength in COPD: validation of the prediction equation

Absence of established reference values limits application of quadriceps maximal voluntary contraction (QMVC) measurement. The impact of muscle mass inclusion in predictions is unclear. Prediction equations encompassing gender, age and size with (FFM+) and without (FFM-), derived in healthy adults (n=175), are presented and compared in two COPD cohorts recruited from primary care (COPD-PC, n=112) and a complex care COPD clinic (COPD-CC, n=189). Explained variance was comparable between the prediction models (R2: FFM+: 0.59, FFM-: 0.60) as were per cent predictions in COPD-PC (88.8%, 88.3%). However, fat-free mass inclusion reduced the prevalence of weakness in COPD, particularly in COPD-CC where 11.9% fewer were deemed weak.

Informative Observation in Health Data: Association of Past Level and Trend with Time to Next Measurement

In routine health data, risk factors and biomarkers are typically measured irregularly in time, with the frequency of their measurement depending on a range of factors - for example, sicker patients are measured more often. This is termed informative observation. Failure to account for this in subsequent modelling can lead to bias. Here, we illustrate this issue using body mass index measurements taken on patients with type 2 diabetes in Salford, UK. We modelled the observation process (time to next measurement) as a recurrent event Cox model, and studied whether previous measurements in BMI, and trends in the BMI, were associated with changes in the frequency of measurement. Interestingly, we found that increasing BMI led to a lower propensity for future measurements. More broadly, this illustrates the need and opportunity to develop and apply models that account for, and exploit, informative observation.

Development and evaluation of an intervention for the prevention of childhood obesity in a multiethnic population: the Born in Bradford applied research programme

Background

There is an absence of evidence about interventions to prevent or treat obesity in early childhood and in South Asian populations, in whom risk is higher.

Objectives

To study patterns and the aetiology of childhood obesity in a multiethnic population and develop a prevention intervention.

Design

A cohort of pregnant women and their infants was recruited. Measures to compare growth and identify targets for obesity prevention, sensitive to ethnic differences, were collected. A feasibility randomised controlled trial (RCT) was undertaken.

Setting

Bradford, UK.

Participants

A total of 1735 mothers, 933 of whom were of South Asian origin.

Intervention

A feasibility trial of a group-based intervention aimed at overweight women, delivered ante- and postnatally, targeting key modifiable lifestyle behaviours to reduce infant obesity.

Main outcome measures

The feasibility and acceptability of the pilot intervention.

Data sources

Routine NHS data and additional bespoke research data.

Review methods

A systematic review of diet and physical activity interventions to prevent or treat obesity in South Asian children and adults.

Results

Routine measures of growth were accurate. The prevalence of risk factors differed between mothers of white British ethnicity and mothers of Pakistani ethnicity and weight and length growth trajectories differed between Pakistani infants and white British infants. Prediction equations for risk of childhood obesity were developed. An evidence-based intervention was evaluated in a pilot RCT and was found to be feasible and acceptable.

Limitations

This was a single-centre observational study and a pilot evaluation.

Conclusions

The programme has been successful in recruiting a unique multiethnic childhood obesity cohort, which has provided new evidence about modifiable risk factors and biethnic growth trajectories. A novel group-based behavioural change intervention has been developed and successfully piloted. A multisite cluster RCT is required to evaluate effectiveness.

Trial registration

Current Controlled Trials ISRCTN56735429.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Ethnic differences in the initiation and duration of breast feeding--results from the born in Bradford Birth Cohort Study

BACKGROUND

Initiation of breast feeding and duration of any breast feeding are known to differ by ethnic group, but there are limited data on differences in exclusive breast feeding. This study aimed to determine if there are ethnic differences in the initiation and duration of any and exclusive breast feeding.

METHODS

Breast-feeding data were obtained from a subsample of 1365 women recruited to a multi-ethnic cohort study (Born in Bradford) between August 2008 and March 2009. Poisson regression was used to investigate the impact of socio-economic, life style and birth factors on ethnic differences in the prevalence of breast feeding.

RESULTS

Compared with white British mothers, initiation of breast feeding was significantly higher in all ethnic groups and this persisted after adjustment for socio-economic, life style and birth factors [Pakistani: prevalence rate ratio (PRR) = 1.19 (95% confidence interval 1.10, 1.29); Other South Asian: PRR = 1.29 (1.18, 1.42); Other ethnicities: PRR = 1.33 (1.21, 1.46)]. There were no differences in exclusive breast feeding at 4 months [Pakistani: PRR = 0.77 (0.54, 1.09); Other South Asian: PRR = 1.55 (0.99, 2.43); Other ethnicities: PRR = 1.50 (0.88, 2.56)]. Any breast feeding at 4 months was significantly higher in mothers of all non-white British ethnicities [Pakistani: PRR = 1.27 (1.02, 1.58); Other South Asian: PRR = 1.99 (1.52, 2.62); Other ethnicities: 2.45 (1.86, 3.21)].

CONCLUSIONS

Whilst women of ethnic minority groups were significantly more likely to initiate breast feeding and continue any breast feeding for 4 months compared with white British women, the rates of exclusive breast feeding at 4 months were not significantly different once socio-economic, life style and birth factors were accounted for.

Introduction and evaluation of a 'pre-ART care' service in Swaziland: an operational research study

OBJECTIVE

To implement and evaluate a formal pre-antiretroviral therapy (ART) care service at a district hospital in Swaziland.

DESIGN

Operational research.

SETTING

District hospital in Southern Africa.

PARTICIPANTS

1171 patients with a previous diagnosis of HIV. A baseline patient group consisted of the first 200 patients using the service. Two follow-up groups were defined: group 1 was all patients recruited from April to June 2009 and group 2 was 200 patients recruited in February 2010.

INTERVENTION

Introduction of pre-ART care-a package of interventions, including counselling; regular review; clinical staging; timely initiation of ART; social and psychological support; and prevention and management of opportunistic infections, such as tuberculosis.

PRIMARY AND SECONDARY OUTCOME MEASURES

Proportion of patients assessed for ART eligibility, proportion of eligible patients who were started on ART and proportion receiving defined evidence-based interventions (including prophylactic co-trimoxazole and tuberculosis screening).

RESULTS

Following the implementation of the pre-ART service, the proportion of patients receiving defined interventions increased; the proportion of patient being assessed for ART eligibility significantly increased (baseline: 59%, group 1: 64%, group 2: 76%; p=0.001); the proportion of ART-eligible patients starting treatment increased (baseline: 53%, group 1: 81%, group: 2, 81%; p<0.001) and the median time between patients being declared eligible for ART and initiation of treatment significantly decreased (baseline: 61 days, group 1: 39 days, group 2: 14 days; p<0.001).

CONCLUSIONS

This intervention was part of a shift in the model of care from a fragmented acute care model to a more comprehensive service. The introduction of structured pre-ART was associated with significant improvements in the assessment, management and timeliness of initiation of treatment for patients with HIV.

Exploring patient perceptions of larval therapy as a potential treatment for venous leg ulceration

OBJECTIVES

To explore patient preferences and acceptability of two forms of larval therapy ('bagged' and 'loose').

BACKGROUND

Larval therapy is frequently used to treat patients with leg ulcers. However, patient preferences and acceptability of larval therapy when compared with other treatments is not established.

DESIGN

A survey of patient preferences between larvae and standard therapy (hydrogel) using randomized allocation of two questionnaires ('bagged' or 'loose' questionnaire). The questionnaire contained closed and open-response questions and was administered by a nurse researcher. Open responses enabled exploration of patients' preferences and the acceptability of larval therapy when compared with a standard treatment. Qualitative data were analysed for thematic content.

SETTING AND PARTICIPANTS

Thirty-five participants, aged 18 years and above, with at least one venous leg ulcer were recruited from a UK Hospital Vascular Outpatients Clinic.

FINDINGS

Majority of participants stated that they would consider larval therapy, irrespective of method of containment. Acceptance of therapy was influenced by length of time with (or recurrence of) ulceration, experiences of other treatments, social contact in hospitals and the experiences of others. Visual imagery was a key influence among participants who would refuse larval therapy. Refusal was mostly among older women (aged 70 years or above).

CONCLUSIONS

Eliciting patient preferences and increasing patient involvement in treatment decisions is an important part of quality improvement and improved health outcomes. These findings have relevance for practitioners offering larval therapy as a treatment option and for the feasibility of clinical trials.

Pressure ulcers

INTRODUCTION

Unrelieved pressure or friction of the skin, particularly over bony prominences, can lead to pressure ulcers in up to a third of people in hospitals or community care, and a fifth of nursing home residents. Pressure ulcers are more likely in people with reduced mobility and poor skin condition, such as older people or those with vascular disease.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of preventive interventions in people at risk of developing pressure ulcers? What are the effects of treatments in people with pressure ulcers? We searched: Medline, Embase, The Cochrane Library and other important databases up to February 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 60 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: air-filled vinyl boots, air-fluidised supports, alternating pressure surfaces (including mattresses), alternative foam mattresses, constant low-pressure supports, debridement, electric profiling beds, electrotherapy, hydrocellular heel supports, low-air-loss beds (including hydrotherapy beds), low-level laser therapy, low-tech constant low-pressure supports, medical sheepskin overlays, nutritional supplements, orthopaedic wool padding, pressure-relieving overlays on operating tables, pressure-relieving surfaces, repositioning (regular "turning"), seat cushions, standard beds, standard care, standard foam mattresses, standard tables, surgery, therapeutic ultrasound, topical lotions and dressings, topical negative pressure, and topical phenytoin.

The role and potential contribution of clinical research nurses to clinical trials

AIMS AND OBJECTIVES

This study explores the scope and potential contribution of the Clinical Research Nurse (CRN) role to clinical trials of a nursing-specific topic.

BACKGROUND

Over the past two decades, there have been increases in the numbers of nurses working as CRNs because of the increasing global demand for clinical trials. CRNs can influence the quality of clinical trials but the scope and contribution of the role to clinical trials is not known.

DESIGN

Qualitative focus group study.

METHODS

A focus group interview was carried out with CRNs (n = 9) employed on a large, multi-centre (six NHS Trusts) randomized controlled trial of pressure area care. The focus group interview was recorded, alongside field notes of participant interactions and behaviours, and transcribed verbatim. Data were analysed for thematic content and process.

FINDINGS

CRNs described their transition to a clinical research role. They reported a lack of confidence, role conflict as researcher and nurse, the challenges of gaining cooperation of clinical nursing staff to comply with trial protocols and difficulties maintaining their own motivation. CRNs provided their perceptions and observations of pressure area care and prevention. They identified areas of inadequate treatment, management and care, influenced by organizational and clinical aspects of care delivery.

CONCLUSIONS

The study reveals challenges associated with training and management of CRNs. CRNs are usually associated with trial recruitment and data collection. This study highlights the additional contributions of CRNs for the study of topics specific to nursing as the result of their unique placement in the research centres as informal 'participant observers.' Such observations enhance understanding of the contexts being studied.

RELEVANCE TO CLINICAL PRACTICE

These findings are relevant to the design and conduct of research studies of nursing care and practice and present ways for investigators to optimize the skills and knowledge of nurses working as CRNs.

Submission to multiple journals: a method of reducing time to publication?

Getting a manuscript accepted by a journal can be a long, drawn out process and delays dissemination of clinical research. Allowing authors to submit to several journals simultaneously could speed up publication