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The Centre for Evidence-Based Medicine (CEBM) at Oxford University develops, promotes and disseminates better evidence for health care.
Online review and rating sites, where patients can leave feedback on their experience of the health-care encounter, are becoming an increasing feature of primary care in the NHS. Previous research has analysed how digital surveillance is re-shaping the clinical gaze, as health-care professionals are subject to increased public monitoring. Here, we draw on an empirical study of 41 GP practice staff to show how the gaze is turning, not simply from the patient to the health-care provider, but additionally to the body politic of the NHS. Drawing on focus group and interview data conducted in five UK practices, we show how discourses of online reviews and ratings are producing new professional subjectivities among health-care professionals and the extent to which the gaze extends not only to individual health-care interactions but to the health-care service writ large. We identify three counter-discourses characterising the evolving ways in which online reviews and ratings are creating new subjects in primary care practices: victimhood, prosumption versus traditional values and taking control. We show how the ways in which staff speak about online feedback are patterned by the social environment in which they work and the constraints of the NHS they encounter on a day-to-day basis.
AIMS: To summarise evidence on tobacco addiction interventions published by the Cochrane Tobacco Addiction Group (CTAG) from 2019 to 2020. METHODS: Narrative summary of all new and updated Cochrane Reviews published by CTAG in 2019 and 2020, outlining key results and promising avenues for future research. RESULTS: CTAG published six new reviews and updated 15 reviews. There is high-certainty evidence that combining fast-acting nicotine replacement therapy (NRT) with transdermal patches helped more people to quit than single-form NRT (risk ratio (RR) 1.25, 95% confidence interval (CI) 1.15-1.36, 14 studies, n=11,356; I2 =4%), and moderate-certainty evidence that using NRT before quitting can increase quit rates more than using NRT from quit day onwards (RR 1.25, 95%CI 1.08-1.44, 9 studies, n=4395; I2 =0%;). Reducing smoking in order to quit completely results in similar quit rates to abrupt quitting (RR 1.01, 95%CI 0.87-1.17; I2 =29%; 22 studies, n=9219; moderate-certainty). Electronic cigarettes may help more people quit than NRT (RR 1.53, 95%CI 1.21-1.93; I2 =0%; 4 studies, n=1924; moderate certainty), nicotine-free electronic cigarettes (RR 1.94, 95%CI 1.21-3.13; I2 =0%; 5 studies, n=1447; moderate-certainty), and behavioural/no support (RR 2.61, 95%CI 1.44-4.74; I2 =0%; 6 studies, n=2886; very low-certainty). Varenicline may help prevent relapse in abstainers (RR 1.23, 95%CI 1.08-1.41; I2 =82%; 11 studies, n=1297; moderate-certainty), but behavioural support did not prevent relapse (RR 0.98, 95%CI 0.87-1.11; I2 =52%; 11 studies, n=5523; moderate-certainty). Financial incentives increased quit rates in the general population (RR 1.49, 95%CI 1.28-1.73; I2 =33%; 30 studies, adjusted n=20,097; high-certainty) and during pregnancy (RR 2.38, 95%CI 1.54-3.69; I2 =41%; 9 studies, n=2273; moderate-certainty). This overview also provides detail on a wider range of interventions. CONCLUSIONS: There is high certainty that using nicotine replacement therapy from quit day increases smoking abstinence and no further research is required. Evidence is less certain that nicotine replacement increases abstinence when used in higher doses tailored to particular groups of smokers or use prior to quit day and further research would be helpful. There is moderate certainty evidence to support the use of e-cigarettes as cessation aids, but research on their role in preventing relapse would be particularly helpful.
Transmission of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) from pre and asymptomatic infected individuals: a systematic review
Background: The role of SARS-Cov-2-infected persons who develop symptoms after testing (presymptomatics) or not at all (asymptomatics) in the pandemic spread is unknown. Objectives: To determine infectiousness and probable contribution of asymptomatic persons (at the time of testing) to pandemic SARS-CoV-2 spread. Data sources: LitCovid, medRxiv, Google Scholar, and WHO Covid-19 databases (to 31 March 2021) and references in included studies. Study eligibility criteria: Studies with a proven or hypothesized transmission chain based either on serial PCR cycle threshold readings and/or viral culture and/or gene sequencing, with adequate follow-up. Participants: People exposed to SARS-CoV-2 within 2–14 days to index asymptomatic (at time of observation) infected individuals. Interventions: Reliability of symptom and signs was assessed within contemporary knowledge; transmission likelihood was assessed using adapted causality criteria. Methods: Systematic review. We contacted all included studies' corresponding authors requesting further details. Results: We included 18 studies from a diverse setting with substantial methodological variation (this field lacks standardized methodology). At initial testing, prevalence of asymptomatic cases was 12.5–100%. Of these, 6–100% were later determined to be presymptomatic, this proportion varying according to setting, methods of case ascertainment and population. Nursing/care home facilities reported high rates of presymptomatic: 50–100% (n = 3 studies). Fourteen studies were classified as high risk of, and four studies as at moderate risk of symptom ascertainment bias. High-risk studies may be less likely to distinguish between presymptomatic and asymptomatic cases. Six asymptomatic studies and four presymptomatic studies reported culturing infectious virus; data were too sparse to determine infectiousness duration. Three studies provided evidence of possible and three of probable/likely asymptomatic transmission; five studies provided possible and two probable/likely presymptomatic SARS-CoV-2 transmission. Conclusion: High-quality studies provide probable evidence of SARS-CoV-2 transmission from presymptomatic and asymptomatic individuals, with highly variable estimated transmission rates.
Value, challenges and practical considerations when designing, conducting and analysing a longitudinal qualitative study in family medicine.
Qualitative longitudinal design has a long tradition in a variety of social science disciplines and is increasingly used in applied healthcare research, including family medicine. While there are many definitions of longitudinal qualitative research (LQR), its most common characteristics are multiple data collection points and its focus on temporality, which prioritise the study of change and continuity. Thus, LQR can provide insights into the nature, causes and consequences of change (or its absence). In this paper, we discuss the key steps and considerations related to designing and conducting LQR in family medicine and community health. These include (1) deciding on the length of data collection and timing and number of interviews, (2) planning recruitment: attrition versus oversampling, (3) approaching data collection: asking the same or different questions, (4) planning and conducting the analysis and writing up findings, and (5) conducting ethical LQR. We also highlight what LQR can offer family medicine and community health, including (1) allowing exploration of views and experiences of a variety of participants over time; (2) following participants through important transitions; (3) studying implementation of new practices, processes or interventions; (4) exploring the importance of historical change and/or macro context on individuals' lives; and (5) developing a deeper understanding of phenomena under study. While a lot of attention has been paid to using LQR when studying patients' and/or carers' experiences, we highlight its value when studying a variety of actors relevant to family medicine, including healthcare professionals and policy makers.
The diagnostic accuracy of HbA1c , compared to the oral glucose tolerance test, for screening for type 2 diabetes mellitus in Africa-a systematic review and meta-analysis.
OBJECTIVE: To assess the diagnostic accuracy of HbA1c , compared to fasting plasma glucose (FPG) and the oral glucose tolerance test (OGTT), in screening for type 2 diabetes (T2D) in Africa. METHODS: We systematically searched databases for studies that compared the HbA1C to either the OGTT, or the FPG for T2D diagnosis were included. The QUADAS 2 tool was used for assessing the quality of included studies. We used the split component synthesis (SCS) method for the meta-analysis of diagnostic accuracy studies to pool the studies for meta-analysis of sensitivity and specificity, primarily at the HbA1C ≥48mmol/mol (6.5%) cut-off and at other cut-offs. We assessed heterogeneity using the I2 statistic and publication bias using Doi plots. RESULTS: Eleven studies, from seven African countries, with 12925 participants, were included. Against the OGTT, HbA1C ≥48mmol/mol (6.5%) had a pooled sensitivity of 57.7% (95%CI 43.4-70.9) and specificity of 92.3% (95%CI 83.9 - 96.5). Against the FPG, HbA1C ≥48mmol/mol (6.5%) had a pooled sensitivity of 64.5% (95%CI 50.5 - 76.4) and specificity of 94.3% (95%CI 87.9 - 97.5). The highest sensitivity for HbA1C , against the OGTT, was at the 42mmol/mol (6.0%) cut off. CONCLUSION: In Africa, the HbA1C ≥48mmol/mol (6.5%) cut-off may miss almost half of the individuals with T2D based on blood glucose measures.
Feasibility and Acceptability of Community COVID-19 Testing Strategies (FACTS) in a University Setting
Background: During the COVID-19 pandemic in 2020, the UK government began a mass SARS-CoV-2 testing programme. This study aimed to determine the feasibility and acceptability of organised regular self-testing for SARS-CoV-2.Methods: This was a mixed methods observational cohort study in asymptomatic students and staff at University of Oxford, who performed SARS-CoV-2 antigen lateral flow self-testing. Data on uptake and adherence, acceptability, and test interpretation were collected via a smartphone app, an online survey, and qualitative interviews.Findings: Across three main sites, 551 participants (25% of those invited) performed 2728 tests during a follow-up of 5.6 weeks. 447 participants (81%) completed at least two, and 340 (62%) completed at least four tests. The survey, completed by 214 participants (39%), found that 98% of people were confident to self-test and believed self-testing to be beneficial. Acceptability of self-testing was high, with 91% of ratings being acceptable or very acceptable. 2711 (99.4%) test results were negative, nine were positive and eight were inconclusive. Results from eighteen qualitative interviews with staff and students revealed that participants valued regular testing, but there were concerns about test accuracy that impacted uptake and adherence.Interpretation: This is the first study to assess feasibility and acceptability of regular SARS-CoV-2 self-testing. It provides evidence to inform recruitment, adherence to, and acceptability of regular SARS-CoV-2 self-testing programmes for asymptomatic individuals using lateral flow tests. We found that self-testing is acceptable and people were able to interpret results accurately.Funding: This work was funded by Oxford University Medical Science DivisionsDeclaration of Interests: LT works part-time for Sensyne Health as R&D Director and holds share options in the company. He also reports a research grant and personal fees from the company.Ethics Approval Statement: FACTS is a mixed methods cohort study conducted at the University of Oxford. It was approved by the University of Oxford Research Ethics Committee in October 2020 (CUREC ethics reference R72896/RE001).
Frequencies and patterns of microbiology test requests from primary care in Oxfordshire, UK, 2008-2018: a retrospective cohort study of electronic health records to inform point-of-care testing.
OBJECTIVES: To inform point-of-care test (POCT) development, we quantified the primary care demand for laboratory microbiology tests by describing their frequencies overall, frequencies of positives, most common organisms identified, temporal trends in testing and patterns of cotesting on the same and subsequent dates. DESIGN: Retrospective cohort study. SETTING: Primary care practices in Oxfordshire. PARTICIPANTS: 393 905 patients (65% female; 49% aged 18-49). PRIMARY AND SECONDARY OUTCOME MEASURES: The frequencies of all microbiology tests requested between 2008 and 2018 were quantified. Patterns of cotesting were investigated with heat maps. All analyses were done overall, by sex and age categories. RESULTS: 1 596 752 microbiology tests were requested. Urine culture±microscopy was the most common of all tests (n=673 612, 42%), was mainly requested without other tests and was the most common test requested in follow-up within 7 and 14 days. Of all urine cultures, 180 047 (27%) were positive and 172 651 (26%) showed mixed growth, and Escherichia coli was the most prevalent organism (132 277, 73% of positive urine cultures). Antenatal urine cultures and blood tests in pregnancy (hepatitis B, HIV and syphilis) formed a common test combination, consistent with their use in antenatal screening. CONCLUSIONS: The greatest burden of microbiology testing in primary care is attributable to urine culture ± microscopy; genital and routine antenatal urine and blood testing are also significant contributors. Further research should focus on the feasibility and impact of POCTs for these specimen types.
The current debate about whether individuals should be entitled to work in the healthcare sector if they decline to be vaccinated against SARS-CoV2 has been largely informed by personal opinions and argument by analogy. A benefit:harm balance analysis suggests that while vaccination has a highly favourable benefit:harm balance, the balance in instituting a "no jab, no job" policy is highly uncertain and may be unfavourable. Furthermore, there are practical difficulties and legal uncertainties. The much misunderstood precautionary principle dictates that if the benefit:harm balance of an intervention is unclear and may be unfavourable, the intervention should not be undertaken. Furthermore, the onus is on those who believe that the benefit:harm balance will be favourable to prove that it is so; it is not for the sceptics to prove that it isn't. In the absence of good evidence in favour, this is an intervention that would be best avoided.
Prediction of disease severity in young children presenting with acute febrile illness in resource-limited settings: A protocol for a prospective observational study
© Introduction In rural and difficult-to-access settings, early and accurate recognition of febrile children at risk of progressing to serious illness could contribute to improved patient outcomes and better resource allocation. This study aims to develop a prognostic clinical prediction tool to assist community healthcare providers identify febrile children who might benefit from referral or admission for facility-based medical care. Methods and analysis This prospective observational study will recruit at least 4900 paediatric inpatients and outpatients under the age of 5 years presenting with an acute febrile illness to seven hospitals in six countries across Asia. A venous blood sample and nasopharyngeal swab is collected from each participant and detailed clinical data recorded at presentation, and each day for the first 48 hours of admission for inpatients. Multianalyte assays are performed at reference laboratories to measure a panel of host biomarkers, as well as targeted aetiological investigations for common bacterial and viral pathogens. Clinical outcome is ascertained on day 2 and day 28. Presenting syndromes, clinical outcomes and aetiology of acute febrile illness will be described and compared across sites. Following the latest guidance in prediction model building, a prognostic clinical prediction model, combining simple clinical features and measurements of host biomarkers, will be derived and geographically externally validated. The performance of the model will be evaluated in specific presenting clinical syndromes and fever aetiologies. Ethics and dissemination The study has received approval from all relevant international, national and institutional ethics committees. Written informed consent is provided by the caretaker of all participants. Results will be shared with local and national stakeholders, and disseminated via peer-reviewed open-access journals and scientific meetings. Trial registration number NCT04285021.
Factors associated with the prescribing of high-dose opioids in primary care: A systematic review and meta-Analysis
© 2020 The Author(s). Background: The risks of harms from opioids increase substantially at high doses, and high-dose prescribing has increased in primary care. However, little is known about what leads to high-dose prescribing, and studies exploring this have not been synthesized. We, therefore, systematically synthesized factors associated with the prescribing of high-dose opioids in primary care. Methods: We conducted a systematic review of observational studies in high-income countries that used patient-level primary care data and explored any factor(s) in people for whom opioids were prescribed, stratified by oral morphine equivalents (OME). We defined high doses as ≥ 90 OME mg/day. We searched MEDLINE, Embase, Web of Science, reference lists, forward citations, and conference proceedings from database inception to 5 April 2019. Two investigators independently screened studies, extracted data, and appraised the quality of included studies using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. We pooled data on factors using random effects meta-Analyses and reported relative risks (RR) or mean differences with 95% confidence intervals (CI) where appropriate. We also performed a number needed to harm (NNTH) calculation on factors when applicable. Results: We included six studies with a total of 4,248,119 participants taking opioids, of whom 3.64% (n = 154,749) were taking high doses. The majority of included studies (n = 4) were conducted in the USA, one in Australia and one in the UK. The largest study (n = 4,046,275) was from the USA. Included studies were graded as having fair to good quality evidence. The co-prescription of benzodiazepines (RR 3.27, 95% CI 1.32 to 8.13, I 2 = 99.9%), depression (RR 1.38, 95% CI 1.27 to 1.51, I 2 = 0%), emergency department visits (RR 1.53, 95% CI 1.46 to 1.61, I 2 = 0%, NNTH 15, 95% CI 12 to 20), unemployment (RR 1.44, 95% CI 1.27 to 1.63, I 2 = 0%), and male gender (RR 1.21, 95% CI 1.14 to 1.28, I 2 = 78.6%) were significantly associated with the prescribing of high-dose opioids in primary care. Conclusions: High doses of opioids are associated with greater risks of harms. Associated factors such as the co-prescription of benzodiazepines and depression identify priority areas that should be considered when selecting, identifying, and managing people taking high-dose opioids in primary care. Coordinated strategies and services that promote the safe prescribing of opioids are needed. Study registration: PROSPERO, CRD42018088057
Incidence of sudden cardiac arrest and death in young athletes and military members: a systematic review and meta-analysis.
OBJECTIVES: The goals of this review are to evaluate the quality of the evidence on the incidence of sudden cardiac arrest and death (SCA/D) in athletes and military members; and to estimate annual incidence of SCA/D. DATA SOURCES: MEDLINE, Embase, Cochrane CENTRAL, Web of Science, BIOSIS, Scopus, SPORT discus, PEDro, and clinicaltrials.gov were searched from inception to dates between 2/21/19-7/29/19. STUDY SELECTION: Studies which reported incidence of SCA/D or both in athletes, or military members under age 40 were eligible for inclusion. 40 studies were identified for inclusion Data Extraction: Risk of bias was assessed using a validated, customized tool for prevalence studies in all included studies. 12 were found to be low ROB, with the remaining 28 moderate or high ROB. Data was extracted for narrative review, and meta-analysis. DATA SYNTHESIS: Random-effects meta-analysis was performed in studies judged to be low risk of bias in two separate categories: 5 studies on regional or national level data including athletes at all levels, and both sexes included 130 events of SCD, with a total of 11,272,560 athlete years showing a cumulative incidence rate of 0.98 [95%CI: 0.62, 1.53] per 100,000 athlete years, with high heterogeneity with I2 of 78%; 3 Studies on competitive athletes aged 14 to 25 were combined, and included 183 events, and 17,798758 athlete years showing an incidence rate of 1.91[95%CI: 0.71; 5.14] per 100,000 athlete years with high heterogeneity with I2 of 97%. The remaining low risk of bias studies were in military members, and were not synthesized. CONCLUSION: The worldwide incidence of SCD is a rare event. Low risk of bias studies indicate incidence to be below 2 per 100,000 athlete years. Overall, the quality of the evidence available is low, but there are high quality individual studies to inform the question of incidence levels. PROSPERO Registration: CRD42019125560.
Screening electrocardiogram in young athletes and military members: a systematic review and meta-analysis.
OBJECTIVE: To determine the effect of electrocardiogram (ECG) screening on prevention of sudden cardiac arrest and death (SCA/D) in young athletes and military members. DATA SOURCES: MEDLINE, Embase, Cochrane CENTRAL, Web of Science, BIOSIS, Scopus, SPORT discus, PEDro, and clinicaltrials.gov were searched from inception to dates between 2/21/19 and 7/29/19. STUDY SELECTION: Randomized and non-randomized controlled trials, where pre-participation examination including ECG was the primary intervention used to screen athletes or military 40 years of age or younger. Accepted controls were no screening, usual care, or pre-participation examination without ECG. 3 published studies , and one conference abstract were identified for inclusion. DATA EXTRACTION: In all four studies, risk of bias was assessed with the Cochrane risk of bias tool, and found to be generally high. Two studies had data extracted for random effects meta-analysis, and the remaining study and conference abstract were included in narrative review. Overall quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Data Synthesis: Four non-randomized studies (11,689,172 participants) were included, all at high risk of bias. Pooled data from two studies (n= 3,869,274; very low quality evidence) observed an inconclusive 42% relative decrease in risk of sudden cardiac death (RR 0.58; 95% CI 0.23, 1.45), equating to an absolute risk reduction of .0016% The findings were consistent with a potential 67% relative decrease to a 45% relative increased risk in participants screened with ECG. Heterogeneity was found to be high as measured with I2 statistic (71%). Data from the remaining study and abstract were similarly inconclusive. CONCLUSION: Existing evidence for the effect of ECG screening is inconclusive and of very low quality. Our meta-analysis observed that screening ECG may result in considerable benefit or harm to participants. Higher quality studies are needed to reduce this uncertainty. PROSPERO Registration: CRD42019125560.
The association between unexpected weight loss and cancer diagnosis in primary care: a matched cohort analysis of 65,000 presentations
Background: We aimed to understand the time period of cancer diagnosis and the cancer types detected in primary care patients with unexpected weight loss (UWL) to inform cancer guidelines. Methods: This retrospective matched cohort study used cancer registry linked electronic health records from the UK’s Clinical Practice Research Datalink from between 2000 and 2014. Univariable and multivariable time-to-event analyses examined the association between UWL, and all cancers combined, cancer site and stage. Results: In all, 63,973 patients had UWL recorded, of whom 1375 (2.2%) were diagnosed with cancer within 2 years (days-to-diagnosis: mean 181; median 80). Men with UWL (HR 3.28 (2.88–3.73)) and women (1.87 (1.68–2.08)) were more likely than comparators to be diagnosed with cancer within 3 months. The association was greatest in men aged ≥50 years and women ≥70 years. The commonest cancers were pancreas, cancer of unknown primary, gastro-oesophageal, lymphoma, hepatobiliary, lung, bowel and renal-tract. The majority were late-stage, but there was some evidence of association with stage II and stage III cancers. In the 3–24 months after presenting with UWL, cancer diagnosis was less likely than in comparators. Conclusion: UWL recorded in primary care is associated with a broad range of cancer sites of early and late-stage.
The health impacts of preventive cardiovascular medication reduction on older populations: protocol for a systematic review and meta-analysis
Background: Polypharmacy is inevitable and appropriate for many conditions, but in some cases, it can be problematic resulting in an increased risk of harm and reduced quality of life. There has been an increasing interest to reduce cardioprotective medications in older adults to potentially reduce the risk of harm due to treatment; however, there is no evidence on safety and efficacy to support this practice currently. This paper describes a protocol for a systematic review on the safety and efficacy of reducing cardioprotective medication in older populations. Methods: MEDLINE (PubMed), Embase (Ovid), and CENTRAL (Cochrane Central Register of Controlled Trials) will be searched from their inception onwards for relevant studies. Randomised controlled trials and non-randomised studies on interventions (prospective, retrospective cohort, case-control) conducted in older adults (75 years or older) examining reduction of cardioprotective medications will be included. The primary outcome of this study will be all-cause hospitalisation. Secondary outcome variables of interest are all-cause hospitalisation, mortality, quality of life, serious adverse events, major adverse cardiovascular events, falls, fractures, cognitive functioning, bleeding events, renal functioning, medication burden, drug reinstatement, time-in-hospital, and frailty status. Two reviewers will independently screen all citations, full-text articles, and extract data. Confidence in cumulative evidence will be assessed using the GRADE approach; the risk of bias will be assessed by the RoB-II tool for randomised controlled studies and ROBINS-I for non-randomised studies. Where sufficient data are available, we will conduct a random effects meta-analysis by combining the outcomes of the included studies. Sub-group analysis and meta-regression are planned to assess the potential harms and risks of different drug classes and the impacts in different patient populations (e.g. sex, cognitive status, renal status, and age). Discussion: The study will be a comprehensive review on all published articles identified using our search strategy on the safety and efficacy of cardioprotective medication reduction in the older population. The findings will be crucial to inform clinicians on potential health outcomes of reducing cardiovascular medication in the elderly. Systematic review registration: PROSPERO CRD42020208223