Aims
This study was designed to evaluate whether survival rates in patients with heart failure (HF) are better than those in patients with diagnoses of the four most common cancers in men and women, ...respectively, in a contemporary primary care cohort in the community in Scotland.
Methods and results
Data were obtained from the Primary Care Clinical Informatics Unit from a database of 1.75 million people registered with 393 general practices in Scotland. Sex‐specific survival modelling was undertaken using Cox proportional hazards models, adjusted for potential confounders. A total of 56 658 subjects were eligible for inclusion in the study. These represented a total of 147 938 person‐years of follow‐up (median follow‐up: 2.04 years). In men, HF (reference group; 5‐year survival: 55.8%) had worse mortality outcomes than prostate cancer hazard ratio (HR) 0.61, 95% confidence interval (CI) 0.57–0.65; 5‐year survival: 68.3%, and bladder cancer (HR 0.88, 95% CI 0.81–0.96; 5‐year survival: 57.3%), but better outcomes than lung cancer (HR 3.86, 95% CI 3.65–4.07; 5‐year survival: 8.4%) and colorectal cancer (HR 1.23, 95% CI 1.16–1.31; 5‐year survival: 48.9%). In women, HF (reference group; 5‐year survival: 49.5%) had worse mortality outcomes than breast cancer (HR 0.55, 95% CI 0.51–0.59; 5‐year survival 77.7%), but better outcomes than colorectal cancer (HR 1.21, 95% CI 1.13–1.29; 5‐year survival 51.5%), lung cancer (HR 3.82, 95% CI 3.60–4.05; 5‐year survival 10.4%), and ovarian cancer (HR 1.98, 95% CI 1.80–2.17; 5‐year survival 38.2%).
Conclusions
Despite advances in management, HF remains as ‘malignant’ as some of the common cancers in both men and women.
Background
Laparoscopic appendectomy is amongst the most common general surgical procedures performed in the developed world. Arguably, the most critical part of this procedure is effective closure ...of the appendix stump to prevent catastrophic intra‐abdominal complications from a faecal leak into the abdominal cavity.
A variety of methods to close the appendix stump are used worldwide; these can be broadly divided into traditional ligatures (such as intracorporeal or extracorporeal ligatures or Roeder loops) and mechanical devices (such as stapling devices, clips, or electrothermal devices). However, the optimal method remains unclear.
Objectives
To compare all surgical techniques now used for appendix stump closure during laparoscopic appendectomy.
Search methods
In June 2017, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 6) in the Cochrane Library, MEDLINE Ovid (1946 to 14 June 2017), Embase Ovid (1974 to 14 June 2017), Science Citation Index ‐ Expanded (14 June 2017), China Biological Medicine Database (CBM), the World Health Organization International Trials Registry Platform search portal, ClinicalTrials.gov, Current Controlled Trials, the Chinese Clinical Trials Register, and the EU Clinical Trials Register (all in June 2017). We searched the reference lists of relevant publications as well as meeting s and Conference Proceedings Citation Index to look for additional relevant clinical trials.
Selection criteria
We included all randomised controlled trials (RCTs) that compared mechanical appendix stump closure (stapler, clips, or electrothermal devices) versus ligation (Endoloop, Roeder loop, or intracorporeal knot techniques) for uncomplicated appendicitis.
Data collection and analysis
Two review authors identified trials for inclusion, collected data, and assessed risk of bias independently. We performed the meta‐analysis using Review Manager 5. We calculated the odds ratio (OR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs).
Main results
We included eight randomised studies encompassing 850 participants. Five studies compared titanium clips versus ligature, two studies compared an endoscopic stapler device versus ligature, and one study compared an endoscopic stapler device, titanium clips, and ligature. In our analyses of primary outcomes, we found no differences in total complications (OR 0.97, 95% CI 0.27 to 3.50, 8 RCTs, very low‐quality evidence), intraoperative complications (OR 0.93, 95% CI 0.34 to 2.55, 8 RCTs, very low‐quality evidence), or postoperative complications (OR 0.80, 95% CI 0.21 to 3.13, 8 RCTs, very low‐quality evidence) between ligature and all types of mechanical devices. However, our analyses of secondary outcomes revealed that use of mechanical devices saved approximately nine minutes of total operating time when compared with use of a ligature (mean difference (MD) ‐9.04 minutes, 95% CI ‐12.97 to ‐5.11 minutes, 8 RCTs, very low‐quality evidence). However, this finding did not translate into a clinically or statistically significant reduction in inpatient hospital stay (MD 0.02 days, 95% CI ‐0.12 to 0.17 days, 8 RCTs, very low‐quality evidence). Available information was insufficient for reliable comparison of total hospital costs and postoperative pain/quality of life between the two approaches. Overall, evidence across all analyses was of very low quality, with substantial potential for confounding factors. Given the limitations of all studies in terms of bias and the low quality of available evidence, a clear conclusion regarding superiority of any one particular type of mechanical device over another is not possible.
Authors' conclusions
Evidence is insufficient at present to advocate omission of conventional ligature‐based appendix stump closure in favour of any single type of mechanical device over another in uncomplicated appendicitis.
Occupancy models (Ecology, 2002; 83: 2248) were developed to infer the probability that a species under investigation occupies a site. Bayesian analysis of these models can be undertaken using ...statistical packages such as WinBUGS, OpenBUGS, JAGS, and more recently Stan, however, since these packages were not developed specifically to fit occupancy models, one often experiences long run times when undertaking an analysis. Bayesian spatial single‐season occupancy models can also be fit using the R package stocc. The approach assumes that the detection and occupancy regression effects are modeled using probit link functions. The use of the logistic link function, however, is algebraically more tractable and allows one to easily interpret the coefficient effects of an estimated model by using odds ratios, which is not easily done for a probit link function for models that do not include spatial random effects. We develop a Gibbs sampler to obtain posterior samples from the posterior distribution of the parameters of various occupancy models (nonspatial and spatial) when logit link functions are used to model the regression effects of the detection and occupancy processes. We apply our methods to data extracted from the 2nd Southern African Bird Atlas Project to produce a species distribution map of the Cape weaver (Ploceus capensis) and helmeted guineafowl (Numida meleagris) for South Africa. We found that the Gibbs sampling algorithm developed produces posterior samples that are identical to those obtained when using JAGS and Stan and that in certain cases the posterior chains mix much faster than those obtained when using JAGS, stocc, and Stan. Our algorithms are implemented in the R package, Rcppocc. The software is freely available and stored on GitHub (https://github.com/AllanClark/Rcppocc).
We developed a Gibbs sampling algorithm to undertake various occupancy type models when using logit link functions.
Abstract
Background
over 50% of older people in hospital are prescribed a pre-admission medicine that is potentially inappropriate; however, deprescribing by geriatricians and pharmacists is limited. ...This study aimed to characterise geriatricians’ and pharmacists’ barriers and enablers to deprescribing in hospital. It also intended to develop a framework of intervention components to facilitate implementation of hospital deprescribing.
Methods
fifty-four geriatricians and pharmacists representing four UK hospitals attended eight focus groups. We designed a topic guide to invite discussions about barriers and enablers to deprescribing. After thematic analysis, themes were mapped to the theoretical domains framework (TDF), enabling prioritisation of domains for behaviour change. We then identified evidence-based intervention components for changing behaviour within prioritised TDF domains.
Results
geriatricians and pharmacists described several deprescribing enablers in the hospital setting including alignment with their role and generalist knowledge, and routine patient monitoring. Five prioritised TDF domains represent the key barriers and enabler: patient and caregiver attachment to medication (social influence); perceptions that deprescribing is riskier than continuing to prescribe (beliefs about consequences); pharmacists’ working patterns limiting capacity to support deprescribing (environmental context and resources); deprescribing being a low hospital priority (goals) and incentives to deprescribe (reinforcement). Prioritised TDF domains aligned with 44 evidence-based intervention components to address the barriers and enabler to hospital deprescribing.
Conclusion
the behavioural determinants and their associated intervention components provide a hospital deprescribing implementation framework (hDIF). Intervention components should be selected from the hDIF to provide a theory and evidence-based intervention tailored to hospital contexts.
Motor evoked potential (MEP) characteristics are potential biomarkers of whether rehabilitation interventions drive motor recovery after stroke. The test-retest reliability of Transcranial Magnetic ...Stimulation (TMS) measurements in sub-acute stroke remains unclear. This study aims to determine the test-retest reliability of upper limb MEP measures elicited by non-neuronavigated transcranial magnetic stimulation in sub-acute-stroke.
In two identical data collection sessions, 1-3 days apart, TMS measures assessed: motor threshold (MT), amplitude, latency (MEP-L), silent period (SP), recruitment curve slope in the biceps brachii (BB), extensor carpi radialis (ECR), and abductor pollicis brevis (APB) muscles of paretic and non-paretic upper limbs. Test-retest reliability was calculated using the intra-class correlation coefficient (ICC) and 95% confidence intervals (CI). Acceptable reliability was set at a lower 95% CI of 0.70 or above. The limits of agreement (LOA) and smallest detectable change (SDC) were calculated.
30 participants with sub-acute stroke were included (av 36 days post stroke) reliability was variable between poor to good for the different MEP characteristics. The SDC values differed across muscles and MEP characteristics in both paretic and less paretic limbs.
The present findings indicate there is limited evidence for acceptable test-retest reliability of non-navigated TMS outcomes when using the appropriate 95% CI for ICC, SDC and LOA values.
Current Controlled Trials: ISCRT 19090862, http://www.controlled-trials.com.
Idiopathic pulmonary fibrosis (IPF) has a poor prognosis and limited treatment options. Patients with IPF have altered lung microbiota, with bacterial burden within the lungs associated with ...mortality; previous studies have suggested benefit with co-trimoxazole (trimethoprim-sulfamethoxazole).
To determine the efficacy of co-trimoxazole in patients with moderate and severe IPF.
Double-blind, placebo-controlled, parallel randomized trial of 342 patients with IPF, breathlessness (Medical Research Council dyspnea scale score >1), and impaired lung function (forced vital capacity ≤75% predicted) conducted in 39 UK specialist interstitial lung disease centers between April 2015 (first patient visit) and April 2019 (last patient follow-up).
Study participants were randomized to receive 960 mg of oral co-trimoxazole twice daily (n = 170) or matched placebo (n = 172) for between 12 and 42 months. All patients received 5 mg of folic acid orally once daily.
The primary outcome was time to death (all causes), lung transplant, or first nonelective hospital admission. There were 15 secondary outcomes, including the individual components of the primary end point respiratory-related events, lung function (forced vital capacity and gas transfer), and patient-reported outcomes (Medical Research Council dyspnea scale, 5-level EuroQol 5-dimension questionnaire, cough severity, Leicester Cough Questionnaire, and King's Brief Interstitial Lung Disease questionnaire scores).
Among 342 individuals who were randomized (mean age, 71.3 years; 46 13% women), 283 (83%) completed the trial. The median (interquartile range) duration of follow-up was 1.02 (0.35-1.73) years. Events per person-year of follow-up among participants randomized to the co-trimoxazole and placebo groups were 0.45 (84/186) and 0.38 (80/209), respectively, with a hazard ratio of 1.2 (95% CI, 0.9-1.6; P = .32). There were no statistically significant differences in other event outcomes, lung function, or patient-reported outcomes. Patients in the co-trimoxazole group had 696 adverse events (nausea n = 89, diarrhea n = 52, vomiting n = 28, and rash n = 31) and patients in the placebo group had 640 adverse events (nausea n = 67, diarrhea n = 84, vomiting n = 20, and rash n = 20).
Among patients with moderate or severe IPF, treatment with oral co-trimoxazole did not reduce a composite outcome of time to death, transplant, or nonelective hospitalization compared with placebo.
ISRCTN Identifier: ISRCTN17464641.
Background
Fractures of the tibial plateau, which are intra‐articular injuries of the knee joint, are often difficult to treat and have a high complication rate, including early‐onset osteoarthritis. ...Surgical fixation is usually used for more complex tibial plateau fractures. Additionally, bone void fillers are often used to address bone defects caused by the injury. Currently there is no consensus on either the best method of fixation or bone void filler.
Objectives
To assess the effects (benefits and harms) of different surgical interventions, and the use of bone void fillers, for treating tibial plateau fractures.
Search methods
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (12 September 2014), the Cochrane Central Register of Controlled Trials (2014 Issue 8), MEDLINE (1946 to September Week 1 2014), EMBASE (1974 to 2014 Week 36), trial registries (4 July 2014), conference proceedings and grey literature (4 July 2014).
Selection criteria
We included randomised and quasi‐randomised controlled clinical trials comparing surgical interventions for treating tibial plateau fractures and the different types of filler for filling bone defects.
Data collection and analysis
Two review authors independently screened search results, selected studies, extracted data and assessed risk of bias. We calculated risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CIs). Only very limited pooling, using the fixed‐effect model, was possible. Our primary outcomes were quality of life measures, patient‐reported outcome measures of lower limb function and serious adverse events.
Main results
We included six trials in the review, with a total of 429 adult participants, the majority of whom were male (63%). Three trials evaluated different types of fixation and three analysed different types of bone graft substitutes. All six trials were small and at substantial risk of bias. We judged the quality of most of the available evidence to be very low, meaning that we are very uncertain about these results.
One trial compared the use of a circular fixator combined with insertion of percutaneous screws (hybrid fixation) versus standard open reduction and internal fixation (ORIF) in people with open or closed Schatzker types V or VI tibial plateau fractures. Results (66 participants) for quality of life scores using the 36‐item Short Form Health Survey (SF‐36)), Hospital for Special Surgery (HSS) scores and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function scores tended to favour hybrid fixation, but a benefit of ORIF could not be ruled out. Participants in the hybrid fixation group had a lower risk for an unplanned reoperation (351 per 1000 people compared with 450 in the ORIF group; 95% CI 197 fewer to 144 more) and were more likely to have returned to their pre‐injury activity level (303 per 1000 people, compared with 121 in the ORIF group; 95% CI 15 fewer to 748 more). Results of the two groups were comparable for the WOMAC pain subscale and stiffness scores, but mean knee range of motion values were higher in the hybrid group.
Another trial compared the use of a minimally invasive plate (LISS system) versus double‐plating ORIF in 84 people who had open or closed bicondylar tibial plateau fractures. Nearly twice as many participants (22 versus 12) in the ORIF group had a bone graft. Quality of life, pain, knee range of motion and return to pre‐injury activity were not reported. The trial provided no evidence of differences in HSS knee scores, complications or reoperation entailing implant removal or revision fixation. A quasi‐randomised trial comparing arthroscopically‐assisted percutaneous reduction and internal fixation versus standard ORIF reported results at 14 months in 58 people with closed Schatzker types II or III tibial plateau fracture. Quality of life, pain and return to pre‐injury activity were not reported. There was very low quality evidence of higher HSS knee scores and higher knee range of motion values in the arthroscopically assisted group. No reoperations were reported.
Three trials compared different types of bone substitute versus autologous bone graft (autograft) for managing bone defects. Quality of life, pain and return to pre‐injury activity were not reported. Only one trial (25 participants) reported on lower limb function, finding good or excellent results in both groups for walking, climbing stairs, squatting and jumping at 12 months. The incidences of individual complications were similar between groups in all three trials. One trial found no cases of inflammatory response in the 20 participants receiving bone substitute, and two found no complications associated with the donor site in the autograft group (58 participants). However, all 38 participants in the autologous iliac bone graft group of one trial reported prolonged pain from the harvest site. Two trials reported similar range of motion results in the two groups, whereas the third trial favoured the bone substitute group.
Authors' conclusions
Currently, there is insufficient evidence to ascertain the best method of fixation or the best method of addressing bone defects during surgery. However, the evidence does not contradict approaches aiming to limit soft‐tissue dissection and damage or to avoid autograft donor site complications through using bone substitutes. Further well‐designed, larger randomised trials are warranted.
A campaign for malaria control, using Long Lasting Insecticide Nets (LLINs) was launched in South Sudan in 2009. The success of such a campaign often depends upon adequate available resources and ...reliable surveillance data which help officials understand existing infections. An optimal allocation of resources for malaria control at a sub-national scale is therefore paramount to the success of efforts to reduce malaria prevalence. In this paper, we extend an existing SIR mathematical model to capture the effect of LLINs on malaria transmission. Available data on malaria is utilized to determine realistic parameter values of this model using a Bayesian approach via Markov Chain Monte Carlo (MCMC) methods. Then, we explore the parasite prevalence on a continued rollout of LLINs in three different settings in order to create a sub-national projection of malaria. Further, we calculate the model's basic reproductive number and study its sensitivity to LLINs' coverage and its efficacy. From the numerical simulation results, we notice a basic reproduction number, Formula: see text, confirming a substantial increase of incidence cases if no form of intervention takes place in the community. This work indicates that an effective use of LLINs may reduce Formula: see text and hence malaria transmission. We hope that this study will provide a basis for recommending a scaling-up of the entry point of LLINs' distribution that targets households in areas at risk of malaria.
Idiopathic pulmonary fibrosis (IPF) is a fatal condition with limited treatment options. However, in a previous small study, co-trimoxazole was found to be beneficial.
In a double-blind multicentre ...study, 181 patients with fibrotic idiopathic interstitial pneumonia (89% diagnosed as definite/probable IPF) were randomised to receive co-trimoxazole 960 mg twice daily or placebo for 12 months in addition to usual care. Measurements were made of forced vital capacity (FVC) (primary endpoint), diffusing capacity of carbon monoxide (Dlco) and EuroQol (EQ5D)-based utility, 6-minute walk test (6MWT) and Medical Research Council (MRC) dyspnoea score (secondary endpoints). All-cause mortality and adverse events were recorded (tertiary endpoints).
Co-trimoxazole had no effect on FVC (mean difference 15.5 ml (95% CI -93.6 to 124.6)), Dlco (mean difference -0.12 mmol/min/kPa (95% CI 0.41 to 0.17)), 6MWT or MRC dyspnoea score (intention-to-treat analysis). The findings of the per-protocol analysis were the same except that co-trimoxazole treatment resulted in a significant improvement in EQ5D-based utility (mean difference 0.12 (95% CI 0.01 to 0.22)), a reduction in the percentage of patients requiring an increase in oxygen therapy (OR 0.05 (95% CI 0.00 to 0.61)) and a significant reduction in all-cause mortality (co-trimoxazole 3/53, placebo 14/65, HR 0.21 (95% CI 0.06 to 0.78), p=0.02)) compared with placebo. The use of co-trimoxazole reduced respiratory tract infections but increased the incidence of nausea and rash.
The addition of co-trimoxazole therapy to standard treatment for fibrotic idiopathic interstitial pneumonia had no effect on lung function but resulted in improved quality of life and a reduction in mortality in those adhering to treatment. ISRCTN22201583.
Growth in waste electrical and electronic equipment (WEEE) is posing increasing problems of waste management, partly resulting from its plastic content. WEEE plastics include a range of polymers, ...some of which can be sorted and extracted for recycling. However a nonrecyclable fraction remains containing a mixture of polymers contaminated with other materials, and pyrolysis is a potential means of recovering the energy content of this. In preparation for a life cycle assessment of this option, described in part 2 of this paper set, data were collected from trials using experimental pyrolysis equipment representative of a continuous commercial process operated at 800 °C. The feedstock contained acrylonitrile-butadiene-styrene and high impact polystyrene with high levels of additives, and dense polymers including polyvinylchloride, polycarbonate, polyphenylene oxide, and polymethyl methacrylate. On average 39% was converted to gases, 36% to oils, and 25% remained as residue. About 35% of the gas was methane and 42% carbon monoxide, plus other hydrocarbons, oxygen and carbon dioxide. The oils were almost all aromatic, forming a similar mixture to fuel oil. The residue was mainly carbon with inorganic compounds from the plastic additives and most of the chlorine from the feedstock. The results showed that the process produced around 70% of the original plastic weight as potential fuel.
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