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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Artificial intelligence and opioid use: a narrative review
BackgroundOpioids are strong pain medications that can be essential for acute pain. However, opioids are also commonly used for chronic conditions and illicitly where there are well-recognised concerns about the balance of their benefits and harms. Technologies using artificial intelligence (AI) are being developed to examine and optimise the use of opioids. Yet, this research has not been synthesised to determine the types of AI models being developed and the application of these models.MethodsWe aimed to synthesise studies exploring the use of AI in people taking opioids. We searched three databases: the Cochrane Database of Systematic Reviews, Embase and Medline on 4 January 2021. Studies were included if they were published after 2010, conducted in a real-life community setting involving humans and used AI to understand opioid use. Data on the types and applications of AI models were extracted and descriptively analysed.ResultsEighty-one articles were included in our review, representing over 5.3 million participants and 14.6 million social media posts. Most (93%) studies were conducted in the USA. The types of AI technologies included natural language processing (46%) and a range of machine learning algorithms, the most common being random forest algorithms (36%). AI was predominately applied for the surveillance and monitoring of opioids (46%), followed by risk prediction (42%), pain management (10%) and patient support (2%). Few of the AI models were ready for adoption, with most (62%) being in preliminary stages.ConclusionsMany AI models are being developed and applied to understand opioid use. However, there is a need for these AI technologies to be externally validated and robustly evaluated to determine whether they can improve the use and safety of opioids.
Sharing study materials in health and medical research.
Making study materials available allows for a more comprehensive understanding of the scientific literature. Sharing can take many forms and include a wide variety of outputs including code and data. Biomedical research can benefit from increased transparency but faces unique challenges for sharing, for instance, confidentiality concerns around participants' medical data. Both general and specialised repositories exist to aid in sharing most study materials. Sharing may also require skills and resources to ensure that it is done safely and effectively. Educating researchers on how to best share their materials, and properly rewarding these practices, requires action from a variety of stakeholders including journals, funders and research institutions.
The psychological journey of weight gain in psychosis
Background: Rapid weight gain is common with antipsychotic medication. Lost confidence, low mood and medication non-adherence often follow. Yet, the dynamic interactions between the physical and psychological consequences of weight gain, and implications for intervention, are unknown. Objectives: We examined first-person accounts of weight gain to identify preferences for weight change interventions. Design: A qualitative design was used to explore patients’ experiences of weight change in the context of psychosis. Method: Semi-structured interviews, analysed using grounded theory, were conducted with 10 patients with psychosis. Sample validation was conducted with peer researchers with lived experience of psychosis. Results: Patients described that initially the extent and speed of weight gain was overshadowed by psychotic experiences and their treatment. This led to a shocking realisation of weight gain. The psychological impact of weight gain, most strikingly on the self-concept, was profound. Loss of self-worth and changed appearance amplified a sense of vulnerability. There were further consequences on mood, activity and psychotic experiences, such as voices commenting on appearance, that were additional obstacles in the challenging process of weight loss. Sedative effects of medication also contributed. Unsuccessful weight loss left little hope and few preferences for interventions. Early information about common weight gain trajectories and working with experts-by-experience were valued. Rebuilding self-confidence, efficacy and worth may be a necessary first step. Conclusions: The journey of weight gain in patients with psychosis is characterised by loss of self-worth, agency and hope. There are multiple stages in the journey, each with different psychological reactions, that may need different treatment responses.
Safety of routine childhood vaccine coadministration versus separate vaccination.
IntroductionAs new vaccines are developed more vaccine coadministrations vaccines are being offered to make delivery more practical for health systems and patients. We compared the safety of coadministered vaccines with separate vaccination for 20 coadministrations by considering nine types of adverse events following immunisation (AEFI).MethodsReal-life immunisation and adverse event data for this observational cohort study were extracted from the Oxford-Royal College of General Practitioners Research and Surveillance Centre for children registered in the database between 2008 and 2018. We applied the self-controlled case series method to calculate relative incidence ratios (RIR) for AEFI. These RIRs compare the RI of AEFI following coadministration with the RI following separate administration of the same vaccines.ResultsWe assessed 3 518 047 adverse events and included 5 993 290 vaccine doses given to 958 591 children. 17% of AEFI occurred less and 11% more frequently following coadministration than would have been expected based on the RIs following separate vaccinations, while there was no significant difference for 72% of AEFI. We found amplifying interaction effects for AEFI after five coadministrations comprising three vaccines: for fever (RIR 1.93 (95% CI 1.63 to 2.29)), rash (RIR 1.49 (95% CI 1.29 to 1.74)), gastrointestinal events (RIR 1.31 (95% CI 1.14 to 1.49)) and respiratory events (RIR 1.27 (1.17-1.38)) following DTaP/IPV/Hib+MenC+ PCV; gastrointestinal events (RIR 1.65 (95% CI 1.35 to 2.02)) following DTaP/IPV/Hib+MenC+ RV; fever (RIR 1.44 (95% CI 1.09 to 1.90)) and respiratory events (RIR 1.40 (95% CI 1.25 to 1.57)) following DTaP/IPV/Hib+PCV+ RV; gastrointestinal (RIR 1.48 (95% CI 1.20 to 1.82)) and respiratory events (RIR 1.43 (95% CI 1.26 to 1.63)) following MMR+Hib/MenC+PCV; gastrointestinal events (RIR 1.68 (95% CI 1.07 to 2.64)) and general symptoms (RIR 11.83 (95% CI 1.28 to 109.01)) following MMR+MenC+PCV. Coadministration of MMR+PCV led to more fever (RIR 1.91 (95% CI 1.83 to 1.99)), neurological events (RIR 2.04 (95% CI 1.67 to 2.49)) and rash (RIR 1.06 (95% CI 1.01 to 1.11)) compared with separate administration, DTaP/IPV/Hib+MMR to more musculoskeletal events (RIR 3.56 (95% CI 1.21 to 10.50)) and MMR+MenC to more fever (RIR 1.58 (95% CI 1.37 to 1.82)). There was no indication that unscheduled coadministrations are less safe than scheduled coadministrations.ConclusionReal-life RIRs of AEFI justify coadministering routine childhood vaccines according to the immunisation schedule. Further research into the severity of AEFI following coadministration is required for a complete understanding of the burden of these AEFI.
Patient-initiated cardiovascular monitoring with commercially available devices: How useful is it in a cardiology outpatient setting? Mixed methods, observational study.
BACKGROUND: The availability, affordability and utilisation of commercially available self-monitoring devices is increasing, but their impact on routine clinical decision-making remains little explored. We sought to examine how patient-generated cardiovascular data influenced clinical evaluation in UK cardiology outpatient clinics and to understand clinical attitudes and experiences with using data from commercially available self-monitoring devices. METHODS: Mixed methods study combining: a) quantitative and qualitative content analysis of 1373 community cardiology clinic letters, recording consultations between January-September 2020 including periods with different Covid-19 related restrictions, and b) semi-structured qualitative interviews and group discussions with 20 cardiology-affiliated clinicians at the same NHS Trust. RESULTS: Patient-generated cardiovascular data were described in 185/1373 (13.5%) clinic letters overall, with the proportion doubling following onset of the first Covid-19 lockdown in England, from 8.3% to 16.6% (p
Erratum: Correction: A Facilitated Web-Based Self-Management Tool for People With Type 1 Diabetes Using an Insulin Pump: Intervention Development Using the Behavior Change Wheel and Theoretical Domains Framework (Journal of medical Internet research (2020) 22 5 (e13980))
[This corrects the article DOI: 10.2196/13980.].
Managing Parkinson’s during the COVID-19 pandemic: Perspectives from people living with Parkinson’s and health professionals
Objectives: The aim of this study was to understand how people living with Parkinson's and healthcare professionals perceived their care management and interactions with health services were affected during the COVID-19 pandemic. Background: During the COVID-19 pandemic, many governments introduced restrictions and services that support Parkinson's care management had to cease or be delivered remotely. These changes may have had an impact on the well-being of people living with Parkinson's. Methods: A qualitative exploratory UK study was carried out. Semi-structured individual interviews with people living with Parkinson's and health professionals were recorded, transcribed verbatim and analysed using Braun´s and Clarke´s thematic analysis. Eleven patients and 10 health professionals were recruited between April and September 2020. The study was reported using the COREQ. Results: Two main themes were identified. In the first theme, many patients and professionals reported that the COVID-19 pandemic made some people living with Parkinson's feel isolated and vulnerable due to disruptions to their social networks and usual activities related to Parkinson's disease care. However, other patients remained connected with their networks. In the second theme, patients and most professionals mentioned that some clinical practices were cancelled, delayed or transformed to remote consultation. Conclusion: The COVID-19 restrictions had an impact on how people living with Parkinson's managed their care and in their interactions with healthcare services. Health professionals should assess the risk of vulnerability, social isolation, physical inactivity and confidence with remote consultations in people living with Parkinson's. This might inform a rethinking of existing clinical interactions with people living with Parkinson's towards a flexible, sustainable, person-centred care model. Relevance to clinical practice: This study has shown that Parkinson's care management and interactions with healthcare services should provide personalised and flexible support. To meet this challenge, the design of the organisation of health services should include greater involvement of patients and person-centred care models.
World guidelines for falls prevention and management for older adults: a global initiative
Abstract Background falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present. Objectives to create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries. Methods a steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting. Recommendations all older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations. Conclusions the core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.
Two Patients With KCNT1-Related Epilepsy Responding to Phenobarbital and Potassium Bromide
KCNT1 encodes a sodium-activated potassium channel highly expressed in the brain, regulating hyperpolarization following repetitive firing. Mutations in KCNT1 were originally implicated in autosomal-dominant nocturnal frontal lobe epilepsy and epilepsy of infancy with migrating focal seizures. It is now known that there is variability in phenotypic expression and incomplete penetrance. We describe 2 patients with KCNT1-related epilepsy, one with epilepsy of infancy with migrating focal seizures and one with multifocal epilepsy. As most patients with KCNT1 variants have treatment-resistant epilepsy, drugs that specifically target the KCNT1 channel have been of great interest. Quinidine, a broad-spectrum potassium channel blocker, has shown promise; however, clinical trial results have been variable. Our patient with epilepsy of infancy with migrating focal seizures did not respond to a trial of quinidine at 6 weeks of age—one of the earliest reported quinidine trials in the literature for KCNT1-related epilepsy. This indicates that timing of treatment and response may not be related. Both patients responded to high-dose phenobarbital. The patient with epilepsy of infancy with migrating focal seizures also had a significant reduction in seizures with potassium bromide (KBr). Our data suggest that alternative therapies to quinidine should be considered as a therapeutic option for patients with KCNT1-related epilepsy. Although improved seizure control led to parent-reported improvements in neurodevelopment, it is unknown if phenobarbital and KBr impact the overall developmental trajectory of patients with KCNT1-related epilepsy. Further multicenter longitudinal studies are required.
Perinatal Regionalization and Implications for Long-Term Health Outcomes in Cerebral Palsy
AbstractBackground: Perinatal regionalization is linked to improved neonatal outcomes; however, the effects on long-term outcomes in cerebral palsy (CP) are not known. We estimate the effect of highest levels of neonatal care available at delivery on the risk of developing a nonambulatory CP status. Methods: Children with CP born in Quebec from the Canadian CP Registry excluding postneonatal causes were included (N=360). We estimate the effect of level of care available at delivery on risk of nonambulatory status among children with CP using propensity score matching and instrumental variables methods to adjust for differences in case mix among the three groups of hospitals. The outcome variable is an indicator for CP nonambulation assigned according to Gross Motor Function Classification System (levels IV and V). This study used data that predated therapeutic hypothermia in Quebec. Results: Propensity score estimates of change in the adjusted risk of having a nonambulatory CP status because of birth at level II versus level I is −0.081, 95% confidence interval (CI; −0.2182 to 0.0562); level III versus level I is −0.072 95% CI (−0.225 to 0.08), and level III versus level II is 0.157 95% CI (0.027 to 0.286). Conclusions: Differences in levels of neonatal care available at hospital where the delivery was carried out are not associated with the risk of a nonambulatory CP phenotype. This suggests that level of care and associated medical technology within the Quebec regionalized neonatal-perinatal system is used efficiently because it does not offer any further marginal benefit in the reduction of severe CP outcomes. The system works well as it is, which is supportive of the perinatal regionalization. The success of the neonatal resuscitation program and referral of high-risk births to regional hospitals with sufficient obstetric and perinatal competence and resources may contribute to this lack of variability.
Childhood cancer hospital resource utilization and costs in Egypt, 2013-2017; patterns, trends, and associated factors for 8886 patients from Children's Cancer Hospital, Egypt
Introduction: There is a lack ofevidence about resource use and costs of childhood cancer care in Egypt. Knowledge about resource use/costs can help in better resource planning to improve care and outcomes efficiently. In this study, we estimated patterns and trends of hospital resource use and costs for children with cancer (n = 8886, aged 0-18 years) treated at Children's Cancer Hospital, Egypt (CCHE), between 2013 and 2017, by ICCC-3 groups, at one and three years post-diagnosis. Methods: We estimated costs from the healthcare provider perspective, expressed in USD 2019. We also studied resource use/cost trends, and factors associated with inpatient days and costs. Results: For all cancers combined, median costs were $14,774 (IQR: $6,559-$23,738) at one year and $19,799 (IQR: $8,921-$34,204) at three years post-diagnosis. Median inpatient days were 38 days (IQR: 17-60) at one year, and 43 days (IQR: 20-74) at three years post-diagnosis. Patients with acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML), and neuroblastoma imposed the greatest financial burden on CCHE, representing 53.1% of total costs. AML patients had the highest costs/resource use of all childhood cancers. Cost trends decreased by 2.9% (P
Assessing the comparative feasibility, acceptability and equivalence of videoconference interviews and face-to-face interviews using the time trade-off technique
This study examines the comparative equivalence, feasibility and acceptability of video and in-person interviews in generating time trade-off (TTO) values. Sample participants in England were recruited using a blended approach of different methods and sampled based on age, gender, ethnicity, and index of multiple deprivation. Participants were randomly allocated to be interviewed either via video or in-person. Participants completed TTO tasks for the same block of 10 EQ-5D-5L health states using the EQ-VTv2 software. Feasibility, acceptability and equivalence was assessed across mode using: sample representativeness; participant understanding, engagement and feedback; participant preferred mode of interview; data quality; mean utility and distribution of values for each health state; and regression analyses assessing the impact of mode whilst controlling for participant characteristics. The video and in-person samples had statistically significant differences in ethnicity and income but were otherwise broadly similar. Video interviews generated marginally lower quality data across some criteria. Participant understanding and feedback was positive and similar across modes. TTO values were similar across modes; whilst mean in-person TTO values were lower for the more severe states, mode was insignificant in most regression analyses. There was no clear preference of mode across all participants, though the characteristics of participants preferring to be interviewed in-person or by video differs. Video and in-person TTO interviews were feasible, acceptable and generated good-quality data, though video interviews had lower quality data across some criteria. Whilst TTO values differed across modes for the more severe states, mode does not appear to be the cause. The study found that the characteristics of people preferring each mode differed, and this should be taken into account in future valuation studies since sample representativeness for some characteristics, and therefore potentially TTO values, could be affected by the choice of mode.
Modelling a preference-based index for EQ-5D-3L and EQ-5D-3L + Sleep using a Bayesian framework
© 2020, Springer Nature Switzerland AG. Background: Conventionally, frequentist approach has been used to model health state valuation data. Recently, researchers started to explore the use of Bayesian methods in this area. Objectives: This paper presents an alternative approach to modelling health state valuation data of the EQ-5D-3L and EQ-5D-3L + Sleep descriptive systems, using a Bayesian framework, and demonstrates its superiority to conventional frequentist methods. Methods: The valuation study is composed of 18 EQ-5D-3L health states and 18 EQ-5D-3L + Sleep health states valued by 160 members of the general public in South Yorkshire, UK, using the time tradeo-ff technique. Three different models were developed for EQ-5D-3L and EQ-5D-3L + Sleep accordingly using Bayesian Markov chain Monte Carlo simulation methods. Bayesian methods were applied to models fitted included a linear regression, random effect and random effect with covariates. The models are compared based on their predictive performance using mean predictions, root mean squared error (RMSE) and deviance information criterion (DIC). All analyses were performed using Bayesian Markov chain Monte Carlo simulation methods. Results: The random effects with covariates model performs best under all criterions for the two preference-based measures, with RMSE (0.037) and DIC (637.5) for EQ-5D-3L and RMSE (0.019), DIC (416.4) for EQ-5D + Sleep. Compared with models previously estimated using frequentist approach, the Bayesian models reported in this paper provided better predictions of observed values. Conclusion: Bayesian methods provide a better way to model EQ-5D-3L valuation data with and without a sleep ‘bolt-on’ and provide a more flexible in characterizing the full range of uncertainty inherent in these estimates.