Individual risk factors predictive of major trauma in pre-hospital injured older patients: a systematic review.

Background: Older adults with major trauma are frequently under-triaged, increasing the risk of preventable morbidity and mortality. The aim of this systematic review was to identify which individual risk factors and predictors are likely to increase the risk of major trauma in elderly patients presenting to emergency medical services (EMS) following injury, to inform future elderly triage tool development. Methods: Several electronic databases (including Medline, EMBASE, CINAHL and the Cochrane Library) were searched from inception to February 2021. Prospective or retrospective diagnostic studies were eligible if they examined a prognostic factor (often termed predictor or risk factor) for, or diagnostic test to identify, major trauma. Selection of studies, data extraction and risk of bias assessments using the Quality in Prognostic Studies (QUIPS) tool were undertaken independently by at least two reviewers. Narrative synthesis was used to summarise the findings. Results: Nine studies, all performed in US trauma networks, met review inclusion criteria. Vital signs (Glasgow Coma Scale (GCS) score, systolic blood pressure, respiratory rate and shock index with specific elderly cut-off points), EMS provider judgement, comorbidities and certain crash scene variables (other occupants injured, occupant not independently mobile and head-on collision) were identified as significant pre-hospital variables associated with major trauma in the elderly in multi-variable analyses. Heart rate and anticoagulant were not significant predictors. Included studies were at moderate or high risk of bias, with applicability concerns secondary to selected study populations. Conclusions: Existing pre-hospital major trauma triage tools could be optimised for elderly patients by including elderly-specific physiology thresholds. Future work should focus on more relevant reference standards and further evaluation of novel elderly relevant triage tool variables and thresholds.

Diagnostic accuracy of prehospital triage tools for identifying major trauma in elderly injured patients: A systematic review.

BACKGROUND: Older adults with major trauma are frequently undertriaged, increasing the risk of preventable morbidity and mortality. The aim of this systematic review was to evaluate the diagnostic performance of prehospital triage tools to identify suspected elderly trauma patients in need of specialized trauma care. METHODS: Several electronic databases (including MEDLINE, EMBASE, and the Cochrane Library) were searched from inception to February 2019. Prospective or retrospective diagnostic studies were eligible if they examined prehospital triage tools as index tests (either scored theoretically using observed patient variables or evaluated according to actual paramedic transport decisions) compared with a reference standard for major trauma in elderly adults who require transport by paramedics following injury. Selection of studies, data extraction, and risk of bias assessments using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool were undertaken independently by at least two reviewers. Narrative synthesis was used to summarize the findings. RESULTS: Fifteen studies met the inclusion criteria, with 11 studies examining theoretical accuracy, three evaluating real-life transport decisions, and one assessing both (of 21 individual index tests). Estimates for sensitivity and specificity were highly variable with sensitivity estimates ranging from 19.8% to 95.5% and 57.7% to 83.3% for theoretical accuracy and real life triage performance, respectively. Specificity results were similarly diverse ranging from 17.0% to 93.1% for theoretical accuracy and 46.3% to 78.9% for actual paramedic decisions. Most studies had unclear or high risk of bias and applicability concerns. There were no obvious differences between different triage tools, and findings did not appear to vary systematically with major trauma prevalence, age, alternative reference standards, study designs, or setting. CONCLUSION: Existing prehospital triage tools may not accurately identify elderly patients with serious injury. Future work should focus on more relevant reference standards, establishing the best trade-off between undertriage and overtriage, optimizing the role prehospital clinician judgment, and further developing geriatric specific triage variables and thresholds. LEVEL OF EVIDENCE: Systematic review, level III.

Improving outcomes for older people in the emergency department: a review of reviews.

BACKGROUND: There has been a recognised trend of increasing use of emergency and urgent care and emergency departments (EDs) by older people, which is marked by a substantial evidence base reporting interventions for this population and guidance from key organisations. Despite this, outcomes for this population remain suboptimal. A plethora of reviews in this area provides challenges for clinicians and commissioners in determining which interventions and models of care best meet people's needs. The aim of this review was to identify effective ED interventions which have been reported for older people, and to provide a clear summary of the myriad reviews and numerous intervention types in this area. METHODS: A review of reviews, reporting interventions for older people, either initiated or wholly delivered within the ED. RESULTS: A total of 15 review articles describing 83 primary studies met our content and reporting standards criteria. The majority (n=13) were systematic reviews (four using meta-analysis.) Across the reviews, 26 different outcomes were reported with inconsistency. Follow-up duration varied within and across the reviews. Based on how authors had reported results, evidence clusters were developed: (1) staff-focused reviews, (2) discharge intervention reviews, (3) population-focused reviews and (4) intervention component reviews. CONCLUSIONS: The evidence base describing interventions is weak due to inconsistent reporting, differing emphasis placed on the key characteristics of primary studies (staff, location and outcome) by review authors and varying quality of reviews. No individual interventions have been found to be more promising, but interventions initiated in the ED and continued into other settings have tended to result in more favourable patient and health service outcomes. Despite many interventions reported within the reviews being holistic and patient focused, outcomes measured were largely service focused. PROSPERO REGISTRATION NUMBER: PROSPERO CRD42018111461.

What are the cost-savings and health benefits of improving detection and management for six high cardiovascular risk conditions in England? An economic evaluation.

OBJECTIVES: To estimate the cost savings and health benefits of improving detection of individuals at high risk of cardiovascular disease (CVD) in England, to determine to which patient subgroups these benefits arise, and to compare different strategies for subsequent management. DESIGN: An economic analysis using the School for Public Health Research CVD Prevention Model. SETTING: England 2018. PARTICIPANTS: Adults aged 16 and older with one or more high cardiovascular risk conditions, including hypertension, diabetes, non-diabetic hyperglycaemia, atrial fibrillation, chronic kidney disease and high cholesterol. INTERVENTIONS: Detection of 100% of individuals with CVD high risk conditions compared with current levels of detection in England. Detected individuals are assumed to be managed either according to current levels of care or National Institute of Health and Care Excellence (NICE) guidelines. MAIN OUTCOME MEASURES: Incremental and cumulative costs, savings, quality adjusted life years (QALYs), CVD cases, and net monetary benefit, from a UK NHS and Personal Social Services perspective. RESULTS: £68 billion could be saved, 4.9 million QALYs gained and 3.4 million cases of CVD prevented over 25 years if all individuals in England with the six CVD high risk conditions were diagnosed and subsequently managed at current levels. Additionally, if all detected individuals were managed according to NICE guidelines, total savings would be £61 billion, 8.1 million QALYs would be gained and 5.2 million CVD cases prevented. Most benefits come from detection of high cholesterol in the short term and diabetes in the long term. CONCLUSIONS: Substantial cost savings and health benefits would accrue if all individuals with conditions that increase CVD risk could be diagnosed, with detection of undiagnosed diabetes producing greatest benefits. Ensuring all conditions are managed according to NICE guidelines would further increase health benefits. Projected cost-savings could be invested in developing acceptable and cost-effective solutions for improving detection and management.

Experiences of living with varicose veins: A systematic review of qualitative research.

AIM: To identify the symptoms and quality of life impacts that are important from the perspective of patients with varicose veins and to compare identified themes to items in varicose vein patient-reported outcome measures (PROMs). BACKGROUND: Varicose veins are common worldwide and are considered a chronic condition with implications for quality of life. Treatment is predominantly conservative; therefore, understanding patients' experiences of living with varicose veins is important to inform the provision of clinical care. PROMs are often used to collect data about patients' quality of life. DESIGN: Thematic synthesis of qualitative research reported according to ENTREQ guidelines. METHODS: Multiple electronic databases, including MEDLINE and CINAHL, were systematically searched to identify qualitative research examining experiences of adults with varicose veins. Thematic synthesis was then conducted on the included studies. RESULTS: Three studies met the inclusion criteria; the quality of the studies was high. The range and intensity of reported symptoms and participant's experiences of living with varicose veins were varied. Five overarching themes were identified: physical, psychological and social impact of varicose veins, adapting to varicose veins and reasons for seeking treatment. The overall key theme to emerge was adaptation, with patients demonstrating how they adapted to the various impacts. CONCLUSION: This review demonstrates that varicose veins have a wide range of symptoms and may have a significant impact on quality of life; people made significant adaptations to enable them to live their lives as fully as possible. RELEVANCE TO CLINICAL PRACTICE: Healthcare professionals need to be aware of the range of symptoms and their impact on quality of life. The use of PROMs to gather information about quality of life and symptoms is well established globally; however, PROMs currently used may not capture the full extent of the impact on patient's quality of life.

The evidence base for circulating tumour DNA blood-based biomarkers for the early detection of cancer: a systematic mapping review.

BACKGROUND: The presence of circulating cell-free DNA from tumours in blood (ctDNA) is of major importance to those interested in early cancer detection, as well as to those wishing to monitor tumour progression or diagnose the presence of activating mutations to guide treatment. In 2014, the UK Early Cancer Detection Consortium undertook a systematic mapping review of the literature to identify blood-based biomarkers with potential for the development of a non-invasive blood test for cancer screening, and which identified this as a major area of interest. This review builds on the mapping review to expand the ctDNA dataset to examine the best options for the detection of multiple cancer types. METHODS: The original mapping review was based on comprehensive searches of the electronic databases Medline, Embase, CINAHL, the Cochrane library, and Biosis to obtain relevant literature on blood-based biomarkers for cancer detection in humans (PROSPERO no. CRD42014010827). The abstracts for each paper were reviewed to determine whether validation data were reported, and then examined in full. Publications concentrating on monitoring of disease burden or mutations were excluded. RESULTS: The search identified 94 ctDNA studies meeting the criteria for review. All but 5 studies examined one cancer type, with breast, colorectal and lung cancers representing 60% of studies. The size and design of the studies varied widely. Controls were included in 77% of publications. The largest study included 640 patients, but the median study size was 65 cases and 35 controls, and the bulk of studies (71%) included less than 100 patients. Studies either estimated cfDNA levels non-specifically or tested for cancer-specific mutations or methylation changes (the majority using PCR-based methods). CONCLUSION: We have systematically reviewed ctDNA blood biomarkers for the early detection of cancer. Pre-analytical, analytical, and post-analytical considerations were identified which need to be addressed before such biomarkers enter clinical practice. The value of small studies with no comparison between methods, or even the inclusion of controls is highly questionable, and larger validation studies will be required before such methods can be considered for early cancer detection.

A systematic review and economic evaluation of exercise referral schemes in primary care: a short report.

BACKGROUND: It is estimated that only 39% of men and 29% of women in England achieve the levels of physical activity that are recommended to protect health and prevent disease. One approach to addressing this problem has been the development of exercise referral schemes (ERSs), in which health professionals refer patients to external exercise providers. These schemes have been widely rolled out across the UK despite concerns that they may not produce sustained changes in levels of physical activity and, therefore, may not be cost-effective interventions. The evidence to determine clinical effectiveness and cost-effectiveness was evaluated in 2009. This review seeks to update this earlier work by incorporating new evidence and re-examining the cost-effectiveness. OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of ERSs compared with usual care. DESIGN: Exhaustive searches of relevant electronic databases and journals were undertaken to identify new studies evaluating ERSs using a randomised controlled trial (RCT) design. RCTs that incorporated a qualitative evaluation of the intervention were identified in order to explore the barriers and facilitators to the uptake of and adherence to ERSs. Data were extracted using a previously designed tool and study quality assessed for potential bias. Where data could be pooled, meta-analyses were carried out. Qualitative analysis was also undertaken using a thematic approach. The cost-effectiveness was evaluated using a Markov structure which estimated the likelihood of becoming physically active and the subsequent risk reduction on coronary heart disease (CHD), stroke and type 2 diabetes mellitus. The model adopts a lifetime horizon, and a NHS and Personal Social Services perspective was taken with discounting at 1.5% for both costs and benefits. RESULTS: The search identified one new RCT and one new qualitative study. The new data were pooled with existing data from the 2011 review by Pavey et al. [Pavey TG, Anokye N, Taylor AH, Trueman P, Moxham T, Fox KR, et al. The clinical effectiveness and cost-effectiveness of exercise referral schemes: a systematic review and economic evaluation. Health Technol Assess 2011;15(44)] to give a total of eight studies with 5190 participants. The proportion of individuals achieving 90-150 minutes of at least moderate-intensity activity per week at 6-12 months' follow-up was greater for ERSs than usual care (relative risk 1.12; 95% confidence interval 1.04 to 1.20). Older patients and those referred for CHD risk factors appeared to be more likely than others to increase their levels of physical activity. Qualitative evidence suggests that interventions enabling the development of social support networks are beneficial in promoting uptake and adherence. Exercise referral gained 0.003 quality-adjusted life-years (QALYs) at an additional cost of £225 per person. The estimated mean incremental cost-effectiveness ratio (ICER) in the probabilistic sensitivity analysis was £76,276. In the univariate sensitivity analysis the results were very sensitive (ICERs ranged from < £30,000 to > £100,000) to changes in the effect of ERSs on physical activity uptake and the duration of the protective effects and the direct health-related quality-of-life gains attributable to physical activity. CONCLUSIONS: Exercise referral schemes result in a small improvement in the number of people who increase their levels of physical activity. The cost-effectiveness analysis indicates that the ICER for ERSs compared with usual care is around £76,000 per QALY, although the cost-effectiveness of ERSs is subject to considerable uncertainty. STUDY REGISTRATION: This study is registered as PROSPERO CRD42013005200. FUNDING: National Institute for Health Research Health Technology Assessment programme.

Weight management during pregnancy: a systematic review of qualitative evidence.

BACKGROUND: increasing overweight and obesity rates in pregnant women present health risks to mother and unborn infant. OBJECTIVES: to identify barriers and facilitators to implementing and carrying out maternal weight management interventions. SEARCH STRATEGY: searches were carried out in medical, midwifery and nursing databases, augmented by hand searching of midwifery journals. SELECTION CRITERIA: articles were included that were published in the UK after 1990, with a focus on women's and health professional's views about weight management during pregnancy. DATA COLLECTION AND ANALYSIS: from 6423 citations, 126 full text papers were retrieved. Of these, 18 (reporting 17 studies) fulfilled the inclusion criteria. Included papers were assessed for quality. Reported findings were analysed and synthesised using thematic analysis. MAIN RESULTS: a major theme was access to relevant and appropriate information; advice was reported as vague or inadequate. Overweight or obese women reported feelings of stigmatisation during routine examinations. Health professionals reported a reluctance to discuss weight with larger women. Perceived risk to the fetus as well as changes in women's physiological responses to pregnancy, were reported barriers to optimal physical activity and dietary intake. Perceptions of control were related to women's feelings about their body image. CONCLUSION: evidence suggests that the complexity of interactions with advice sources, bodily changes, feelings of control, as well as perceived risks may explain the relative ineffectiveness of weight management interventions during pregnancy. Focusing on healthy diet and physical activity levels may be more useful and less stigmatising than focusing on weight.