Demographic disparities in dental school selection: An analysis of current UK practices.

INTRODUCTION: Specific social groups remain under-represented within dentistry. While the University Clinical Aptitude Test (UCAT) aims to widen participation in under-represented social groups, there is no evidence in dental education that this aim is being met. MATERIALS AND METHODS: Data over two admission cycles (2012 and 2013), including 3246 applicants to 10 UK dental schools, were analysed. Applicant and selected pools were compared to the UK population. Multiple logistic regression was used to investigate the association between demographic variables and UCAT and receiving an offer of a place at dental school. RESULTS: Over-representation of Female, Asian, least deprived and grammar school groups were found in applicant and selected pools compared with the UK population. White ethnic applicants were significantly more selected than Black (OR 0.25), Asian (OR 0.57) and Mixed (OR 0.80) ethnicities, while least deprived applicants were significantly more selected than most deprived (OR 0.59). Grammar school education increased odds of selection by 1.8 when compared to state school. The addition of UCAT to the model for applicants reduced ethnic disparities but led to disparities between other groups. CONCLUSION: Current widening participation practices focus on attracting applicants from lower socio-economic groups. However, this study showed that ethnicity, sex and educational background biases also affect demographic diversity in dentistry. The UCAT shows promise in levelling the playing field; however, widening access measures will only succeed if selection committees radically change selection processes to address the systemic biases, enabling the dentists of tomorrow to represent the society they serve.

The burden of diarrhoeal diseases in the Democratic Republic of Congo: a time-series analysis of the global burden of disease study estimates (1990-2019).

BACKGROUND: Diarrhoeal diseases are important causes of disability and mortality being one of the main causes of mortality in the Democratic Republic of Congo (DRC). One of the largest and wealthiest African countries, DRC has been for long subjected to continuous political and economic instability, conflicts and disease outbreaks. This study aimed to address the knowledge gap in understanding how prevalence, mortality and burden of diseases in DRC changed over time and examine the influence of specific factors in these disease-related outcomes. METHODS: A time-series analysis of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 estimates was performed to describe prevalence, years lived with disabilities (YLDs) and mortality due to diarrhoeal diseases, by age-group and sex, between 1990-2019 in DRC. The contribution of water, sanitation and hygiene (WASH) and child malnutrition risk factors to these outcomes was also analysed. Piecewise regression analysis was used to assess trends over time. RESULTS: The overall age-standardised prevalence of diarrhoeal diseases for both sexes in DRC was 1350.84 (UI:1240.16-1461.62) cases per 100,000 people in 1990. The prevalence increased until 2019, also fuelled by the movement of Rwandan refugees to DRC and First/Second Congo wars between 1996-2003. Age-standardised prevalence and mortality were consistently higher in males, compared to females, decreasing by 42% and 54%, respectively, between 1990 and 2019. Overall prevalence was also usually higher in over 70 years old, except between 1998-2003 when mortality in under five years old was the highest. Unsafe water sources and child wasting among under five years old were the main contributors to YLDs and deaths associated to diarrhoeal diseases in DRC. CONCLUSION: Diarrhoeal diseases are important and preventable causes of disability and mortality in DRC. National measures of surveillance and cost-effective interventions targeting the identified risk groups could be effective in reducing its prevalence and associated burden.

Pregnancy after bariatric surgery and adverse perinatal outcomes: A systematic review and meta-analysis.

BACKGROUND: Women who undergo bariatric surgery prior to pregnancy are less likely to experience comorbidities associated with obesity such as gestational diabetes and hypertension. However, bariatric surgery, particularly malabsorptive procedures, can make patients susceptible to deficiencies in nutrients that are essential for healthy fetal development. The objective of this systematic review and meta-analysis is to investigate the association between pregnancy after bariatric surgery and adverse perinatal outcomes. METHODS AND FINDINGS: Searches were conducted in Medline, Embase, PsycINFO, CINAHL, Scopus, and Google Scholar from inception to June 2019, supplemented by hand-searching reference lists, citations, and journals. Observational studies comparing perinatal outcomes post-bariatric surgery to pregnancies without prior bariatric surgery were included. Outcomes of interest were perinatal mortality, congenital anomalies, preterm birth, postterm birth, small and large for gestational age (SGA/LGA), and neonatal intensive care unit (NICU) admission. Pooled effect sizes were calculated using random-effects meta-analysis. Where data were available, results were subgrouped by type of bariatric surgery. We included 33 studies with 14,880 pregnancies post-bariatric surgery and 3,979,978 controls. Odds ratios (ORs) were increased after bariatric surgery (all types combined) for perinatal mortality (1.38, 95% confidence interval [CI] 1.03-1.85, p = 0.031), congenital anomalies (1.29, 95% CI 1.04-1.59, p = 0.019), preterm birth (1.57, 95% CI 1.38-1.79, p < 0.001), and NICU admission (1.41, 95% CI 1.25-1.59, p < 0.001). Postterm birth decreased after bariatric surgery (OR 0.46, 95% CI 0.35-0.60, p < 0.001). ORs for SGA increased (2.72, 95% CI 2.32-3.20, p < 0.001) and LGA decreased (0.24, 95% CI 0.14-0.41, p < 0.001) after gastric bypass but not after gastric banding. Babies born after bariatric surgery (all types combined) weighed over 200 g less than those born to mothers without prior bariatric surgery (weighted mean difference -242.42 g, 95% CI -307.43 to -177.40 g, p < 0.001). There was low heterogeneity for all outcomes (I2 < 40%) except LGA. Limitations of our study are that as a meta-analysis of existing studies, the results are limited by the quality of the included studies and available data, unmeasured confounders, and the small number of studies for some outcomes. CONCLUSIONS: In our systematic review of observational studies, we found that bariatric surgery, especially gastric bypass, prior to pregnancy was associated with increased risk of some adverse perinatal outcomes. This suggests that women who have undergone bariatric surgery may benefit from specific preconception and pregnancy nutritional support and increased monitoring of fetal growth and development. Future studies should explore whether restrictive surgery results in better perinatal outcomes, compared to malabsorptive surgery, without compromising maternal outcomes. If so, these may be the preferred surgery for women of reproductive age. TRIAL REGISTRATION: PROSPERO CRD42017051537.

The association between maternal body mass index and child obesity: A systematic review and meta-analysis.

BACKGROUND: There is a global obesity crisis, particularly among women and disadvantaged populations. Early-life intervention to prevent childhood obesity is a priority for public health, global health, and clinical practice. Understanding the association between childhood obesity and maternal pre-pregnancy weight status would inform policy and practice by allowing one to estimate the potential for offspring health gain through channelling resources into intervention. This systematic review and meta-analysis aimed to examine the dose-response association between maternal body mass index (BMI) and childhood obesity in the offspring. METHODS AND FINDINGS: Searches in MEDLINE, Child Development & Adolescent Studies, CINAHL, Embase, and PsycInfo were carried out in August 2017 and updated in March 2019. Supplementary searches included hand-searching reference lists, performing citation searching, and contacting authors. Two researchers carried out independent screening, data extraction, and quality assessment. Observational studies published in English and reporting associations between continuous and/or categorical maternal and child BMI or z-score were included. Categorical outcomes were child obesity (≥95th percentile, primary outcome), overweight/obesity (≥85th percentile), and overweight (85th to 95th percentile). Linear and nonlinear dose-response meta-analyses were conducted using random effects models. Studies that could not be included in meta-analyses were summarised narratively. Seventy-nine of 41,301 studies identified met the inclusion criteria (n = 59 cohorts). Meta-analyses of child obesity included 20 studies (n = 88,872); child overweight/obesity, 22 studies (n = 181,800); and overweight, 10 studies (n = 53,238). Associations were nonlinear and there were significantly increased odds of child obesity with maternal obesity (odds ratio [OR] 3.64, 95% CI 2.68-4.95) and maternal overweight (OR 1.89, 95% CI 1.62-2.19). Significantly increased odds were observed for child overweight/obesity (OR 2.69, 95% CI 2.10-3.46) and for child overweight (OR 1.80, 95% CI 1.25, 2.59) with maternal obesity. A limitation of this research is that the included studies did not always report the data in a format that enabled inclusion in this complex meta-analysis. CONCLUSIONS: This research has identified a 264% increase in the odds of child obesity when mothers have obesity before conception. This study provides substantial evidence for the need to develop interventions that commence prior to conception, to support women of childbearing age with weight management in order to halt intergenerational obesity.

Behavioural intervention for weight loss maintenance versus standard weight advice in adults with obesity: A randomised controlled trial in the UK (NULevel Trial).

BACKGROUND: Scalable weight loss maintenance (WLM) interventions for adults with obesity are lacking but vital for the health and economic benefits of weight loss to be fully realised. We examined the effectiveness and cost-effectiveness of a low-intensity technology-mediated behavioural intervention to support WLM in adults with obesity after clinically significant weight loss (≥5%) compared to standard lifestyle advice. METHODS AND FINDINGS: The NULevel trial was an open-label randomised controlled superiority trial in 288 adults recruited April 2014 to May 2015 with weight loss of ≥5% within the previous 12 months, from a pre-weight loss BMI of ≥30 kg/m2. Participants were self-selected, and the majority self-certified previous weight loss. We used a web-based randomisation system to assign participants to either standard lifestyle advice via newsletter (control arm) or a technology-mediated low-intensity behavioural WLM programme (intervention arm). The intervention comprised a single face-to-face goal-setting meeting, self-monitoring, and remote feedback on weight, diet, and physical activity via links embedded in short message service (SMS). All participants were provided with wirelessly connected weighing scales, but only participants in the intervention arm were instructed to weigh themselves daily and told that they would receive feedback on their weight. After 12 months, we measured the primary outcome, weight (kilograms), as well as frequency of self-weighing, objective physical activity (via accelerometry), psychological variables, and cost-effectiveness. The study was powered to detect a between-group weight difference of ±2.5 kg at follow-up. Overall, 264 participants (92%) completed the trial. Mean weight gain from baseline to 12 months was 1.8 kg (95% CI 0.5-3.1) in the intervention group (n = 131) and 1.8 kg (95% CI 0.6-3.0) in the control group (n = 133). There was no evidence of an effect on weight at 12 months (difference in adjusted mean weight change from baseline: -0.07 [95% CI 1.7 to -1.9], p = 0.9). Intervention participants weighed themselves more frequently than control participants and were more physically active. Intervention participants reported greater satisfaction with weight outcomes, more planning for dietary and physical activity goals and for managing lapses, and greater confidence for healthy eating, weight loss, and WLM. Potential limitations, such as the use of connected weighing study in both trial arms, the absence of a measurement of energy intake, and the recruitment from one region of the United Kingdom, are discussed. CONCLUSIONS: There was no difference in the WLM of participants who received the NULevel intervention compared to participants who received standard lifestyle advice via newsletter. The intervention affected some, but not all, process-related secondary outcomes of the trial. TRIAL REGISTRATION: This trial is registered with the ISRCTN registry (ISRCTN 14657176; registration date 20 March 2014).

Socio-economic inequalities in mortality in children with congenital heart disease: A systematic review and meta-analysis.

BACKGROUND: The impact of socio-economic status (SES) on congenital heart disease (CHD)-related mortality in children is not well established. OBJECTIVES: We aimed to systematically review and appraise the existing evidence on the association between SES (including poverty, parental education, health insurance, and income) and mortality among children with CHD. DATA SOURCES: Seven electronic databases (Medline, Embase, Scopus, PsycINFO, CINAHL, ProQuest Natural, and Biological Science Collections), reference lists, citations, and key journals were searched. STUDY SELECTION AND DATA EXTRACTION: We included articles reporting original research on the association between SES and mortality in children with CHD if they were full papers published in the English language and regardless of (a) timing of mortality; (b) individual or area-based measures of SES; (c) CHD subtype; (d) age at ascertainment; (e) study period examined. Screening for eligibility, data extraction, and quality appraisal were performed in duplicate. SYNTHESIS: Meta-analyses were performed to estimate pooled ORs for in-hospital mortality according to health insurance status. RESULTS: Of 1388 identified articles, 28 met the inclusion criteria. Increased area-based poverty was associated with increased odds/risk of postoperative (n = 1), neonatal (n = 1), post-discharge (n = 1), infant (n = 1), and long-term mortality (n = 2). Higher parental education was associated with decreased odds/risk of neonatal (n = 1) and infant mortality (n = 5), but not with long-term mortality (n = 1). A meta-analysis of four US articles showed increased unadjusted odds of in-hospital mortality in those with government/public versus private health insurance (OR 1.40, 95% CI 1.24, 1.56). The association between area-based income and CHD-related mortality was conflicting, with three of eight articles reporting significant associations. CONCLUSION: This systematic review provides evidence that children of lower SES are at increased risk of CHD-related mortality. As these children are over-represented in the CHD population, interventions targeting socio-economic inequalities could have a large impact on improving CHD survival.

Intravitreal Aflibercept for Retinal Angiomatous Proliferation: Results of a Prospective Case Series at 96 Weeks.

INTRODUCTION: Retinal angiomatous proliferation (RAP) is a subtype of neovascular age-related macular degeneration (nAMD). Untreated, the lesions are thought to be aggressive and lead to a poor visual outcome. Despite some limitations, studies reporting the treatment of RAP lesions with the intravitreal anti-VEGF drugs ranibizumab and bevacizumab have demonstrated variable but generally favourable responses. More recently, aflibercept has been licensed for the treatment of nAMD and may offer some advantages over other agents. We present the visual and anatomical outcomes at 96 weeks of patients with RAP lesions who were treated with intravitreal aflibercept, according to the pivotal VIEW study nAMD treatment protocol. METHODS: This is a prospective study of treatment-naïve patients with Reading Centre-graded RAP lesions. The patients received aflibercept every 8 weeks, after 3 initial monthly injections, up to and including week 48. During weeks 52-96, patients received injections at least every 12 weeks, with monthly evaluations for interim injections if they fulfilled the retreatment criteria. At each visit, best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) central macular thickness (CMT) were measured. RESULTS: Forty-six patients reached study completion at week 96. Mean BCVA had improved by 6.0 (standard deviation [SD] 7.9) and 4.8 (SD 7.4) ETDRS letters at 52 (p = 0.003) and 96 (p = 0.02) weeks, respectively, from a baseline of 57.3 (SD 12.0) letters. At 52- and 96-week time points, 45/46 (98%) and 41/46 (89%) of patients, respectively, had maintained their vision (<15 letters of BCVA lost). At the 96-week time point, 13/46 (28%) of patients had gained ≥15 letters and also demonstrated a mean reduction in CMT of 162 µm (SD 106) (p = <0.0001), with 72% of maculae being fluid-free. Using univariate analysis, we found no significant difference between any of the visual outcome measures in this study and the pivotal VIEW study; the mean number of injections required and change in CMT were also similar. CONCLUSIONS: In this study, we present the 96-week results, of the largest series to date, of patients treated prospectively with aflibercept for RAP using the VIEW protocol. We show that they benefited from treatment to a degree similar to those with type 1 and 2 nAMD.

Changes in physical activity during the retirement transition: a series of novel n-of-1 natural experiments.

BACKGROUND: Existing evidence about the impact of retirement on physical activity (PA) has primarily focused on the average change in PA level after retirement in group-based studies. It is unclear whether findings regarding the direction of PA change after retirement from group-based studies apply to individuals. This study aimed to explore changes in PA, PA determinants and their inter-relationships during the retirement transition at the individual level. METHODS: A series of n-of-1 natural experiments were conducted with seven individuals who were aged 55-76 years and approaching retirement. PA was measured by tri-axial accelerometry. Twice-daily self-report and ecological momentary assessments of evidence- and theory-based determinants of PA (e.g. sleep length/quality, happiness, tiredness, stress, time pressure, pain, intention, perceived behavioural control, priority, goal conflict and goal facilitation) were collected via a questionnaire for a period of between 3 and 7 months, which included time before and after the participant's retirement date. A personalised PA determinant was also identified by each participant and measured daily for the duration of the study. Dynamic regression models for discrete time binary data were used to analyse data for each individual participant. RESULTS: Two participants showed a statistically significant increase in the probability of engaging in PA bouts after retirement and two participants showed a significant time trend for a decrease and increase in PA bouts over time during the pre- to post-retirement period, respectively. There was no statistically significant change in PA after retirement for the remaining participants. Most of the daily questionnaire variables were significantly associated with PA for one or more participants but there were no consistent pattern of PA predictors across participants. For some participants, the relationship between questionnaire variables and PA changed from pre- to post-retirement. CONCLUSIONS: The findings from this study demonstrate the impact of retirement on individual PA trajectories. Using n-of-1 methods can provide information about unique patterns and determinants of individual behaviour over time, which has been obscured in previous research. N-of-1 methods can be used as a tool to inform personalised PA interventions for individuals within the retirement transition.

The implementation and impact of non-invasive prenatal testing (NIPT) for Down's syndrome into antenatal screening programmes: A systematic review and meta-analysis.

BACKGROUND: Non-invasive prenatal testing (NIPT) is a widely adopted maternal blood test that analyses foetal originating DNA to screen for foetal chromosomal conditions, including Down's syndrome (DS). The introduction of this test, which may have implications for important decisions made during pregnancy, requires continual monitoring and evaluation. This systematic review aims to assess the extent of NIPT introduction into national screening programmes for DS worldwide, its uptake, and impact on pregnancy outcomes. METHODS AND FINDINGS: The study protocol was published in PROSPERO (CRD42022306167). We systematically searched MEDLINE, CINAHL, Scopus, and Embase for population-based studies, government guidelines, and Public Health documents from 2010 onwards. Results summarised the national policies for NIPT implementation into screening programmes geographically, along with population uptake. Meta-analyses estimated the pooled proportions of women choosing invasive prenatal diagnosis (IPD) following a high chance biochemical screening result, before and after NIPT was introduced. Additionally, we meta-analysed outcomes (termination of pregnancy and live births) amongst high chance pregnancies identified by NIPT. Results demonstrated NIPT implementation in at least 27 countries. Uptake of second line NIPT varied, from 20.4% to 93.2% (n = 6). Following NIPT implementation, the proportion of women choosing IPD after high chance biochemical screening decreased from 75% (95% CI 53%, 88%, n = 5) to 43% (95%CI 31%, 56%, n = 5), an absolute risk reduction of 38%. A pooled estimate of 69% (95% CI 52%, 82%, n = 7) of high chance pregnancies after NIPT resulted in termination, whilst 8% (95% CI 3%, 21%, n = 7) had live births of babies with DS. CONCLUSIONS: NIPT has rapidly gained global acceptance, but population uptake is influenced by healthcare structures, historical screening practices, and cultural factors. Our findings indicate a reduction in IPD tests following NIPT implementation, but limited pre-NIPT data hinder comprehensive impact assessment. Transparent, comparable data reporting is vital for monitoring NIPT's potential consequences.

Evaluation of the impacts of road runoff in a Mediterranean reservoir in Portugal.

Road runoff is a linear diffuse source of pollution, with very specific characteristics. This study intends to improve the understanding of road runoff impacts in water bodies in Portugal. The chosen case study is S. Domingos reservoir catchment. The study analyzed land uses, the presence of pollution sources, and gathered temporal water quality data and performed site measurements and sample collection. The water quality data for the reservoir was provided by the national water quality monitoring system from the Portuguese Water Institute. The parameters selected were TSS, COD, NO3 (-), Cl(-), and Cu. The results obtained revealed that the presence of IP6 highway at S. Domingos catchment affects the water quality; however, the impacts are not significant due to the high dilution effect of the reservoir volume. Agriculture, the main land use of the catchment, is responsible for introducing pollutants such as TSS, Cl(-), COD, N, and P in the local water streams and at the reservoir. TSS, COD, and Cu are pollutants generated by the road. The success of the study was very much dependent on the availability of 12 years of historic water quality data for S. Domingos reservoir, and the use of the moving average method. Taking into consideration the high variability of hydrological variables in Mediterranean climates, the concentration of pollutants in the water bodies must always be assessed in a significant time period.

Identifying multimorbidity clusters in an unselected population of hospitalised patients.

Multimorbidity (multiple coexisting chronic health conditions) is common and increasing worldwide, and makes care challenging for both patients and healthcare systems. To ensure care is patient-centred rather than specialty-centred, it is important to know which conditions commonly occur together and identify the corresponding patient profile. To date, no studies have described multimorbidity clusters within an unselected hospital population. Our aim was to identify and characterise multimorbidity clusters, in a large, unselected hospitalised patient population. Linked inpatient hospital episode data were used to identify adults admitted to hospital in Grampian, Scotland in 2014 who had ≥ 2 of 30 chronic conditions diagnosed in the 5 years prior. Cluster analysis (Gower distance and Partitioning around Medoids) was used to identify groups of patients with similar conditions. Clusters of conditions were defined based on clinical review and assessment of prevalence within patient groups and labelled according to the most prevalent condition. Patient profiles for each group were described by age, sex, admission type, deprivation and urban-rural area of residence. 11,389 of 41,545 hospitalised patients (27%) had ≥ 2 conditions. Ten clusters of conditions were identified: hypertension; asthma; alcohol misuse; chronic kidney disease and diabetes; chronic kidney disease; chronic pain; cancer; chronic heart failure; diabetes; hypothyroidism. Age ranged from 51 (alcohol misuse) to 79 (chronic heart failure). Women were a higher proportion in the chronic pain and hypothyroidism clusters. The proportion of patients from the most deprived quintile of the population ranged from 6% (hypertension) to 14% (alcohol misuse). Identifying clusters of conditions in hospital patients is a first step towards identifying opportunities to target patient-centred care towards people with unmet needs, leading to improved outcomes and increased efficiency. Here we have demonstrated the face validity of cluster analysis as an exploratory method for identifying clusters of conditions in hospitalised patients with multimorbidity.

Evaluating sources of PAHs in urban streams based on land use and biomonitors.

Toxic polycyclic aromatic hydrocarbons (PAHs) can be found in wastewaters and sewages released from industries and/or urban areas. When discharged untreated to stream waters, they can be a problem to human health. This work represents the first attempt to use PAH and metal concentrations in aquatic moss transplants together with land-use information to identify water pollution sources in urban areas. To do this, the moss Fontinalis antipyretica was collected from a natural stream and transplanted to four different streams in a densely populated area of Lisbon, Portugal. After three months of exposure, mosses were collected and analyzed for metals and for the 16 priority PAHs recommended by the U.S. EPA. Urban streams seem to have a scattered contamination of 6-ring PAHs. Correlations among land-use, metal concentrations, and PAH concentrations indicated that areas occupied by activities of tertiary and industrial sectors had higher PAH concentrations in transplanted mosses, mainly for the sum of the 16 EPA-PAHs and for the 2-, 3- and 5-ringed PAHs, than areas occupied by urban and wooded areas. These PAHs were associated with enhanced Zn and Cu and land use activities that linked the sites to high traffic density. Industrial land use influences PAH concentration in water up to 1000 m of distance from the stream, whereas tertiary sector land use influences it up to 500 m.

Perspective: Application of N-of-1 Methods in Personalized Nutrition Research.

Personalized and precision nutrition aim to examine and improve health on an individual level, and this requires reconsideration of traditional dietary interventions or behavioral study designs. The limited frequency of measurements in group-level human nutrition trials cannot be used to infer individual responses to interventions, while in behavioral studies, retrospective data collection does not provide an accurate measure of how everyday behaviors affect individual health. This review introduces the concept of N-of-1 study designs, which involve the repeated measurement of a health outcome or behavior on an individual level. Observational designs can be used to monitor a participant's usual health or behavior in a naturalistic setting, with repeated measurements conducted in real time using an Ecological Momentary Assessment. Interventional designs can introduce a dietary or behavioral intervention with predictors and outcomes of interest measured repeatedly either during or after 1 or more intervention and control periods. Due to their flexibility, N-of-1 designs can be applied to both short-term physiological studies and longer-term studies of eating behaviors. As a growing number of disease markers can be measured outside of the clinic, with self-reported data delivered via electronic devices, it is now easier than ever to generate large amounts of data on an individual level. Statistical techniques can be utilized to analyze changes in an individual or to aggregate data from sets of N-of-1 trials, enabling hypotheses to be tested on a small number of heterogeneous individuals. Although their designs necessitate extra methodological and statistical considerations, N-of-1 studies could be used to investigate complex research questions and to study underrepresented groups. This may help to reveal novel associations between participant characteristics and health outcomes, with repeated measures providing power and precision to accurately determine an individual's health status.

Analysing N-of-1 observational data in health psychology and behavioural medicine: a 10-step SPSS tutorial for beginners.

Background: N-of-1 observational studies can be used to describe natural intra-individual changes in health-related behaviours or symptoms over time, to test behavioural theories and to develop highly personalised health interventions. To date, N-of-1 observational methods have been under-used in health psychology and behavioural medicine. One reason for this may be the perceived complexity of statistical analysis of N-of-1 data. Objective: This tutorial paper describes a 10-step procedure for the analysis of N-of-1 observational data using dynamic regression modelling in SPSS for researchers, students and clinicians who are new to this area. The 10-step procedure is illustrated using real data from an N-of-1 observational study exploring the relationship between pain and physical activity. Conclusion: The availability of a user-friendly and robust statistical technique for the analysis of N-of-1 data using SPSS may foster increased awareness, knowledge and skills and establish N-of-1 designs as a useful methodological tool in health psychology and behavioural medicine.

Mortality factors in infants with congenital diaphragmatic hernia: A systematic review.

BACKGROUND: Congenital diaphragmatic hernia (CDH) is a malformation of the diaphragm accounting for 8% of all major congenital anomalies. Although many clinical factors of survival in children with CDH have been established, limited research exists on the role of sociodemographic and other factors. We aimed to systematically identify and summarize all available international literature, published from January 2000 to July 2017, evaluating specific mortality factors for children with prenatally diagnosed, isolated, left-sided CDH. METHODS: MEDLINE, PROSPERO, EMBASE, Scopus, The Cochrane Library databases, and the table of contents for the past 5 years for relevant journals were searched systematically. The risk factors of interest were as follows: birth weight, gestational age (GA) at diagnosis, GA at birth, infant sex, maternal age, ethnicity, socioeconomic status (SES), and plurality. The primary outcome measure was survival. Data were extracted on study design, study quality, participant data, and survival-related effect estimates. RESULTS: Seven studies fulfilled the inclusion criteria. In total, 347 children were included in the review. Birth weight, GA at diagnosis, and GA at birth were evaluated in five studies each, infant sex in two, and maternal age in one. None of these factors were significantly associated with survival. No studies evaluated the influence of plurality, ethnicity or SES. CONCLUSION: Although the factors of interest showed no significant association with survival, more evidence is required to confirm these findings. Understanding whether sociodemographic factors are associated with survival may help inform the development of public health interventions to improve survival rates for children with CDH.

Understanding and predicting a complex behavior using n-of-1 methods: Photoprotection in xeroderma pigmentosum.

OBJECTIVE: Xeroderma pigmentosum (XP) is a very rare inherited disease; the most important aspect of clinical management is rigorous photoprotection from ultraviolet radiation. The aims of this novel study were to (a) understand and categorize the behavioral complexity and within-participant variability in photoprotection of the face in XP; (b) determine the predictors of photoprotection; and (c) identify individual needs for personalized interventions. METHOD: A total of 20 adults with XP completed an ecological momentary assessment (EMA) study over 50 days. Measures included an ultraviolet radiation diary of photoprotective behaviors used at each outdoor occasion (e.g., hat, face visor, sunscreen), and a mobile phone survey assessing self-reported protection (0-100), satisfaction with protection achieved, and predictive variables (e.g., motivation, effort, mood). Descriptive statistics for photoprotective behavior were computed, per person. When possible, individual dynamic logistic regression models were used to investigate the predictors of photoprotection, and correspondence between self-reported protection and behavior. RESULTS: Photoprotection (clothing and sunscreen) was suboptimal for most participants, and discrepancies between self-reported protection and behavior were identified. Modeling of photoprotection was conducted for six participants who went outside sufficient times and used varied protection. Different predictors were identified across participants. Weekend versus weekday, physical symptoms, stress, and feeling self-conscious were most frequently associated with protection. CONCLUSION: The findings support the need for intervention and have implications for the selection of individually tailored behavioral outcomes and intervention targets to improve photoprotection. The method of profiling multiple preventive behaviors using EMA may be of use in other rare conditions involving complex behaviors. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Self-taken vaginal swabs versus clinician-taken for detection of candida and bacterial vaginosis: a case-control study in primary care.

BACKGROUND: Vaginal discharge and vulvitis are common presenting symptoms in general practice. Few studies have specifically looked at the validity of self-taken low vulvovaginal swabs (LVS) for the diagnosis of vulvovaginal candidiasis (VVC) and bacterial vaginosis (BV). AIM: To assess if patient self-taken LVS are a valid alternative to clinician-taken high vaginal swabs (HVS) for the detection of VVC and BV. DESIGN AND SETTING: Case-control study with the patient acting as their own control in an urban sexual health centre in Newcastle upon Tyne, UK. METHOD: Females aged 16-65 years attending with symptomatic vaginal discharge, vulval irritation, genital pain, and an offensive genital smell were recruited into the study. Participants took a self-taken LVS before vaginal examination, during which a clinician took an HVS (reference standard). Main outcome measures were the diagnosis of BV or VVC infection. RESULTS: A total of 104 females were enrolled. Of those, 45 were diagnosed with VVC and 26 with BV. The sensitivities of self-taken LVS for VVC and BV were 95.5% and 88.5% respectively. Cohen's κ coefficient showed 'strong agreement' for the detection of both VVC and BV. Vulval itching was the most common symptom associated with VVC (69%), whereas 50% of females diagnosed with BV presented with an offensive discharge. Both symptoms had poor positive predictive values (0.63 and 0.50, respectively). CONCLUSION: Self-taken LVS appears to be a valid alternative to clinician-taken HVS for detecting VVC and BV infections. Symptoms were found to be a poor indicator of underlying infection.

Dynamic modelling of n-of-1 data: powerful and flexible data analytics applied to individualised studies.

N-of-1 studies are based on repeated observations within an individual or unit over time and are acknowledged as an important research method for generating scientific evidence about the health or behaviour of an individual. Statistical analyses of n-of-1 data require accurate modelling of the outcome while accounting for its distribution, time-related trend and error structures (e.g., autocorrelation) as well as reporting readily usable contextualised effect sizes for decision-making. A number of statistical approaches have been documented but no consensus exists on which method is most appropriate for which type of n-of-1 design. We discuss the statistical considerations for analysing n-of-1 studies and briefly review some currently used methodologies. We describe dynamic regression modelling as a flexible and powerful approach, adaptable to different types of outcomes and capable of dealing with the different challenges inherent to n-of-1 statistical modelling. Dynamic modelling borrows ideas from longitudinal and event history methodologies which explicitly incorporate the role of time and the influence of past on future. We also present an illustrative example of the use of dynamic regression on monitoring physical activity during the retirement transition. Dynamic modelling has the potential to expand researchers' access to robust and user-friendly statistical methods for individualised studies.

The state of the art and future opportunities for using longitudinal n-of-1 methods in health behaviour research: a systematic literature overview.

n-of-1 studies test hypotheses within individuals based on repeated measurement of variables within the individual over time. Intra-individual effects may differ from those found in between-participant studies. Using examples from a systematic review of n-of-1 studies in health behaviour research, this article provides a state of the art overview of the use of n-of-1 methods, organised according to key methodological considerations related to n-of-1 design and analysis, and describes future challenges and opportunities. A comprehensive search strategy (PROSPERO:CRD42014007258) was used to identify articles published between 2000 and 2016, reporting observational or interventional n-of-1 studies with health behaviour outcomes. Thirty-nine articles were identified which reported on n-of-1 observational designs and a range of n-of-1 interventional designs, including AB, ABA, ABABA, alternating treatments, n-of-1 randomised controlled trial, multiple baseline and changing criterion designs. Behaviours measured included treatment adherence, physical activity, drug/alcohol use, sleep, smoking and eating behaviour. Descriptive, visual or statistical analyses were used. We identify scope and opportunities for using n-of-1 methods to answer key questions in health behaviour research. n-of-1 methods provide the tools needed to help advance theoretical knowledge and personalise/tailor health behaviour interventions to individuals.

Cataract surgery in patients with late-onset retinal degeneration.

PURPOSE: To review the outcomes in a series of patients with long anterior lens zonular fibers associated with late-onset retinal degeneration who had phacoemulsification cataract surgery. SETTING: Newcastle Eye Centre, Newcastle upon Tyne, United Kingdom. DESIGN: Retrospective case series. METHODS: Inclusion criteria were patients with genetically confirmed late-onset retinal degeneration requiring cataract surgery. Perioperative data relating to surgery were collected. In addition, the corrected distance visual acuity (CDVA) and retinal imaging data were recorded. Selected lens capsules were examined using immunohistochemistry or scanning electron microscopy (SEM). RESULTS: Eleven eyes of 7 patients were included. The long anterior lens zonular fibers made capsulorhexis challenging; however, it was completed safely in all cases. There were no intraoperative or postoperative issues with lens stability. The CDVA improved postoperatively in those cases with intact foveal photoreceptors and retinal pigment epithelium. Over the longer term, the CDVA slowly declined because of progressive atrophy of the macula. Most patients noticed a subjective improvement in vision, even those with advanced disease at baseline. Immunohistochemistry showed that the C1QTNF5 protein was expressed within the lens capsule epithelial cells, although SEM of the long anterior lens zonular fibers showed them to be smaller in diameter than normal anterior lens zonular fibers and to be composed of a helix of fibers. CONCLUSIONS: In this small series of patients with late-onset retinal degeneration, cataract surgery was successfully performed without long-term complications involving intraocular lens stability. The objective improvement in CDVA seemed to be limited to patients with good foveal photoreceptor architecture.