Help seeking by male victims of domestic violence and abuse: an example of an integrated mixed methods synthesis of systematic review evidence defining methodological terms.

BACKGROUND: Domestic violence and abuse is a violation of human rights which damages the health and wellbeing of victims, their families and their friends. There has been less research on the experiences and support needs of male victims than those of women. Historically research on men's experiences has not focused on what constitutes effective, needs-led service provision. The aim of this paper was to conduct an integrated mixed methods synthesis of systematic review evidence on the topic of help-seeking by male victims of domestic violence and abuse. METHODS: An integrated mixed methods synthesis approach was taken to enhance our understanding of the complex phenomenon of help seeking by, and service provision to male victims. This process also identifies gaps in the evidence. Using previously identified systematic review data; mixed methods data from four primary-level service evaluation studies, along with expert and patient consultation were used to develop research propositions. Primary-level qualitative interview and survey data from 12 studies of men experiences were mapped onto the propositions to support them. RESULTS: Fourteen propositions were composed. Seven propositions were supported or at least partly supported by the qualitative data. These supported propositions were used to make recommendations for policy and practice particularly concerning service preferences of male victims. The remaining seven propositions were not specifically supported by the qualitative data. These unsupported propositions were used to develop research recommendations concerning the need to further understand the potential blurred boundaries of victim-perpetrator, hybrid perpetrator-victim experiences, men who are/have been victims of childhood sexual abuse and determining the level of risk for men. They also highlight the need to produce better guidance for the response of the police & the criminal justice system. Finally, they highlight the need to produce the most appropriate service for men in terms of access, linkage, substance/alcohol abuse, mental health, sexuality, and race. CONCLUSION: Integrated mixed-methods synthesis of systematic review evidence is a relatively novel approach. This approach can lead to recommendations for policy and practice as well as highlighting gaps in the research agenda as shown in this example.

Methodological exemplar of integrating quantitative and qualitative evidence - supportive care for men with prostate cancer: what are the most important components?

AIMS: To present a methodological exemplar of integrating findings from a quantitative and qualitative review on the same topic to provide insight into components of care that contribute to supportive care that is acceptable to men with prostate cancer. BACKGROUND: Men with prostate cancer are likely to live a long time with the disease, experience side effects from treatment and therefore have ongoing supportive care needs. Quantitative and qualitative reviews have been published but the findings have yet to be integrated. DESIGN: Integration of quantitative and qualitative synthesized evidence. DATA SOURCE: Two previously published systematic reviews. REVIEW METHODS: Synthesized evidence on supportive care for men with prostate cancer was integrated from two previously published systematic reviews: a narrative quantitative review and a qualitative review with thematic synthesis. These two streams of synthesized evidence were synthesized using concurrent narrative summary. Data from both reviews were used to develop a set of propositions from which a summary of components of care that likely to contribute to supportive care acceptable to men with prostate cancer were identified. RESULTS: Nine propositions were developed which covered men's supportive care focusing on the role of health professionals. These propositions were used to compose nine components of care likely to lead to supportive care that is acceptable to men with prostate cancer. Some of these components are no/low cost such as developing a more empathic personalized approach, but more specific approaches need further investigation in randomized controlled trials, for example, online support. CONCLUSION: This methodological exemplar demonstrates the integration of quantitative and qualitative synthesized data to determine components of care likely to lead to provision of supportive care acceptable to men with prostate cancer.

Pharmacist-led interventions to reduce unplanned admissions for older people: a systematic review and meta-analysis of randomised controlled trials.

PURPOSE: medication problems are thought to cause between 10 and 30% of all hospital admissions in older people. This systematic review aimed to evaluate the effectiveness of interventions led by hospital or community pharmacists in reducing unplanned hospital admissions for older people. METHODS: eighteen databases were searched with a customised search strategy. Relevant websites and reference lists of included trials were checked. Randomised controlled trials were included that evaluated pharmacist-led interventions compared with usual care, with unplanned admissions or readmissions as an outcome. Two authors independently extracted data and assessed methodological quality. RESULTS: twenty-seven randomised controlled trials (RCTs) were identified; seven trials were excluded. The 20 included trials comprised 16 for older people and 4 for older people with heart failure. Interventions led by hospital pharmacists (seven trials) or community pharmacists (nine trials) did not reduce unplanned admissions in the older population (risk ratios 0.97 95% CI: 0.88, 1.07; 1.07 95% CI: 0.96, 1.20). Three trials in older people with heart failure showed that interventions delivered by a hospital pharmacist reduced the relative risk of admissions. However, these trials were heterogeneous in intensity and duration of follow-up. One trial had a high risk of bias. CONCLUSIONS: evidence from three randomised controlled trials suggests that interventions led by hospital pharmacists reduce unplanned hospital admissions in older patients with heart failure, although these trials were heterogeneous. Data from 16 trials do not support the concept that interventions led by hospital or community pharmacists for the general older population reduces unplanned admissions.

Understanding non-recreational prescription medication-sharing behaviours: a systematic review.

BACKGROUND: Prescription medication sharing refers to the lending or borrowing of prescription medications where the recipient is someone other than the person for whom the prescription is intended. Sharing prescription medication can cause significant harm. Adverse consequences include an increased risk of side effects, delayed health seeking, and severity of disease. Prevalence estimates vary across different populations and people's reasons for, and perceptions of risks from, sharing are poorly understood. AIM: To better understand prescription medication-sharing behaviours and practices - specifically, the prevalence, types of medications, reasons, perceived benefits and risks, and factors associated with medication sharing. DESIGN AND SETTING: This systematic review included primary studies in any setting, focusing on people who engage in medication sharing. METHOD: Electronic databases were searched from inception of databases to February 2023. RESULTS: In total, 19 studies were included. Prevalence of lifetime sharing ranged from 13% to 78%. All 19 studies reported that analgesics were the most shared, followed by antibiotics (n = 12) and allergy medication (n = 9). Common reasons for sharing were running out of medication (n = 7), cost (n = 7), and emergency (n = 6). Perceived benefits included resolution of the problem and convenience. Perceived risks included adverse drug reactions and misdiagnosis. Characteristics associated with sharing included age, female sex, having asthma, and unused medicines stored at home. CONCLUSION: Findings suggest that medication-sharing behaviour is common and involves a range of medicines for a variety of reasons. Data on the prevalence and predictors of prescription medication sharing are inconsistent. A better understanding of non-modifiable and potentially modifiable behavioural factors that contribute to sharing is needed to support development of effective interventions aimed at mitigating unsafe sharing practices.

Pre-existing musculoskeletal pain and its association with mortality in newly diagnosed co-morbid conditions: an electronic health record cohort study.

Objective: Musculoskeletal pain is a common risk factor for co-morbid conditions and might increase the risk of poor outcomes. The objective was to determine whether patients with pre-existing musculoskeletal pain have an increased risk for mortality following a new diagnosis of a co-morbid condition. Methods: Patients aged ≥45 years with a new diagnosis of acute coronary syndrome (ACS), stroke, cancer, dementia or pneumonia recorded in a UK electronic primary care database linked to hospital and mortality records were examined. The association of mortality with musculoskeletal pain (inflammatory conditions, OA and regional pain) was determined. Results: The sample size varied from 128 649 (stroke) to 406 289 (cancer) by cohort, with 22-31% having pre-existing musculoskeletal conditions. In the ACS cohort, there was a higher rate of mortality for all musculoskeletal types. There were also higher unadjusted mortality rates in patients with inflammatory arthritis compared with those without musculoskeletal pain in the stroke, cancer and dementia cohorts and for patients with OA in the stroke and cancer cohorts. After adjustment for the number of prescribed medications and age, the increased risk of mortality remained only for patients with inflammatory arthritis in the ACS cohort (adjusted hazard ratio = 1.07; 95% CI 1.03, 1.10). Conclusion: Older adults with inflammatory arthritis and OA have increased risk of mortality when they develop a new condition, which seems to be related to the prescription of multiple medicines. Pre-existing musculoskeletal pain is an indicator of a complex patient who is at risk of poorer outcomes at the onset of new illnesses.

Is case management effective in reducing the risk of unplanned hospital admissions for older people? A systematic review and meta-analysis.

BACKGROUND: Case management is a collaborative practice involving coordination of care by a range of health professionals, both within the community and at the interface of primary and secondary care. It has been promoted as a way of reducing unplanned admissions in older people. OBJECTIVE: The objective was to systematically review evidence from randomized controlled trials regarding the effectiveness of case management in reducing the risk of unplanned hospital admissions in older people. METHODS: Eighteen databases were searched from inception to June 2010. Relevant websites were searched with key words and reference lists of included studies checked. A risk-of-bias tool was used to assess included studies and data extraction performed using customized tables. The primary outcome of interest was enumeration of unplanned hospital admission or readmissions. RESULTS: Eleven trials of case management in the older population were included. Risk of bias was generally low. Six were trials of hospital-initiated case management. Three were suitable for meta-analysis, of which two showed a reduction in unplanned admissions. Overall, there was no statistically significant reduction in unplanned admissions [relative rate: 0.71 (95% confidence interval, CI: 0.49 to 1.03)]. Three trials reported reduced length of stay. Five trials were of community-initiated case management. None showed a reduction in unplanned admissions. Three were suitable for meta-analysis [mean difference in unplanned admissions: 0.05 (95% CI: -0.04 to 0.15)]. CONCLUSIONS: The identified trials included a range of case management interventions. Nine of the 11 trials showed no reduction of unplanned hospital admissions with case management compared with the same with usual care.

Estimating the direct healthcare utilization and cost of musculoskeletal pain among people with comorbidity: a retrospective electronic health record study.

OBJECTIVE: To investigate the impact of pre-existing painful musculoskeletal conditions on healthcare utilization and costs among patients with five common conditions: acute coronary syndrome (ACS), stroke, cancer, dementia and pneumonia. METHODS: Using primary and secondary care services data from electronic health records, a negative binomial regression model was used to compare resource use while a two-part model was used to compare costs across the five conditions, between those with and without a pre-existing musculoskeletal pain. RESULTS: The study included 760,792 patients (144,870 with ACS, 121,208 with stroke, 231,702 with cancer, 134,638 with dementia, and 128,374 with pneumonia) in the complete case analysis. Pre-existing musculoskeletal pain had an incident rate ratio of above one for most healthcare resources over the follow-up period and an adjusted additional mean cumulative total healthcare costs per patient of £674.59 (95%CI 570.30 to 778.87) for ACS; £613.34 (95%CI 496.87 to 729.82) for stroke; £459.26 (95%CI 376.60 to 541.91) for cancer; and £766.23 (95%CI 655.06 to 877.39) for dementia over five years after diagnosis; and £200.85 (95%CI 104.16 to 297.55) for pneumonia over one year after diagnosis compared to those without musculoskeletal pain. CONCLUSION: This study highlights that individuals with painful musculoskeletal conditions have higher healthcare utiliszation and costs than those without painful musculoskeletal conditions. Given the high occurrence of musculoskeletal pain in patients with other conditions, effective management strategies are needed to reduce the burden on healthcare resources.

Musculoskeletal pain and its impact on prognosis following acute coronary syndrome or stroke: A linked electronic health record cohort study.

OBJECTIVE: Musculoskeletal painful conditions are a risk factor for cardiovascular disease (CVD), but less is known about whether musculoskeletal pain also worsens prognosis from CVD. The objective was to determine whether patients with musculoskeletal pain have poorer prognosis following acute coronary syndrome (ACS) or stroke. METHODS: The study utilised UK electronic primary care records (CPRD Aurum) with linkage to hospital and mortality records. Patients aged ≥45 years admitted to hospital with incident ACS/stroke were categorised by healthcare use for musculoskeletal pain (inflammatory conditions, osteoarthritis [OA], and regional pain) based on primary care consultations in the prior 24 months. Outcomes included mortality, length of stay, readmission and management of index condition (ACS/stroke). RESULTS: There were 171,670 patients with incident ACS and 138,512 with stroke; 30% consulted for musculoskeletal pain prior to ACS/stroke and these patients had more comorbidity than those without musculoskeletal pain. Rates of mortality and readmission, and length of stay were higher in those with musculoskeletal pain, particularly OA and inflammatory conditions, in ACS. Readmission was also higher for patients with musculoskeletal pain in stroke. However, increased risks associated with musculoskeletal pain did not remain after adjustment for age and polypharmacy. Inflammatory conditions were associated with increased likelihood of prescriptions for dual anti-platelets (ACS only) and anti-coagulants. CONCLUSIONS: Patients with musculoskeletal pain have higher rates of poor outcome from ACS which relates to being older but also increased polypharmacy. The high rates of comorbidity including polypharmacy highlight the complexity of patients with musculoskeletal pain who have new onset ACS/stroke.

Group psychological therapies for depression in the community: systematic review and meta-analysis.

BACKGROUND: Psychological therapies have been shown to be effective in the treatment of depression. However, evidence is focused on individually delivered therapies, with less evidence for group-based therapies. AIMS: To conduct a systematic review and meta-analysis of the efficacy of group-based psychological therapies for depression in primary care and the community. METHOD: We searched MEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled Trials and the Cochrane Collaboration Depression, Anxiety and Neurosis Review Group database from inception to July 2010. The Cochrane risk of bias methodology was applied. RESULTS: Twenty-three studies were included. The majority showed considerable risk of bias. Analysis of group cognitive-behavioural therapy (CBT) v. usual care alone (14 studies) showed a significant effect in favour of group CBT immediately post-treatment (standardised mean difference (SMD) -0.55 (95% CI -0.78 to -0.32)). There was some evidence of benefit being maintained at short-term (SMD = -0.47 (95% CI -1.06 to 0.12)) and medium- to long-term follow-up (SMD = -0.47 (95% CI - 0.87 to -0.08)). Studies of group CBT v. individually delivered CBT therapy (7 studies) showed a moderate treatment effect in favour of individually delivered CBT immediately post-treatment (SMD = 0.38 (95% CI 0.09-0.66)) but no evidence of difference at short- or medium- to long-term follow-up. Four studies described comparisons for three other types of group psychological therapies. CONCLUSIONS: Group CBT confers benefit for individuals who are clinically depressed over that of usual care alone. Individually delivered CBT is more effective than group CBT immediately following treatment but after 3 months there is no evidence of difference. The quality of evidence is poor. Evidence about group psychological therapies not based on CBT is particularly limited.

Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide.

PURPOSE: Many patients consulting in primary care have multiple conditions (multimorbidity). Aims of this review were to identify measures of multimorbidity and morbidity burden suitable for use in research in primary care and community populations, and to investigate their validity in relation to anticipated associations with patient characteristics, process measures, and health outcomes. METHODS: Studies were identified using searches in MEDLINE and EMBASE from inception to December 2009 and bibliographies. RESULTS: Included were 194 articles describing 17 different measures. Commonly used measures included disease counts (n = 98), Chronic Disease Score (CDS)/RxRisk (n = 17), Adjusted Clinical Groups (ACG) System (n = 25), the Charlson index (n = 38), the Cumulative Index Illness Rating Scale (CIRS; n = 10) and the Duke Severity of Illness Checklist (DUSOI; n = 6). Studies that compared measures suggest their predictive validity for the same outcome differs only slightly. Evidence is strongest for the ACG System, Charlson index, or disease counts in relation to care utilization; for the ACG System in relation to costs; for Charlson index in relation to mortality; and for disease counts or Charlson index in relation to quality of life. Simple counts of diseases or medications perform almost as well as complex measures in predicting most outcomes. Combining measures can improve validity. CONCLUSIONS: The measures most commonly used in primary care and community settings are disease counts, Charlson index, ACG System, CIRS, CDS, and DUSOI. Different measures are most appropriate according to the outcome of interest. Choice of measure will also depend on the type of data available. More research is needed to directly compare performance of different measures.

A pilot study of the mistletoe and breast cancer (MAB) trial: a protocol for a randomised double-blind controlled trial.

BACKGROUND: A Cochrane review of mistletoe therapy concludes that there is some evidence that mistletoe extracts may offer benefits on measures of quality of life during chemotherapy for breast cancer, but these results need replication. Our aim is to add to this evidence base by initially testing the feasibility of a UK pilot placebo-controlled, double-blind randomised controlled trial of mistletoe therapy in patients with breast cancer undergoing chemotherapy with or without radiotherapy. METHODS/DESIGN: A mixed phase pilot placebo-controlled, double-blind randomised controlled trial of mistletoe therapy in patients with breast cancer (EudraCT number: 2018-000279-34). There will be three arms (groups) in the trial: Iscador M, Iscador P, with physiological saline as the placebo. The aim is to recruit 45 adult patients with a new diagnosis of early or locally advanced breast cancer, up to 12 weeks following definitive breast surgery whose standard treatment plan includes chemotherapy with or without radiotherapy. They will be taught to administer the mistletoe and breast cancer (MAB) therapies subcutaneously. MAB therapy will continue throughout their standard chemotherapy and radiotherapy and 1 month beyond. The main outcome of the MAB study is the feasibility of conducting such a trial within the NHS in order to inform a future fully powered investigative trial. Feasibility will be measured through recruitment, retention and patient experience using clinical research forms, patient diaries, cancer-related questionnaires and qualitative interviews conducted with both patients and oncology staff. DISCUSSION: This trial is the first of its kind in the UK. Currently, mistletoe therapy is mostly available through private practice in the UK. Completion of this feasibility study will support applications for further funding for a fully powered randomised controlled trial which will measure effectiveness and cost-effectiveness of this herbal therapy.

Nocturia and Chronic Kidney Disease: Systematic Review and Nominal Group Technique Consensus on Primary Care Assessment and Treatment.

CONTEXT: Reduced renal function impairs salt and water homeostasis, which can drive nocturnal or 24-h polyuria. Nocturia can arise early in chronic kidney disease (CKD). Evidence-based recommendations can facilitate management outside nephrology clinics. OBJECTIVE: To conduct a systematic review (SR) of nocturia in CKD and achieve expert consensus for management in primary care and in specialist clinics outside nephrology. EVIDENCE ACQUISITION: Four databases were searched from January 2000 to April 2020. A total of 4011 titles and abstracts were screened, and 108 studies underwent full-text screening. Seven studies met the inclusion criteria and two were identified through other sources. Consensus was achieved among an expert panel with public involvement using the nominal group technique (NGT). EVIDENCE SYNTHESIS: Several plausible mechanisms contribute to nocturnal or 24-h polyuria in CKD, but there is little evidence on interventions to improve nocturia. NGT assessment recommendations for nocturia (at least two voids per night) in patients with CKD or at risk of CKD being assessed in a non-nephrology setting are: history (thirst, fluid intake), medication review (diuretics, lithium, calcium channel antagonists, nonsteroidal anti-inflammatory medications), examination (oedematous state, blood pressure), urinalysis (haematuria and albumin/creatinine ratio), blood tests (blood urea, serum creatinine and electrolytes, estimated glomerular filtration rate), and a bladder diary. Renal ultrasound should follow local CKD guidelines. Treatment options include optimising blood pressure control, dietary adjustment to reduce salt intake, fluid advice, and a medication review. Referral to specialist nephrology services should follow local guidelines. CONCLUSIONS: CKD should be considered when evaluating patients with nocturia. The aim of assessment is to identify mechanisms and instigate therapy, but the latter may be more applicable to reducing wider morbidity associated with CKD than nocturia itself. PATIENT SUMMARY: People with kidney disease can suffer severe sleep disturbance because of a need to pass urine overnight. We looked at published research and found some useful information about the underlying mechanisms. A group of experts was able to develop practical approaches for assessing and treating this condition.

Association of Sleep Disorders with Nocturia: A Systematic Review and Nominal Group Technique Consensus on Primary Care Assessment and Treatment.

CONTEXT: Sleep disorders affect responsiveness to sensory information and can cause nocturnal polyuria and reduced sleep depth; hence, these are potentially influential in understanding the mechanism of nocturia. OBJECTIVE: To report the systematic review (SR) and expert consensus for primary care management of nocturia in sleep disorders. EVIDENCE ACQUISITION: Four databases were searched from January to April 2020. A total of 1658 titles and abstracts were screened, and 23 studies potentially applicable were included for full-text screening. The nominal group technique (NGT) was used to derive a consensus on recommendations for management using an expert panel with public involvement. EVIDENCE SYNTHESIS: Thirteen studies met the SR inclusion criteria, all of which studied obstructive sleep apnoea (OSA), with ten evaluating the effect of continuous positive airway pressure. The NGT consensus discussed the assessment of OSA with other key sleep disorders, notably insomnia, restless legs syndrome/periodic limb movements of sleep, and parasomnias, including non-rapid eye movement (non-REM) parasomnias and REM sleep behaviour disorder (RBD). The NGT considered that the use of screening questions to reach a clinical diagnosis is a sufficient basis for offering conservative therapy within primary care. Reasons for referral to a sleep clinic are suspected sleep disorder with substantially impaired daytime function despite conservative treatment. Suspected RBD should be referred, and if confirmed, neurology opinion is indicated. Referrals should follow local guidelines. Persisting nocturia is not currently considered an indication for referral to a sleep clinic. CONCLUSIONS: Sleep disorders are potentially highly influential in nocturia, but are often overlooked. PATIENT SUMMARY: People with sleep disorders can experience nocturia due to easy waking or increased bladder filling. We looked at published research, and information was limited to one form of sleep disturbance-obstructive sleep apnoea. We assembled a group of experts, to develop practical approaches for assessing and treating nocturia in the potentially relevant sleep disorders.

Assessment and Treatment of Nocturia in Neurological Disease in a Primary Care Setting: Systematic Review and Nominal Group Technique Consensus.

CONTEXT: Neurological disease can affect the rate of urine production and bladder storage function, increasing nocturia severity, with additional risks if mobility or cognition is impaired. OBJECTIVE: To conduct a systematic review (SR) of nocturia in neurological diseases and achieve expert consensus for management in clinics without neurologist input. EVIDENCE ACQUISITION: Four databases were searched from January 2000 to April 2020. A total of 6262 titles and abstracts were screened and 43 studies were included for full-text screening. Eleven of these met the inclusion criteria and two studies were identified through other sources. The nominal group technique (NGT) was used to develop consensus in panel comprising experts and public representation. EVIDENCE SYNTHESIS: Thirteen studies (seven in Parkinson's disease, five in multiple sclerosis) were included, all undertaken in secondary care. Neurological disease severity was incompletely described, and nocturia severity was generally measured subjectively. NGT consensus supported basic neurological assessment, and the use of bladder diaries where neurological impairment permits. Treatments include pelvic-floor muscle training, review of medications, risk mitigation, improving bowel function, therapy for overactive bladder syndrome (if urgency is reported in association with nocturia episodes), treatment of postvoid residual and desmopressin according to licence. Measures to improve mobility and mitigate risk when using the toilet overnight should be considered. Multifactorial issues such as obstructive sleep apnoea and hypoventilation must be considered. CONCLUSIONS: Nocturia in neurological disease is complex and lacks a robust evidence base, with very little research done in the primary care context. Guidance should be pragmatic, with reduction of risk a key requirement, until a multidisciplinary evidence base can be developed. PATIENT SUMMARY: People with a neurological disease can suffer severe sleep disturbance because of the need to pass urine several times overnight (called nocturia). We looked at published research and found very little information to help general practitioners in managing this condition. We assembled a group of experts to develop practical approaches for assessing and treating nocturia in neurological disease.

Implications of Cardiovascular Disease for Assessment and Treatment of Nocturia in Primary Care: Systematic Review and Nominal Group Technique Consensus.

CONTEXT: Heart conditions affect salt and water homeostasis as a consequence of the underlying condition, compensatory processes, and therapy, and can result in nocturnal polyuria. These processes need to be identified as part of a full evaluation of nocturia. OBJECTIVE: To conduct a systematic review of nocturia in cardiovascular disease and achieve expert consensus for primary care management. Primary care was defined as a health care setting in which the expertise did not include specialist cardiology. EVIDENCE ACQUISITION: Four databases were searched from January 2000 to April 2020. A total of 3524 titles and abstracts were screened and 27 studies underwent full-text screening. Of these, eight studies were included in the analysis. The nominal group technique (NGT) was used to achieve consensus among an expert panel incorporating public involvement. EVIDENCE SYNTHESIS: Most studies focused on nocturia related to blood pressure (BP), while one investigated leg oedema. Hypertension, particularly overnight blood pressure above normal, corresponds with higher risk of nocturia. NGT identified fluid and salt overload, nondipping hypertension, and some therapeutic interventions as key nocturia contributors. History taking and examination should identify raised jugular venous pressure/ankle swelling, with relevant investigations including measurement of BP, resting electrocardiogram, and B-type natriuretic peptide. Treatment recommends reducing salt (including substitutes), alcohol and caffeine. Heart failure is managed according to local guidance and controlling fluid intake to 1-2 l daily. If there is no fluid retention, reduce or discontinue diuretics or calcium channel blockers and follow up to reassess the condition. The target clinic blood pressure is 140/90 mm Hg. CONCLUSIONS: Cardiovascular disease and its treatment are influential for understanding nocturia. Management aims to identify and treat heart failure and/or hypertension. PATIENT SUMMARY: People with cardiovascular disease can suffer severe sleep disturbance because of a need to pass urine at night due to increased overnight blood pressure or heart failure. Following a detailed evaluation of the published research, a group of experts recommended practical approaches for assessing and treating these issues.

Assessment and Treatment of Nocturia in Endocrine Disease in a Primary Care Setting: Systematic Review and Nominal Group Technique Consensus.

CONTEXT: Salt and water homeostasis is regulated hormonally, so polyuria can result from endocrine disease directly or via secondary effects. These mechanisms are not consistently considered in primary care management of nocturia. OBJECTIVE: To conduct a systematic review (SR) of nocturia in endocrine disease and reach expert consensus for primary care management. EVIDENCE ACQUISITION: Four databases were searched from January 2000 to April 2020. A total of 4382 titles and abstracts were screened, 36 studies underwent full-text screening, and 14 studies were included in the analysis. Expert and public consensus was achieved using the nominal group technique (NGT). EVIDENCE SYNTHESIS: Twelve studies focused on mechanisms of nocturia, while two evaluated treatment options; none of the studies took place in a primary care setting. NGT consensus identified key clinical evaluation themes, including the presence of thirst, a medical background of diabetes mellitus or insipidus, thyroid disease, oestrogen status, medications (fluid loss or xerostomia), and general examination including body mass index. Proposed investigations include a bladder diary, renal and thyroid function, calcium, and glycated haemoglobin. Morning urine osmolarity should be examined in the context of polyuria of >2.5 l/24 h persisting despite fluid advice, with urine concentration >600 mOsm/l after fluid restriction excluding diabetes insipidus. Treatment should involve education, including adjustment of lifestyle and medication where possible. Any underlying endocrine disorder should be managed according to local guidance. Referral to endocrinology is needed if there is hyperthyroidism, hyperparathyroidism, or morning urine osmolarity <600 mOsm/l after overnight fluid avoidance. CONCLUSIONS: Endocrine disease can result in nocturia via varied salt and water regulation pathways. The aim of management is to identify and treat causative factors, but secondary effects can restrict improvements in nocturia. PATIENT SUMMARY: People with altered hormone function can suffer from severe sleep disturbance because of a need to pass urine caused by problems in controlling water and salt levels. An expert panel recommended the best ways to assess and treat these problems on the basis of the rather small amount of up-to-date published research available.

Antibiotic-induced changes in the human gut microbiota for the most commonly prescribed antibiotics in primary care in the UK: a systematic review.

OBJECTIVE: The gut microbiota influences many aspects of human health. We investigated the magnitude and duration of changes in gut microbiota in response to antibiotics commonly prescribed in UK primary care. METHODS: We searched MEDLINE, EMBASE and AMED, all years up to May 2020 including all study designs, collecting and analysing data on the effect of antibiotics prescribed for respiratory and urinary tract infections. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane standard methods. Risk of bias was evaluated using the Critical Appraisal Skills Programme. Narrative synthesis was used to report the themes emerging from the data. MAIN OUTCOME MEASURES: Primary outcomes were antibiotic-induced changes in the composition and/or diversity of the gut microbiota. Secondary outcome was the time for the microbiota to return to baseline. RESULTS: Thirty-one articles with low or unclear risk of bias showed that antibiotics impact the gut microbiota by causing rapid and diminished levels of bacterial diversity and changes in relative abundances. After cessation of treatment, gut bacteria recover, in most individuals, to their baseline state within a few weeks. Some studies suggested longer term effects from 2 to 6 months. Considerable heterogeneity in methodology makes the studies prone to biases and other confounding factors. Doxycycline was associated with a marked short-term decrease in Bifidobacterium diversity. Clarithromycin decreased the populations of Enterobacteria, and the anaerobic bacteria Bifidobacterium sp and Lactobacillus sp in numbers and diversity for up to 5 weeks. Phenoxymethylpenicillin, nitrofurantoin and amoxicillin had very little effect on the gut microbiome. CONCLUSIONS: Despite substantial heterogeneity of the studies and small sample sizes, there is evidence that antibiotics commonly used in primary care influence the composition of the gastrointestinal microbiota. Larger population-based studies are needed to fully understand how antibiotics modulate the microbiota, and to determine if these are associated with (longer term) health consequences. PROSPERO REGISTRATION NUMBER: CRD42017073750.

Determining when a hospital admission of an older person can be avoided in a subacute setting: a systematic review and concept analysis.

OBJECTIVE: To conduct a systematic review of the evidence for when a hospital admission for an older person can be avoided in subacute settings. We examined the definition of admission avoidance and the evidence for the factors that are required to avoid admission to hospital in this setting. METHODS: Using defined PICOD criteria, we conducted searches in three databases (Medline, Embase and Cinahl) from January 2006 to February 2018. References were screened by title and abstract followed by full paper screening by two reviewers. Additional studies were searched from the grey literature, experts in the field and forward and backward referencing. Data were narratively described, and concept analysis was used to investigate the definition of admission avoidance. RESULTS: A total of 17 studies were considered eligible for review; eight provided a definition of admission avoidance and 10 described admission avoidance criteria. We identified three factors which play a key role in admission avoidance in the subacute setting: (1) ambulatory care sensitive conditions and common medical scenarios for the older person, which included respiratory infections or pneumonia, urinary tract infections and catheter care, dehydration and associated symptoms, falls and behavioural management, and managing ongoing chronic conditions; (2) criteria/tools, referring to interventions that have used clinical expertise in conjunction with a range of general and geriatric triage tools; in condition-specific interventions, the decision whether to admit or not was based on level of risk determined by defined clinical tools; and (3) personnel and resources, referring to the need for experts to make the initial decision to avoid an admission. Supervision by nurses or physicians was still needed at subacute level, requiring resources such as short-stay beds, intravenous antibiotic treatment or fluids for rehydration and rapid access to laboratory tests. CONCLUSION: The review identified a set of criteria for ambulatory care sensitive conditions and common medical scenarios for the older person that can be treated in the subacute setting with appropriate tools and resources. This information can help commissioners and care providers to take on these important elements and deliver them in a locally designed way.

A systematic review and evidence synthesis of non-medical triage, self-referral and direct access services for patients with musculoskeletal pain.

INTRODUCTION: The demand for musculoskeletal (MSK) care is rising, and is a growing challenge for general practice. Direct access to physiotherapy and other healthcare services may offer appropriate care for MSK pain patients but there is uncertainty regarding the effectiveness or efficiency of this approach in practice. This study aimed to review the evidence regarding characteristics, outcomes, barriers and facilitators of MSK triage and direct access services. METHODS: A comprehensive search of eight databases (including MEDLINE, EMBASE, and Cochrane library) up to February 2018 was conducted to identify studies (trials, cohorts and qualitative evidence) on direct access services for MSK in primary care settings. Using predefined inclusion and exclusion criteria, titles, abstracts, and subsequent full texts were independently screened by reviewers. Methodological quality of eligible studies was assessed using the mixed methods appraisal tool, and extracted data regarding study characteristics and results were independently reviewed. A narrative synthesis and grading of evidence was undertaken. Approaches to MSK triage and direct access were profiled along with their respective outcomes of care relating to patient-oriented and socioeconomic outcomes. Barriers and facilitators of each model of direct access services were also highlighted. RESULTS: 9010 unique citations were screened, of which 26 studies were eligible. Three approaches (open access, combination and service pathway models) to MSK triage and direct access shared similar goals but were heterogeneous in application. MSK patients using direct access showed largely similar characteristics (age, sex and duration of symptoms) compared to GP-led care, although they were often younger, slightly more educated and with better socio-economic status than patients seen through GP-led care. Although many studies showed limitations in design or methods, outcomes of care (patient oriented outcomes of pain, and disability) did not show large differences between direct access and GP-led care. In most studies direct access patients were reported to have lower healthcare utilisation (fewer physiotherapy or GP consultations, analgesics or muscle relaxants prescriptions, or imaging procedures) and less time off work compared to GP-led care. DISCUSSION: This study provides insight into the current state of evidence regarding MSK triage and direct access services and highlights potential implications for future research, healthcare services planning, resource utilisation and organising care for MSK patients in primary care. There is consistent, although limited, evidence to suggest that MSK triage and direct access services lead to comparable clinical outcomes with lower healthcare consumption, and can help to manage GP workload. However, due to the paucity of strong empirical data from methodologically robust studies, a scale up and widespread roll out of direct access services cannot as yet be assumed to result in long term health and socio-economic gains. PROSPERO-ID: CRD42018085978.

Research priorities in advanced heart failure: James Lind alliance priority setting partnership.

OBJECTIVE: To determine research priorities in advanced heart failure (HF) for patients, carers and healthcare professionals. METHODS: Priority setting partnership using the systematic James Lind Alliance method for ranking and setting research priorities. An initial open survey of patients, carers and healthcare professionals identified respondents' questions, which were categorised to produce a list of summary research questions; questions already answered in existing literature were removed. In a second survey of patients, carers and healthcare professionals, respondents ranked the summary research questions in order of priority. The top 25 unanswered research priorities were then considered at a face-to-face workshop using nominal group technique to agree on a 'top 10'. RESULTS: 192 respondents submitted 489 responses each containing one or more research uncertainty. Out-of-scope questions (35) were removed, and collating the responses produced 80 summary questions. Questions already answered in the literature (15) were removed. In the second survey, 65 questions were ranked by 128 respondents. The top 10 priorities were developed at a consensus meeting of stakeholders and included a focus on quality of life, psychological support, the impact on carers, role of the charity sector and managing prognostic uncertainty. Ranked priorities by physicians and patients were remarkably divergent. CONCLUSIONS: Engaging stakeholders in setting research priorities led to a novel set of research questions that might not have otherwise been considered. These priorities can be used by researchers and funders to direct future research towards the areas which matter most to people living with advanced HF.