Impact of oropharyngeal dysphagia on healthcare cost and length of stay in hospital: a systematic review.

BACKGROUND: Healthcare systems internationally are under an ever-increasing demand for services that must be delivered in an efficient, effective and affordable manner. Several patient-related and organisational factors influence health-care expenditure and utilisation, including oropharyngeal dysphagia. Here, we present a systematic review of the literature and meta-analyses investigating how oropharyngeal dysphagia influences healthcare utilisation through length of stay (LOS) and cost. METHODS: Using a standardised approach, eight databases were systematically searched for relevant articles reporting on oropharyngeal dysphagia attributable inpatient LOS and healthcare costs through June 2016. Study methodologies were critically appraised and where appropriate, extracted LOS data were analysed in an overall summary statistic. RESULTS: Eleven studies reported on cost data, and 23 studies were included reporting on LOS data. Descriptively, the presence of dysphagia added 40.36% to health care costs across studies. Meta-analysis of all-cause admission data from 13 cohort studies revealed an increased LOS of 2.99 days (95% CI, 2.7, 3.3). A subgroup analysis revealed that admission for stroke resulted in higher and more variable LOS of 4.73 days (95% CI, 2.7, 7.2). Presence of dysphagia across all causes was also statistically significantly different regardless of geographical location: Europe (8.42 days; 95% CI, 4.3; 12.5), North America (3.91 days; 95% CI, 3.3, 4.5). No studies included in meta-analysis were conducted in Asia. CONCLUSIONS: This systematic review demonstrated that the presence of oropharyngeal dysphagia significantly increases healthcare utilisation and cost, highlighting the need to recognise oropharyngeal dysphagia as an important contributor to pressure on healthcare systems.

Venous thromboembolism (VTE) risk assessment: rural nurses' knowledge and use in a rural acute care hospital.

It is estimated that about 2000 people die as a result of venous thromboembolism (VTE) each year, with a further 30,000 being hospitalized. Prophylaxis significantly reduces VTE morbidity and mortality, and thus represents a real long-term health-care benefit. The aim of this study was twofold: (i) to assess the current level of compliance to VTE risk assessment and prophylaxis best practice guidelines within an Australian rural hospital; and (ii) to determine the effectiveness of nurse education on that compliance. VTE compliance information was obtained from auditing patient notes for a 3-month period prior to nurse education and was repeated after the education. Nurse knowledge of VTE risk assessment and prophylaxis use was also measured. Both compliance with and knowledge of best practice VTE risk assessment and prophylaxis increased following nurse education. Although the sample size was relatively small, this study has shown nurse education to be effective at increasing VTE compliance and awareness within an Australian rural hospital. This relatively inexpensive and simple intervention bears consideration and could lead to reductions in the morbidity and mortality associated with VTE, as well as reduction in associated health-care costs.

Effectiveness of mifamurtide in addition to standard chemotherapy for high-grade osteosarcoma: a systematic review.

BACKGROUND: Osteosarcoma mostly occurs during the period of rapid bone growth in children and adolescents as high-grade osteosarcomas. Current treatment recommended for high-grade non-metastatic and metastatic and/or relapsed osteosarcoma involves neoadjuvant multiagent conventional chemotherapy, followed by surgical resection of macroscopically detected tumor and postoperative adjuvant chemotherapy. However, residual micrometastatic deposits that develop following surgery have shown resistance to postoperative/adjuvant chemotherapy. Therefore, there is a critical need for more effective and innovative therapeutic approaches such as immune stimulatory agents. The most extensively studied immune stimulatory agent in the treatment of osteosarcoma is mifamurtide. The aim of this systematic review was to identify and synthesize the evidence on the effectiveness of mifamurtide in addition to standard chemotherapy on survival outcomes. OBJECTIVES: To present the best available evidence on the treatment of high-grade non-metastatic and metastatic osteosarcoma with mifamurtide in addition to standard chemotherapy. INCLUSION CRITERIA TYPES OF PARTICIPANTS: All populations of patients regardless of age, gender or ethnicity with high-grade, resectable, non-metastatic and metastatic osteosarcoma based on histological diagnosis. TYPES OF INTERVENTIONS AND COMPARATORS: This review focused on intravenous infusion of either of the pharmaceutical formulations of mifamurtide (MTP-PE or L-MTP-PE) in addition to standard chemotherapy, and the comparator was chemotherapy alone. TYPES OF STUDIES: This review considered any experimental study design including randomized controlled trials, non-randomized trials and quasi-experimental studies. OUTCOMES: The primary outcomes of interest were event-free survival, overall survival and recurrence of osteosarcoma. Secondary outcomes that were considered included health-related quality of life and any mifamurtide-related adverse events. SEARCH STRATEGY: A search for published and unpublished literature in English was undertaken (seven published literature databases, four unpublished literature databases, and three government agency and organizational websites were searched). Studies published between 1990 to June 2016 were considered. A three-step strategy was developed using MeSH terminology and keywords to ensure that all relevant studies were included related to this review. METHODOLOGICAL QUALITY: The methodological quality of included studies was assessed by two reviewers, who appraised each study independently, using a standardized Joanna Briggs Institute (JBI) critical appraisal tool. DATA EXTRACTION: Data was extracted from the studies that were identified as meeting the criteria for methodological quality using the standard JBI data extraction tool. DATA SYNTHESIS: Due to the heterogeneity of populations and interventions in available studies, meta-analysis was not possible and results are presented in narrative form. RESULTS: Three papers outlining two studies involving 802 patients evaluated the effectiveness of mifamurtide in addition of chemotherapy. Results indicated no significant difference in event-free survival between the addition of mifamurtide to standard chemotherapy regimen and chemotherapy alone, both in non-metastatic and metastatic osteosarcoma patients. There was a significant difference in progression-free survival favoring the addition of mifamurtide in pulmonary metastatic and/or relapsed osteosarcoma. There was no significant difference in overall survival between the addition of mifamurtide and chemotherapy alone in metastatic osteosarcoma; however there was a significant difference favoring the addition of mifamurtide in non-metastatic osteosarcoma patients. The addition of mifamurtide resulted in a significant difference in survival after relapse in pulmonary metastatic and/or relapsed osteosarcoma patients. Both studies reported on mifamurtide-related adverse events - the first was reported as toxicity which included haematological, hepatic, renal, gastrointestinal disorders, cardiac, rhythm and nervous system disorders, ear disorders and others (infection, fever; and performance status) in metastatic osteosarcoma patients. Results were similar across all combined treatment regimens. Although no statistical analysis was undertaken, the figures suggest there were no significant differences between the treatment regimens. In the other study, mifamurtide-related adverse events were reported as clinical toxic effects of mifamurtide in relapsed osteosarcoma, which included chills, fever and headache for the initial dose of mifamurtide, while for the subsequent doses of mifamurtide all patients reported toxicity as delayed fatigue. CONCLUSIONS: The available evidence on the effectiveness of mifamurtide in addition to a standard chemotherapy regimen for the treatment of high-grade osteosarcoma is limited and therefore no definitive conclusions can be made.

Effectiveness of nurse-led clinics on service delivery and clinical outcomes in adults with chronic ear, nose and throat complaints: a systematic review.

BACKGROUND: Ear, nose and throat complaints are very common and can cause significant disruption to patients' lives. Many conditions are of a chronic nature and are not currently managed in a timely manner by general practitioners in the community. This may be due to a lack of specialized knowledge, necessary diagnostic equipment or time for lengthy patient education on management of their condition. A nurse-led model of care may be an effective alternative. OBJECTIVE: To examine the effectiveness of nurse-led clinics on adults with chronic ear, nose and throat complaints. INCLUSION CRITERIA PARTICIPANTS: Adult patients, aged 18 years and older, attending ear, nose and throat clinics, regardless of the complaint. INTERVENTIONS: Nurse-led care in general practice and acute care in which the nurse was identified as taking a lead role in the care of the patients with chronic ear, nose and throat complaints. COMPARATOR: General practitioner-led care, or ear, nose and throat consultant-led care, sometimes described as "standard care". OUTCOMES: Service delivery outcomes, clinical and health outcomes and financial outcomes. STUDIES: Any relevant quantitative studies published in English between 1980 and 2013 were considered. SEARCH STRATEGY: A standardized three-step search strategy aimed to find both published and unpublished studies. Databases searched include PubMed, CINAHL, Cochrane Library (CENTRAL), Scopus, Embase, MedNar and ProQuest Theses and Dissertations. METHODOLOGICAL QUALITY: Methodological validity was assessed independently by two reviewers using standardized critical appraisal instruments from the Joanna Briggs Institute. DATA SYNTHESIS: Due to methodological heterogeneity of the included studies, no statistical pooling was possible and all results are presented narratively. RESULTS: The search identified 13,536 titles, of which 20 potentially relevant articles were retrieved. Of these 20, 17 were excluded following full-text review leaving three studies that were assessed for methodological quality and included in the review. Service delivery outcome findings were that patient satisfaction was equal or higher and waiting times were shorter in nurse led clinics. The other service delivery outcomes were not addressed. Clinical and health outcomes findings were that lower pain/discomfort levels were demonstrated in nurse led clinics but other clinical/health outcomes were not addressed. Financial outcomes findings were that nurse-led clinics were cost effective when compared with medical-led clinics. CONCLUSIONS: While all studies reported evidence of the effectiveness of nurse-led clinics in service delivery and clinical outcomes in adults with chronic ear, nose and throat complaints, most of the data was self-reported and many of the outcomes of interest were not considered. The lack of experimental trials means that the level of evidence is low and further research is needed. There was also not enough detail in the financial outcomes from which clear conclusions of the cost benefit of nurse-led clinics could be drawn. IMPLICATIONS FOR PRACTICE: Evidence from included studies indicated higher levels of patient satisfaction, cost benefits and lower levels of pain/discomfort in nurse-led clinics, which suggests that nurse-led ear, nose and throat clinics may be considered in the management of adult patients with ear, nose and throat complaints. IMPLICATIONS FOR RESEARCH: Currently there is little evidence examining the effectiveness of nurse-led ear, nose and throat clinics. Areas to be addressed by future research should include: levels of patient education, booking queues, levels of self-treatment change in presentation to clinic episodes, reinfection rates, prevention and cure and representation of patients at clinics for same complaint.

The influence of workplace culture on nurses' learning experiences: a systematic review of qualitative evidence.

BACKGROUND: A healthy workplace culture enables nurses to experience valuable learning in the workplace. Learning in the workplace enables the provision of evidence-based and continuously improving safe patient care, which is central to achieving good patient outcomes. Therefore, nurses need to learn within a workplace that supports the implementation of evidence-based, professional practice and enables the best patient outcomes; the influence of workplace culture may play a role in this. OBJECTIVES: The purpose of this review was to critically appraise and synthesize the best available qualitative evidence to understand both the nurses' learning experiences within the workplace and the factors within the workplace culture that influence those learning experiences. INCLUSION CRITERIA TYPES OF PARTICIPANTS: Registered and enrolled nurses regulated by a nursing and midwifery board and/or recognized health practitioner regulation agency (or their international equivalent). PHENOMENA OF INTEREST: This review considered studies that described two phenomena of interest: the nurses' learning experience, either within an acute healthcare workplace or a workplace-related learning environment and the influence of workplace culture on the nurses' learning experience (within the workplace or workplace-related learning environment). CONTEXT: This review considered studies that included nurses working in an acute healthcare organization within a Western culture. TYPES OF STUDIES: This review considered studies that focused on qualitative evidence and included the following research designs: phenomenological, grounded theory and critical theory. SEARCH STRATEGY: Published and unpublished studies in English from 1980 to 2013 were identified using a three-step search strategy, searching various databases, and included hand searching of the reference lists within articles selected for appraisal. METHODOLOGICAL QUALITY: For studies meeting the inclusion criteria, methodological quality was assessed using a standardized checklist from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI). DATA EXTRACTION: Qualitative data were extracted from articles included in the review using the standardized data extraction tool from the JBI-QARI. DATA SYNTHESIS: Qualitative research findings were pooled using the Joanna Briggs Institute Qualitative Appraisal and Review Instrument (JBI-QARI). This involved the aggregation and synthesis of findings to generate a set of categories, which were then subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings that could be used as a basis for evidence-based practice. RESULTS: Fourteen articles were identified following appraisal and a total of 105 findings (85 unequivocal and 20 credible) were extracted from included studies and grouped into eight categories based on similarity of meaning. Subsequently, categories were grouped into two synthesized findings. The two synthesized findings were as follows: ORGANIZATIONAL INFLUENCES: Enabling nurses to demonstrate accountability for their own learning, along with clear organizational systems that provide resources, time, adequate staffing and support, demonstrates encouragement for and the value of nurses' learning and education. RELATIONAL DYNAMICS: Nurses value their peers, expert nurses, preceptors, mentors and educators facilitating and encouraging their learning and professional development. CONCLUSION: An optimal workplace culture is central for nurses to experience valuable and relevant learning in the workplace. To emphasize the importance of nurses' learning in the workplace, working and learning is understood as an integrated experience. Consequently, a dual system that enables nurses to demonstrate accountability for their own learning, along with clear organizational and educational systems, is required to demonstrate the value in nurses' learning and education.

Effectiveness of allied health therapy in the symptomatic management of progressive supranuclear palsy: a systematic review.

BACKGROUND: Progressive supranuclear palsy (PSP) is an adult onset neurodegenerative condition associated with mobility, balance, speech, swallowing, vision and cognitive changes. The condition is diagnosed using the National Institute for Neurological Disorders and Stroke (NINDS) and the Society of Progressive Supranuclear Palsy (SPSP) criteria. Therapeutic interventions for PSP are important, and a healthcare team should include a physiotherapist, occupational therapist and speech therapist. Mobility, speech and swallowing problems are commonly experienced, and aspiration pneumonia is the leading cause of death. A preliminary search of the literature has indicated that beyond small case series, there is very little evidence to guide specific allied health therapies in PSP. Many strategies for optimizing independence and function for PSP predominately rely on data extrapolated from the study of Parkinson's disease. OBJECTIVES: The objective of this review was to examine the effectiveness of physical, occupational and speech therapy interventions in the symptomatic management of PSP. INCLUSION CRITERIA TYPES OF PARTICIPANTS: This review included participants with PSP as per the NINDS and the SPSP criteria, aged over 40 years of age from all community and clinical settings. TYPES OF INTERVENTIONS: This review included studies evaluating any allied health therapy that addressed mobility, vision, swallowing, communication or cognitive/neuropsychiatric difficulties experienced by patients with PSP. Studies examining interventions within the current scope of practice, and emerging interventions (non-invasive brain stimulation therapy) were eligible for inclusion. TYPES OF COMPARATOR: The effectiveness of interventions of interest was compared with usual care and/or baseline measurements. OUTCOMES: Outcomes of interest included the degree of change, or no change, in the symptoms experienced by patients with PSP relevant to allied health. These included difficulties with mobility, vision, swallowing, communication and cognition. TYPES OF STUDIES: All types of quantitative study designs published in English from the time of development of the NINDS and the SPSP criteria in 1996-2014 were considered for inclusion. SEARCH STRATEGY: A broad range of synonyms for PSP and a three-step search strategy was utilized to identify possible published and unpublished studies from 11 different databases. An initial limited search via MEDLINE (PubMed), CINAHL, Health Informit, PsycINFO, PEDRO, OTSeeker and SpeechBite was undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was then undertaken across all included databases. Third, hand-searching was conducted and the reference list of all identified reports and articles was searched for additional studies. METHODOLOGICAL QUALITY: Critical appraisal was conducted by two independent reviewers using standardized instruments. DATA EXTRACTION: Quantitative data were extracted from articles included in the review using standardized data extraction tools. DATA SYNTHESIS: As the quantitative articles examined different interventions, pooling of data was not appropriate. Instead, the findings were presented in narrative summary and tabular form. RESULTS: Following methodological appraisal, six studies were included in the review. Aside from one small quasi-randomized control study, most studies were small case series and one was a case report. Five of the six studies examined the effectiveness of a range of different physiotherapy rehabilitation programs targeting gait, balance and physical capability, with one study also targeting gaze control. The sixth study examined non-invasive brain stimulation in improving gait and midline symptoms in PSP. No studies examined the effectiveness of occupational therapy or speech therapy interventions in PSP. CONCLUSIONS: Research into the effectiveness of allied health therapeutic interventions for PSP symptoms is in its infancy. This review found preliminary evidence to support the use of various physiotherapy rehabilitation programs to improve balance, gait and gaze control in people affected by PSP. Further research is urgently required to identify effective interventions to manage mobility, vision, swallowing, communication and cognitive/neuropsychiatric symptoms associated with this devastating condition.

Diagnostic test accuracy: methods for systematic review and meta-analysis.

Systematic reviews are carried out to provide an answer to a clinical question based on all available evidence (published and unpublished), to critically appraise the quality of studies, and account for and explain variations between the results of studies. The Joanna Briggs Institute specializes in providing methodological guidance for the conduct of systematic reviews and has developed methods and guidance for reviewers conducting systematic reviews of studies of diagnostic test accuracy. Diagnostic tests are used to identify the presence or absence of a condition for the purpose of developing an appropriate treatment plan. Owing to demands for improvements in speed, cost, ease of performance, patient safety, and accuracy, new diagnostic tests are continuously developed, and there are often several tests available for the diagnosis of a particular condition. In order to provide the evidence necessary for clinicians and other healthcare professionals to make informed decisions regarding the optimum test to use, primary studies need to be carried out on the accuracy of diagnostic tests and the results of these studies synthesized through systematic review. The Joanna Briggs Institute and its international collaboration have updated, revised, and developed new guidance for systematic reviews, including systematic reviews of diagnostic test accuracy. This methodological article summarizes that guidance and provides detailed advice on the effective conduct of systematic reviews of diagnostic test accuracy.

Diagnostic performance of a stand-alone central blood pressure monitor: application of central blood pressure in the diagnosis of high blood pressure.

BACKGROUND: Oscillometric central blood pressure (CBP) monitors have emerged as a new technology for blood pressure (BP) measurements. With a newly proposed diagnostic threshold for CBP, we investigated the diagnostic performance of a novel CBP monitor. METHODS: We recruited a consecutive series of 138 subjects (aged 30-93 years) without previous use of antihypertensive agents for simultaneous invasive and noninvasive measurements of BP in a catheterization laboratory. With the cutoff (CBP ≥130/90 mm Hg) for high blood pressure (HBP), the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the novel CBP monitor were calculated with reference to the measured CBP. In comparison, the diagnostic performance of the conventional cuff BP was also evaluated. RESULTS: The noninvasive CBP for detecting HBP in a sample with a prevalence of 52% showed a sensitivity of 93% (95% confidence interval (CI) = 91-95), specificity of 95% (95% CI = 94-97), PPV of 96% (95% CI = 94-97), and NPV of 93% (95% CI = 90-95). In contrast, with cuff BP and the traditional HBP criterion (cuff BP ≥140/90 mm Hg), the sensitivity, specificity, PPV, and NPV were 49% (95% CI = 44-53), 94% (95% CI = 92-96), 90% (95% CI = 86-93), and 63% (95% CI 59-66), respectively. CONCLUSIONS: A stand-alone oscillometric CBP monitor may provide CBP values with acceptable diagnostic accuracy. However, with reference to invasively measured CBP, cuff BP had low sensitivity and NPV, which could render possible management inaccessible to a considerable proportion of HBP patients, who may be identifiable through noninvasive CBP measurements from the CBP monitor.

Periodontal Disease as a Risk Factor for Rheumatoid Arthritis: A Systematic Review.

REVIEW OBJECTIVE: The objective of this systematic review is to identify and synthesise the best available evidence to examine whether periodontal disease is a risk factor for rheumatoid arthritis. BACKGROUND: Rheumatoid arthritis (RA) is a chronic inflammatory disease of unknown aetiology and has a complex multifactorial pathogenesis affecting joints and other tissues. The natural history of rheumatoid arthritis is poorly defined; its clinical course fluctuates and the prognosis unpredictable. Rheumatoid arthritis affects up to 1-3% of the population, with a 3:1 female preponderance disappearing in older age. There is also evidence of a genetic predisposition to the disease. Rheumatoid arthritis is characterised by progressive and irreversible damage of the synovial-lined joints causing loss of joint space, bone and function, leading to deformity. Extracellular matrix degradation is a hallmark of rheumatoid arthritis which is responsible for the typical destruction of cartilage, ligaments, tendons, and bone.Rheumatoid arthritis is characteristically a symmetric arthritis (symmetrical swelling of the joints). Articular and periarticular manifestations include joint swelling and tenderness to palpation, with morning stiffness and severe motion impairment in the involved joints. Extra-articular signs can involve pulmonary, cardiovascular, nervous, and reticuloendothelial systems. The clinical presentation of rheumatoid arthritis rheumatoid arthritis varies, but an insidious onset of pain with symmetric swelling of the small joints is the most frequent finding. Rheumatoid arthritis onset is acute or subacute in about 25% of patients. Early rheumatoid arthritis is characterised by symmetric polyarthritis involving the small joints of the hands and feet with no radiologic changes. Rheumatoid arthritis most frequently affects the metacarpophalangeal, proximal interphalangeal and wrist joints. Although any joint, including the cricoarytenoid joint, can be affected, the distal interphalangeal, the sacroiliac and the lumbar spine joints are rarely involved, which is peculiar because these are some of the most typical targets of seronegative spondylarthropathies, such as psoriatic arthritis and ankylosing spondylitis. The clinical manifestations of rheumatoid arthritis vary, depending on the involved joints and the disease stage. The clinical features of synovitis are particularly apparent in the morning. Morning stiffness in and around the joints, lasting at least 1 hour before maximal improvement is a typical sign of rheumatoid arthritis. It is a subjective sign and the patient needs to be carefully informed as to the difference between pain and stiffness. Morning stiffness duration is related to disease activity. Progression of rheumatoid arthritis can be measured by laboratory tests and clinical evaluation (questionnaires of disease activity and physical examination). Laboratory tests include blood tests for Rheumatoid factor (RF) and Acute-phase reaction tests while clinical evaluation can be measured by the Disease activity using the Disease Activity Score (DAS). Periodontitis is a destructive inflammatory disease of the dental supporting tissues which leads to erosion of bone around teeth resulting in tooth loss. Severe periodontitis affects about 5-15% of the adult population. In periodontitis, the clinical findings of bone resorption and loss of clinical attachment level around tooth are a result of inflammatory mediated alterations to the bone remodelling balance. The inflammatory infiltrate present between the plaque biofilm, bone and connective tissues regulate the host immune response to the bacteria. The host produces proteases and substances that degrade the extracellular matrix, and lead to resorption of the alveolar bone, resulting in irreversible loss of tissue attachment.Bone is a dynamic tissue and bone homeostasis involves the opposing events of resorption and apposition; dissolution of the existing bone mineral, resorption of the extracellular matrix, and formation of a new matrix. Bone homeostasis mechanisms maintain bone integrity in the alveolar bone (regulates periodontal bone loss) and, elsewhere in the body. It also functions to regulate the calcium balance within the body; this is an important ion as it is involved in the clotting of blood, formation of glandular secretions and regulation of the cardiac pacemaker.Rheumatoid arthritis and periodontitis are arguably the most prevalent chronic inflammatory diseases in humans and associated with significant morbidities. rheumatoid arthritis and periodontitis share similar clinical and pathogenic characteristics. Both rheumatoid arthritis and periodontitis present an imbalance between pro-inflammatory and anti-inflammatory cytokines, which is thought to be responsible for the tissue damage. In this sense, both conditions are associated with destruction of bone, mediated by inflammatory cytokines such as interleukin-1, tumour necrosis factor and prostaglandin E2.Several studies have suggested a relationship between periodontitis and rheumatoid arthritis; rheumatoid arthritis may have a negative impact on periodontal condition and vice versa. Mercado et al. in 2001 reported a significantly high prevalence of moderate to severe periodontitis in individuals with rheumatoid arthritis. In addition, the converse is true: periodontitis patients have a higher prevalence of rheumatoid arthritis compared to the general population. One study found that induction of experimental arthritis in rats resulted in periodontal destruction and increased cytokines and matrix metalloproteinases in the periodontal tissues.Oral bacterial DNA (deoxyribonucleic acids) is detected in serum and synovial fluid of patients with rheumatoid arthritis. Patients with rheumatoid arthritis also have a significantly higher level of immunoglobulin G antibody against P. gingivalis, Prevotella intermedia, and Tannerella forsythia. Furthermore, two recent clinical trials suggested that the treatment of periodontal disease might have a significant impact on rheumatoid arthritis severity. Similarly, subjects with rheumatoid arthritis have significantly increased periodontal attachment loss.In a recent research article, Ogrendik et al. in 2009 concluded that antibodies formed against these oral bacteria could be important to the aetiopathogenesis of rheumatoid arthritis. They recommended that gingival tissue infections should be considered in rheumatoid arthritis pathogenesis and that periodontal infections should be treated and prevented from becoming chronic. If successful results are observed against periodontal infections in clinical, radiologic, and laboratory data of the rheumatoid arthritis patients, the essential role of these bacteria in the aetiology of rheumatoid arthritis can be proven. One hypothesis that links rheumatoid arthritis and periodontitis is the recently published "two-hit" model that attempts to link experimental evidence from animal models and is supported by evidence from human clinical studies. In this theory, the first "hit" involves the periodontopathic subgingival biofilm and its microbial products, such as endotoxin. The second "hit" involves a medical systemic disease, such as rheumatoid arthritis, which increases biomarkers of systemic inflammation in the circulation, including C reactive protein (CRP), cytokines (e.g. IL-6), prostanoids (e.g. PGE2), and matrix metalloproteinases (e.g. MMP-9), and tumour necrosis factor alpha (TNF- α). These cytokines are thought to stimulate resident cells in the synovium and the periodontium to produce MMPs mediating connective tissue destruction, and induce the differentiation and activity of osteoclasts to destroy bone In particular, TNF-α, also promotes bone resorption: (i) by up-regulating inducible nitric oxide synthase (iNOS) and the production of nitric oxide (NO); and (ii) by modulating the receptor activator of nuclear factor _B (NF_B) ligand (RANKL) in osteoblasts, and its antagonist osteoprotegerin (OPG), thus altering the RANKL/OPG ratio, which enhances osteoclast activity, and finally, lead to periodontal breakdown. Most recently Bartold et al, reported a series of experiments to examine the plausibility of the "two hit" theory investigated whether the onset and severity of experimental arthritis in a rodent model was influenced by the presence of a pre-existing extra-synovial chronic inflammatory reaction to P. gingivalis. They discovered that severe arthritis developed more rapidly in animals with a pre-existing P. gingivalis induced inflammatory lesion, thus providing further evidence for a relationship between the presence of periodontal pathogen-associated inflammation and the development of rheumatoid arthritis. Aggressive periodontitis is rapid progression of periodontal disease with severe periodontal breakdown. The amount and pattern of periodontal destruction is very aggressive indicating there may be other characteristics in addition that contribute to its rate of destruction, and hence is outside of the scope of this review.Before undertaking this review, the JBI Library of Systematic Reviews, Cochrane Library of Systematic Reviews, Medline and CINAHL were searched. As no systematic review has been identified as been either published or underway on this topic, the aim of this systematic review is to identify and synthesise the best available evidence of periodontal disease as a risk factor for rheumatoid arthritis.

Venous Thromboembolism (VTE) Risk Assessment and Prophylaxis: A Comprehensive Systematic Review of the Facilitators and Barriers to Healthcare Worker Compliance with Clinical Practice Guidelines in the Acute Care Setting.

BACKGROUND: Even though guidelines for venous thromboembolism risk assessment and prophylaxis are available, patients with identifiable risk factors admitted to acute hospitals are not receiving appropriate prophylaxis. The incidence of venous thromboembolism in hospitalized patients is higher than that of people living in the community who have similar demographics. Knowledge of barriers to healthcare professional compliance with clinical practice guidelines and facilitators to improve compliance will aid appropriate use of venous thromboembolism clinical practice guidelines. OBJECTIVES: The main objective of this review was to identify the barriers and facilitators to healthcare professional compliance with clinical practice guidelines for venous thromboembolism assessment and prophylaxis. INCLUSION CRITERIA: Studies were considered for inclusion regardless of the designation of the healthcare professional involved in the acute care setting.The focus of the review was compliance with venous thromboembolism clinical practice guidelines and identified facilitators and barriers to clinical use of these guidelines.Any experimental, observational studies or qualitative research studies were considered for inclusion in this review.The outcomes of interest were compliance with venous thromboembolism guidelines and identified barriers and facilitators to compliance. SEARCH STRATEGY: A comprehensive, three-step search strategy was conducted for studies published from May 2003 to November 2011, aimed to identify both published and unpublished studies in the English language across six major databases. METHODOLOGICAL QUALITY: Retrieved papers were assessed by two independent reviewers prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute. DATA COLLECTION: Both quantitative and qualitative data were extracted from papers included in the review using standardized data tools from the Joanna Briggs Institute. DATA SYNTHESIS: Quantitative data was pooled using narrative summary due to heterogeneity in the ways in which data was reported. Qualitative data was pooled using Joanna Briggs Institute software. RESULTS: Twenty studies were included in the review with methodological quality ranging from low to high.Reported compliance at baseline ranged from 6.25% to 70.4% and compliance post intervention ranged from 36% to 100%.Eight main categories of barriers and nine main categories of facilitators were identified. The quantitative and qualitative studies identified very similar barriers and facilitators which fell under the same categories. The studies all had components of education involved in their intervention and the review found that passive dissemination or one mode of intervention was not enough to affect and sustain change in clinical practice. CONCLUSIONS: This review identified 20 studies that assessed compliance with venous thromboembolism clinical practice guidelines, and identified barriers and facilitators to that compliance. The studies showed that many different forms of intervention can improve compliance with clinical practice guidelines. They provided evidence that interventions can be developed for the specific audience and setting they are being used for, and that not all interventions are appropriate for all areas, such as computer applications not being suitable where system capacity is lacking.Healthcare professionals need to be aware of venous thromboembolism clinical practice guidelines and improve patient outcomes by using them in the hospital setting. There are a number of interventions that can improve guideline compliance, keeping in mind the barriers and adjusting practice to avoid them.Venous thromboembolism compliance within rural Australian hospitals has not been determined, however as inequalities have been identified in other areas of healthcare between urban and rural regions this would be a logical area to research.

Perceived Facilitators and Barriers to Interventions Aimed at Reducing Unintended Pregnancies among Adolescents in Low and Middle Income (Developing) Countries: a Systematic Review of Qualitative Evidence.

BACKGROUND: Adolescent pregnancies are most often the result of sexual risk taking. Such pregnancies are in themselves "risks" perpetuating other adverse social outcomes on the adolescents who go through such pregnancies. Of the close to 14 million births among adolescents each year, between one-third and two-thirds are unplanned. Unplanned pregnancies coupled with societal restrictions result in adolescents opting for abortions under unsafe conditions. OBJECTIVES: The objective of this review is to present the best available evidence on perceived facilitators and barriers to successful outcomes of programs aimed at reducing pregnancies among adolescents in low and middle income countries. INCLUSION CRITERIA: Persons aged between 10 and 19 years residing in low and middle income countries, but during the review process, those up to 25 years, adults and opinion leaders were included.Perceived facilitators and barriers to interventions aimed at reducing pregnancies among adolescents in developing countries.The review considered studies that used qualitative study designs, including but not limited to: phenomenology, grounded theory, action research, narrative studies, descriptive studies, ethnographies, cultural studies, behavioural studies, case studies and feminist research. SEARCH STRATEGY: The search strategy aimed to find both published and unpublished studies in English over the period of January, 1960 to December, 2010. METHODOLOGICAL QUALITY: Critical appraisal of papers was conducted using standardized tools from the Joanna Briggs Institute by two independent reviewers. DATA COLLECTION: Data was extracted using standardized tools from the Joanna Briggs Institute. DATA SYNTHESIS: Findings were synthesized on the basis of similarity of meaning using software from the Joanna Briggs Institute. RESULTS: Fourteen studies were included in the review which generated 103 findings, grouped into 22 categories and then further grouped into 11 synthesized findings, based on similarity of meaning. Seventeen categories (eight synthesized findings) described perceived barriers and five categories (three synthesized findings) described perceived facilitators. CONCLUSIONS: Synthesized findings on both the barriers and facilitators encompassed adolescent, parental, community, health facility, care providers, school environment and societal contributing factors. IMPLICATIONS FOR PRACTICE: IMPLICATIONS FOR RESEARCH: Further research should be conducted into the following.