A systematic review of active case-finding strategies for tuberculosis in homeless populations.

SETTING: Tuberculosis (TB) is prevalent in the homeless population, and can create health inequalities and challenges for eradication. Evidence-based approaches to active case finding (ACF) are needed. OBJECTIVES: To determine the effectiveness of ACF for TB control, and identify strategies to improve uptake of screening and the diagnostic pathway in homeless populations in low- and medium-burden settings. Secondary objectives were to assess the yield of screening and participant characteristics. DESIGN: A systematic search of electronic databases and grey literature sources identified ACF studies that reported population measures (prevalence or incidence) of TB control, and/or uptake and/or yield of screening for latent tuberculous infection (LTBI) or active TB affecting any site. Studies were described using narrative synthesis. RESULTS: Twenty studies met the inclusion criteria. Studies were heterogeneous across multiple elements, including programme design, which likely contributed to variability in outcomes. ACF was associated with reductions in TB rates in three time-trend analyses. The strongest evidence for improving uptake of screening was for incentives, with mixed evidence for peer educators. At the observational level, professional support and mandatory screening may also improve uptake, and additional community support enhanced completion of the diagnostic pathway. Those most likely to be diagnosed with TB appeared less likely to accept screening. Yield of screening was 1.5-57% (41 684 participants) for LTBI, and 0-3.1% (91 771 participants) for active TB. CONCLUSION: Observational evidence suggests that ACF is effective. Strategies to improve screening uptake were identified. Variability in uptake and yield necessitates programmes tailored to local populations; areas for further research were identified.

Anti-TNF therapy is not associated with an increased risk of post-colectomy complications, a population-based study.

AIM: Previous studies have raised concerns that the use of anti-tumour necrosis factor (anti-TNF) therapy in patients with ulcerative colitis (UC) undergoing surgery may increase the risk of postoperative complications. We have taken a population-based approach to investigate whether there is an association between anti-TNF therapy and postoperative complications in UC patients undergoing subtotal colectomy. METHOD: Hospital Episode Statistics (HES) data and procedural coding were used to identify all patients in England between April 2006 and March 2015 undergoing subtotal colectomy for UC. Patients were grouped into those who received anti-TNF therapy within 12 or 4 weeks of surgery and those who did not. The incidence of postoperative complications was evaluated by HES coding and compared between groups. RESULTS: In all, 6225 UC patients underwent subtotal colectomy. 753 patients received anti-TNF therapy within 12 weeks prior to surgery (418 within 4 weeks). There was no difference in postoperative complications between groups although groups were not comparable for age and comorbidities. Logistic regression with complications as the outcome variable did not show any significant association between anti-TNF therapy and complications. Colectomy performed during an unplanned admission (vs planned admission) and smoking were associated with complications. CONCLUSION: This large population-based study does not demonstrate any association between preoperative anti-TNF therapy and postoperative complications in UC patients undergoing subtotal colectomy. The only variables associated with complications were colectomy performed during an unplanned admission and smoking.

Sex-related Outcome Inequalities in Endovascular Aneurysm Repair.

OBJECTIVE/BACKGROUND: Women are known to have a higher rate of postoperative complications and mortality following open abdominal aortic aneurysm (AAA) repair. It is less clear whether this remains true of endovascular aneurysm repair (EVAR). This study examines the association between sex and hospital length of stay (LoS), readmission rates, and mortality following elective EVAR in the population of England between April 2006 and March 2015. METHODS: Retrospective analysis of Hospital Episode Statistics (HES) was performed, including regression analysis of potential factors that may affect the primary outcomes (age, sex, deprivation, comorbidities and Trust volume). RESULTS: In total, 20,780 EVARs were performed in the time period, 11.2% (n = 2,304) on women. The women were older (78 years [interquartile range {IQR} 74-82 years] vs. 76 years [IQR 70-80 years]; p < .001) and had a longer LoS (5 days [IQR 3-8 days] vs. 4 days [IQR 3-6 days]; p < .001). Women also had a higher readmission rate and mortality rate at both 30 days and 1 year. Following multivariate logistic regression, being female remained significantly related to poor outcome on all outcomes: LoS (odds ratio [OR] 1.86, 95% confidence interval [CI] 1.69-2.05), 30-day readmission (OR 1.23, 95% CI 1.09-1.40), 1-year readmission (OR 1.16, 95% CI 1.06-1.28); 30-day mortality (OR 1.54, 95% CI 1.15-2.07), 1-year mortality (OR 1.24, 95% CI 1.06-1.45). Advancing age and increased comorbidity score were significantly related to longer LoS, higher readmission rates, and higher mortality. Deprivation score was associated with LoS and 1-year readmission rate but not with 30-day readmission and with increased mortality. Higher-volume Trusts (>50 EVARs per year) had higher readmission rates and 1-year mortality. CONCLUSION: These population-based data show that, following EVAR, women have a longer LoS and higher readmission and mortality than men. This reflects the same disparity in outcomes that is found in open AAA repair. Further work to clarify the cause of this is needed.

Lessons learned from the AFLY5 RCT process evaluation: implications for the design of physical activity and nutrition interventions in schools.

BACKGROUND: Systematic reviews have highlighted that school-based diet and physical activity (PA) interventions have had limited effects. This study used qualitative methods to examine how the effectiveness of future primary (elementary) school diet and PA interventions could be improved. METHODS: Data are from the Active For Life Year 5 (AFLY5) study, which was a cluster randomised trial conducted in 60 UK primary schools. Year 5 (8-9 years of age) pupils in the 30 intervention schools received a 12-month intervention. At the end of the intervention period, interviews were conducted with: 28 Year 5 teachers (including 8 teachers from control schools); 10 Headteachers (6 control); 31 parents (15 control). Focus groups were conducted with 70 year 5 pupils (34 control). Topics included how the AFLY5 intervention could have been improved and how school-based diet and PA interventions should optimally be delivered. All interviews and focus groups were transcribed and thematically analysed across participant groups. RESULTS: Analysis yielded four themes. Child engagement: Data suggested that programme success is likely to be enhanced if children feel that they have a sense of autonomy over their own behaviour and if the activities are practical. School: Finding a project champion within the school would enhance intervention effectiveness. Embedding diet and physical activity content across the curriculum and encouraging teachers to role model good diet and physical activity behaviours were seen as important. Parents and community: Encouraging parents and community members into the school was deemed likely to enhance the connection between schools, families and communities, and "create a buzz" that was likely to enhance behaviour change. Government/Policy: Data suggested that there was a need to adequately resource health promotion activity in schools and to increase the infrastructure to facilitate diet and physical activity knowledge and practice. DISCUSSION AND CONCLUSIONS: Future primary school diet and PA programmes should find ways to increase child engagement in the programme content, identify programme champions, encourage teachers to work as role models, engage parents and embed diet and PA behaviour change across the curriculum. However, this will require adequate funding and cost-effectiveness will need to be established. TRIAL REGISTRATION: ISRCTN50133740.

An evaluation of the recording of folic acid use in the South West Congenital Anomaly Register.

OBJECTIVE: Some congenital anomaly registers are collecting data on risk factors for pregnancies affected by anomalies; yet the quality of that information is rarely assessed. We assessed the quality of the risk factor data in the South West Congenital Anomaly Register (SWCAR) through a review of the data held on folic acid use, in cases of neural tube defect (NTD). METHODS: We reviewed all cases of NTD reported to SWCAR over 2 years and compared information held in the register with that in handwritten and computerised prenatal records, where available. RESULTS: Data on folic acid use was recorded in only 41 (36.9%) of the prenatal records of the 111 cases of NTDs reviewed. Information on any folic acid use in the prenatal records was transferred to the register in all instances where it existed. Information on the time of taking folic acid or not taking folic acid was rarely recorded in prenatal records. CONCLUSION: Incomplete recording of folic acid use and timing in prenatal records has limited the ability of SWCAR to collect accurate information on folic acid use in cases of NTDs. Minimal recording information on folic acid use in prenatal records is suggested.