Co-designing adult weight management services: a qualitative study exploring barriers, facilitators, and considerations for future commissioning.

BACKGROUND: Weight management services have not always benefitted everyone equally. People who live in more deprived areas, racially minoritised communities, those with complex additional needs (e.g., a physical or mental disability), and men are less likely to take part in weight management services. This can subsequently widen health inequalities. One way to counter this is to co-design services with under-served groups to better meet their needs. Using a case study approach, we explored how co-designed adult weight management services were developed, the barriers and facilitators to co-design, and the implications for future commissioning. METHODS: We selected four case studies of adult weight management services in Southwest England where co-design had been planned, representing a range of populations and settings. In each case, we recruited commissioners and providers of the services, and where possible, community members involved in co-design activities. Interviews were conducted online, audio-recorded, transcribed verbatim, and analysed using thematic analysis. RESULTS: We interviewed 18 participants (8 female; 10 male): seven commissioners, eight providers, and three community members involved in co-designing the services. The case studies used a range of co-design activities (planned and actualised), from light-touch to more in-depth approaches. In two case studies, co-design activities were planned but were not fully implemented due to organisational time or funding constraints. Co-design was viewed positively by participants as a way of creating more appropriate services and better engagement, thus potentially leading to reduced inequalities. Building relationships- with communities, individual community members, and with partner organisations- was critical for successful co-design and took time and effort. Short-term and unpredictable funding often hindered co-design efforts and could damage relationships with communities. Some commissioners raised concerns over the limited evidence for co-design, while others described having to embrace "a different way of thinking" when commissioning for co-design. CONCLUSIONS: Co-design is an increasingly popular approach to designing health in services but can be difficult to achieve within traditional funding and commissioning practices. Drawing on our case studies, we present key considerations for those wanting to co-design health services, noting the importance of building strong relationships, creating supportive organisational cultures, and developing the evidence base.

Comparison of lotions, creams, gels and ointments for the treatment of childhood eczema: the BEE RCT.

Background: Emollients are recommended for children with eczema (atopic eczema/dermatitis). A lack of head-to-head comparisons of the effectiveness and acceptability of the different types of emollients has resulted in a 'trial and error' approach to prescribing. Objective: To compare the effectiveness and acceptability of four commonly used types of emollients for the treatment of childhood eczema. Design: Four group, parallel, individually randomised, superiority randomised clinical trials with a nested qualitative study, completed in 2021. A purposeful sample of parents/children was interviewed at ≈ 4 and ≈ 16 weeks. Setting: Primary care (78 general practitioner surgeries) in England. Participants: Children aged between 6 months and 12 years with eczema, of at least mild severity, and with no known sensitivity to the study emollients or their constituents. Interventions: Study emollients sharing the same characteristics in the four types of lotion, cream, gel or ointment, alongside usual care, and allocated using a web-based randomisation system. Participants were unmasked and the researcher assessing the Eczema Area Severity Index scores was masked. Main outcome measures: The primary outcome was Patient-Oriented Eczema Measure scores over 16 weeks. The secondary outcomes were Patient-Oriented Eczema Measure scores over 52 weeks, Eczema Area Severity Index score at 16 weeks, quality of life (Atopic Dermatitis Quality of Life, Child Health Utility-9 Dimensions and EuroQol-5 Dimensions, five-level version, scores), Dermatitis Family Impact and satisfaction levels at 16 weeks. Results: A total of 550 children were randomised to receive lotion (analysed for primary outcome 131/allocated 137), cream (137/140), gel (130/135) or ointment (126/138). At baseline, 86.0% of participants were white and 46.4% were female. The median (interquartile range) age was 4 (2-8) years and the median Patient-Oriented Eczema Measure score was 9.3 (SD 5.5). There was no evidence of a difference in mean Patient-Oriented Eczema Measure scores over the first 16 weeks between emollient types (global p = 0.765): adjusted Patient-Oriented Eczema Measure pairwise differences - cream-lotion 0.42 (95% confidence interval -0.48 to 1.32), gel-lotion 0.17 (95% confidence interval -0.75 to 1.09), ointment-lotion -0.01 (95% confidence interval -0.93 to 0.91), gel-cream -0.25 (95% confidence interval -1.15 to 0.65), ointment-cream -0.43 (95% confidence interval -1.34 to 0.48) and ointment-gel -0.18 (95% confidence interval -1.11 to 0.75). There was no effect modification by parent expectation, age, disease severity or the application of UK diagnostic criteria, and no differences between groups in any of the secondary outcomes. Median weekly use of allocated emollient, non-allocated emollient and topical corticosteroids was similar across groups. Overall satisfaction was highest for lotions and gels. There was no difference in the number of adverse reactions and there were no significant adverse events. In the nested qualitative study (n = 44 parents, n = 25 children), opinions about the acceptability of creams and ointments varied most, yet problems with all types were reported. Effectiveness may be favoured over acceptability. Parents preferred pumps and bottles over tubs and reported improved knowledge about, and use of, emollients as a result of taking part in the trial. Limitations: Parents and clinicians were unmasked to allocation. The findings may not apply to non-study emollients of the same type or to children from more ethnically diverse backgrounds. Conclusions: The four emollient types were equally effective. Satisfaction with the same emollient types varies, with different parents/children favouring different ones. Users need to be able to choose from a range of emollient types to find one that suits them. Future work: Future work could focus on how best to support shared decision-making of different emollient types and evaluations of other paraffin-based, non-paraffin and 'novel' emollients. Trial registration: This trial is registered as ISRCTN84540529 and EudraCT 2017-000688-34. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (HTA 15/130/07) and will be published in full in Health Technology Assessment; Vol. 27, No. 19. See the NIHR Journals Library website for further project information.

One in five children in the UK have eczema, a long-term, itchy, dry skin condition. It can significantly affect both the child and their family. Most children are diagnosed and looked after by their family doctor (general practitioner) and are prescribed moisturisers (also called emollients) to relieve skin dryness and other creams (topical corticosteroids) to control flare-ups. However, there are many different types of emollients and, to our knowledge, limited research to show which is better. In the Best Emollients for Eczema clinical trial, we compared the four main types of moisturisers ­ lotions, creams, gels and ointments. These types vary in their consistency, from thin to thick. We recruited 550 children (most of whom were white and had moderate eczema) and randomly assigned them to use one of the four different types as their main moisturiser for 16 weeks. We found no difference in effectiveness. Parent-reported eczema symptoms, eczema severity and quality of life were the same for all the four types of moisturisers. However, overall satisfaction was highest for lotions and gels. Ointments may need to be used less and cause less stinging. We interviewed 44 parents and 25 children who took part. Opinions of all four types of moisturisers varied. What one family liked about a moisturiser was not necessarily the same for another and preferences were individual to each user. Sometimes there was a tension between how well a moisturiser worked (effectiveness) and how easy it was to use (acceptability). In these cases, effectiveness tended to decide whether or not parents kept using it. People found moisturisers in pumps and bottles easier to use than those in tubs. A number of participants valued the information they were given about how to use moisturisers. Our results suggest that the type of moisturiser matters less than finding one that suits the child and family.

Providing men at risk of suicide with emotional support and advice with employment, housing and financial difficulties: a qualitative evaluation of the Hope service.

BACKGROUND: Men at risk of suicide often face difficulties with finances, employment, or housing, yet support services are usually psychologically based. This study evaluated the Hope service which provides integrated psychosocial support alongside practical, financial and specialist advice. AIMS: To examine how the Hope service supports men at risk of suicide and factors that influence its impact and usefulness. METHODS: Twenty-six qualitative interviews with 16 service users, six Hope staff, two specialist money advice workers funded to work for Hope and two NHS referral staff, thematically analysed. RESULTS: The Hope service provided an essential service for men at risk of suicide, with complex needs including addiction, job loss, homelessness, debt, relationship-breakdown and bereavement who often would otherwise have fallen through service provision gaps. Working in a person-centred, non-judgemental way elicited trust and specialist advice tackled problems such as housing needs, debt, benefit claims and employment, enabling men to regain a sense of control over their lives. Some men shared histories of abuse, for which specialist counselling was hard to access. CONCLUSIONS: Hope provides an effective integrated support package for suicidal men. Funding for services like Hope are important to tackle structural issues such as homelessness and debt, alongside emotional support.

Preventing male suicide through a psychosocial intervention that provides psychological support and tackles financial difficulties: a mixed method evaluation.

BACKGROUND: To help resolve high suicide rates in Bristol, North Somerset and South Gloucestershire, the charity Second Step was commissioned to roll-out the Hope service offering a psychosocial intervention for men, supporting them through acute distress and addressing financial difficulties. This study evaluated the impact of the Hope service on men at risk of suicide experiencing financial and other difficulties. METHODS: Mixed methods study using: (i) a prospective cohort study design to compare depression, suicidal ideation and financial self-efficacy scores of men aged 30-64, referred to the service between October 2018 and July 2020, at baseline and 6 months follow-up and between low and moderate to high-intensity service users; and (ii) a qualitative interview study to evaluate the acceptability and impact of the Hope service to Hope service users. RESULTS: There was a 49% reduction in depression score (mean reduction - 10.0, 95% CI - 11.7 to - 8.3) and in the proportion of service users with suicidal ideation (percent reduction - 52.5, 95% CI - 64.1% to - 40.9%) at 6 months follow-up compared to baseline. Financial self-efficacy scores increased by 26% (mean increase 2.9, 95% CI 1.8 to 3.9). Qualitative accounts illustrated how 'Hope saved my life' for several men interviewed; most respondents described being able to move forward and tackle challenges with more confidence following the Hope intervention. Professional advice to tackle financial and other difficulties such as housing helped to relieve anxiety and stress and enable practical issues to be resolved. CONCLUSIONS: The Hope service offered practical and emotional support to men who have experienced suicidal feelings, redundancy, homelessness and poverty and occupies an important space between mental health and social care provision. Hope demonstrates the value of an intervention which cuts across traditional boundaries between psychiatric care and social advice agencies to provide, what is, in effect, an integrated care service.

Behavioural interventions for smoking cessation: an overview and network meta-analysis.

BACKGROUND: Smoking is a leading cause of disease and death worldwide. In people who smoke, quitting smoking can reverse much of the damage. Many people use behavioural interventions to help them quit smoking; these interventions can vary substantially in their content and effectiveness. OBJECTIVES: To summarise the evidence from Cochrane Reviews that assessed the effect of behavioural interventions designed to support smoking cessation attempts and to conduct a network meta-analysis to determine how modes of delivery; person delivering the intervention; and the nature, focus, and intensity of behavioural interventions for smoking cessation influence the likelihood of achieving abstinence six months after attempting to stop smoking; and whether the effects of behavioural interventions depend upon other characteristics, including population, setting, and the provision of pharmacotherapy. To summarise the availability and principal findings of economic evaluations of behavioural interventions for smoking cessation, in terms of comparative costs and cost-effectiveness, in the form of a brief economic commentary. METHODS: This work comprises two main elements. 1. We conducted a Cochrane Overview of reviews following standard Cochrane methods. We identified Cochrane Reviews of behavioural interventions (including all non-pharmacological interventions, e.g. counselling, exercise, hypnotherapy, self-help materials) for smoking cessation by searching the Cochrane Library in July 2020. We evaluated the methodological quality of reviews using AMSTAR 2 and synthesised data from the reviews narratively. 2. We used the included reviews to identify randomised controlled trials of behavioural interventions for smoking cessation compared with other behavioural interventions or no intervention for smoking cessation. To be included, studies had to include adult smokers and measure smoking abstinence at six months or longer. Screening, data extraction, and risk of bias assessment followed standard Cochrane methods. We synthesised data using Bayesian component network meta-analysis (CNMA), examining the effects of 38 different components compared to minimal intervention. Components included behavioural and motivational elements, intervention providers, delivery modes, nature, focus, and intensity of the behavioural intervention. We used component network meta-regression (CNMR) to evaluate the influence of population characteristics, provision of pharmacotherapy, and intervention intensity on the component effects. We evaluated certainty of the evidence using GRADE domains. We assumed an additive effect for individual components. MAIN RESULTS: We included 33 Cochrane Reviews, from which 312 randomised controlled trials, representing 250,563 participants and 845 distinct study arms, met the criteria for inclusion in our component network meta-analysis. This represented 437 different combinations of components. Of the 33 reviews, confidence in review findings was high in four reviews and moderate in nine reviews, as measured by the AMSTAR 2 critical appraisal tool. The remaining 20 reviews were low or critically low due to one or more critical weaknesses, most commonly inadequate investigation or discussion (or both) of the impact of publication bias. Of note, the critical weaknesses identified did not affect the searching, screening, or data extraction elements of the review process, which have direct bearing on our CNMA. Of the included studies, 125/312 were at low risk of bias overall, 50 were at high risk of bias, and the remainder were at unclear risk. Analyses from the contributing reviews and from our CNMA showed behavioural interventions for smoking cessation can increase quit rates, but effectiveness varies on characteristics of the support provided. There was high-certainty evidence of benefit for the provision of counselling (odds ratio (OR) 1.44, 95% credibility interval (CrI) 1.22 to 1.70, 194 studies, n = 72,273) and guaranteed financial incentives (OR 1.46, 95% CrI 1.15 to 1.85, 19 studies, n = 8877). Evidence of benefit remained when removing studies at high risk of bias. These findings were consistent with pair-wise meta-analyses from contributing reviews. There was moderate-certainty evidence of benefit for interventions delivered via text message (downgraded due to unexplained statistical heterogeneity in pair-wise comparison), and for the following components where point estimates suggested benefit but CrIs incorporated no clinically significant difference: individual tailoring; intervention content including motivational components; intervention content focused on how to quit. The remaining intervention components had low-to very low-certainty evidence, with the main issues being imprecision and risk of bias. There was no evidence to suggest an increase in harms in groups receiving behavioural support for smoking cessation. Intervention effects were not changed by adjusting for population characteristics, but data were limited. Increasing intensity of behavioural support, as measured through the number of contacts, duration of each contact, and programme length, had point estimates associated with modestly increased chances of quitting, but CrIs included no difference. The effect of behavioural support for smoking cessation appeared slightly less pronounced when people were already receiving smoking cessation pharmacotherapies. AUTHORS' CONCLUSIONS: Behavioural support for smoking cessation can increase quit rates at six months or longer, with no evidence that support increases harms. This is the case whether or not smoking cessation pharmacotherapy is also provided, but the effect is slightly more pronounced in the absence of pharmacotherapy. Evidence of benefit is strongest for the provision of any form of counselling, and guaranteed financial incentives. Evidence suggested possible benefit but the need of further studies to evaluate: individual tailoring; delivery via text message, email, and audio recording; delivery by lay health advisor; and intervention content with motivational components and a focus on how to quit. We identified 23 economic evaluations; evidence did not consistently suggest one type of behavioural intervention for smoking cessation was more cost-effective than another. Future reviews should fully consider publication bias. Tools to investigate publication bias and to evaluate certainty in CNMA are needed.

ANTECEDENTES: El tabaquismo es una causa principal de enfermedad y muerte en todo el mundo. En las personas que fuman, dejar de fumar puede revertir gran parte del daño. Muchas personas utilizan intervenciones conductuales para ayudarles a dejar de fumar y estas intervenciones pueden variar considerablemente en contenido y efectividad. OBJETIVOS: Resumir la evidencia de las revisiones Cochrane que evaluaron el efecto de las intervenciones conductuales diseñadas para apoyar los intentos de abandono del hábito de fumar y realizar un metanálisis en red para determinar cómo las modalidades de prestación; la persona que administra la intervención; y la naturaleza, el enfoque y la intensidad de las intervenciones conductuales para el abandono del hábito de fumar influyen en la probabilidad de lograr la abstinencia seis meses después de intentar dejar de fumar; y si los efectos de las intervenciones conductuales dependen de otras características, como la población, el contexto y la administración de farmacoterapia. Resumir la disponibilidad y los hallazgos principales de las evaluaciones económicas de intervenciones conductuales para dejar de fumar, en términos de costes y coste­efectividad, mediante un breve comentario económico. MÉTODOS: Este artículo comprende dos elementos principales. 1. Se realizó una revisión global Cochrane de revisiones según los métodos estándar de Cochrane. Mediante una búsqueda en la Biblioteca Cochrane en julio de 2020 se identificaron las revisiones Cochrane de intervenciones conductuales (incluidas todas las intervenciones no farmacológicas, p.ej., orientación, ejercicio, hipnoterapia, materiales de autoayuda) para el abandono del hábito de fumar. La calidad metodológica de las revisiones se evaluó mediante AMSTAR 2 y los datos de las revisiones se resumieron de manera narrativa. 2. Las revisiones incluidas se utilizaron para identificar los ensayos controlados aleatorizados de intervenciones conductuales para el abandono del hábito de fumar en comparación con otras intervenciones conductuales o ninguna intervención para el abandono del hábito de fumar. Para ser incluidos, los estudios debían incluir a fumadores adultos y medir la abstinencia de fumar a los seis meses o más. La selección, la extracción de los datos y la evaluación del riesgo de sesgo siguieron los métodos Cochrane estándar. Los datos se resumieron mediante un metanálisis en red de componentes (MARC) bayesiano, y se examinaron los efectos de 38 componentes diferentes en comparación con una intervención mínima. Los componentes incluyeron elementos conductuales y motivacionales, proveedores de la intervención, modos de administración, naturaleza, enfoque e intensidad de la intervención conductual. Se utilizó la metarregresión en red de componentes (MRRC) para evaluar la influencia de las características de la población, la administración de farmacoterapia y la intensidad de la intervención sobre los efectos de los componentes. La certeza de la evidencia se evaluó mediante los dominios de GRADE. Se presupuso un efecto aditivo para los componentes individuales. RESULTADOS PRINCIPALES: Se incluyeron 33 revisiones Cochrane, de las cuales 312 ensayos controlados aleatorizados, que representaban a 250 563 participantes y 845 grupos de estudio distintos, cumplieron los criterios para su inclusión en el metanálisis en red de componentes. Esto representó 437 combinaciones diferentes de componentes. De las 33 revisiones, la confianza en los hallazgos de la revisión fue alta en cuatro y moderada en nueve, medida con la herramienta de lectura crítica AMSTAR 2. Las 20 revisiones restantes tuvieron una confianza baja o críticamente baja debido a una o más deficiencias graves, las más habituales fueron una investigación o discusión (o ambas) insuficiente acerca del impacto del sesgo de publicación. Cabe señalar que las debilidades críticas identificadas no afectaron los elementos de la búsqueda, la selección o la extracción de los datos del proceso de revisión, que mantienen una relación directa en este MARC. Entre los estudios incluidos, 125/312 tuvieron un riesgo general de sesgo bajo, 50 un riesgo de sesgo alto y el resto un riesgo de sesgo poco claro. Los análisis de las revisiones contribuyentes y de este MARC mostraron que las intervenciones conductuales para dejar de fumar pueden aumentar las tasas de abandono del hábito, pero la efectividad varía según las características del apoyo proporcionado. Hubo evidencia de certeza alta de un efecto beneficioso de la prestación de orientación (odds ratio [OR] 1,44; intervalo de credibilidad [ICr] del 95%: 1,22 a 1,70, 194 estudios, n = 72 273) y de los incentivos económicos garantizados (OR 1,46; ICr del 95% 1,15 a 1,85, 19 estudios, n = 8877). La evidencia de un efecto beneficioso se mantuvo cuando se eliminaron los estudios con alto riesgo de sesgo. Estos hallazgos fueron concordantes con los metanálisis pareados de las revisiones contribuyentes. Hubo evidencia de certeza moderada de un efecto beneficioso de las intervenciones administradas a través de mensajes de texto (la certeza se disminuyó debido a una heterogeneidad estadística inexplicada en la comparación pareada), y de los siguientes componentes en los que las estimaciones puntuales indicaron un efecto beneficioso pero los ICr no incorporaron una diferencia clínicamente significativa: personalización; contenido de la intervención con componentes motivacionales; contenido de la intervención centrado en cómo dejar de fumar. Los otros componentes de la intervención tuvieron evidencia de certeza muy baja a baja, y sus problemas principales fueron la imprecisión y el riesgo de sesgo. No hubo evidencia que indicara un aumento de los efectos perjudiciales en los grupos que recibieron apoyo conductual para dejar de fumar. Los efectos de la intervención no cambiaron al ajustar las características de la población, pero los datos fueron limitados. El aumento de la intensidad del apoyo conductual, medido a través del número de contactos, la duración de cada contacto y la duración del programa, tuvo estimaciones puntuales asociadas con un modesto aumento de las posibilidades de dejar de fumar, pero los ICr no incluyeron una diferencia. El efecto del apoyo conductual para dejar de fumar pareció ser ligeramente menos pronunciado cuando las personas ya recibían farmacoterapias para dejar de fumar. CONCLUSIONES DE LOS AUTORES: El apoyo conductual para dejar de fumar puede aumentar las tasas de abandono a los seis meses o más, sin evidencia de que este apoyo aumente los efectos perjudiciales. Esto es así tanto si se proporciona una farmacoterapia para dejar de fumar como si no, pero el efecto es ligeramente más pronunciado sin farmacoterapia. La evidencia de un efecto beneficioso es más sólida para la prestación de cualquier tipo de orientación y de incentivos económicos garantizados. La evidencia indicó un posible efecto beneficioso, pero la necesidad de realizar más estudios para evaluar: la personalización; la administración mediante mensajes de texto, correos electrónicos y grabaciones de audio; la administración por parte de un asesor de salud no profesional; y el contenido de la intervención con componentes motivacionales y centrada en cómo dejar de fumar. Se identificaron 23 evaluaciones económicas; la evidencia no indicó de manera homogénea que un tipo de intervención conductual para el abandono del hábito de fumar fuera más coste­efectiva que otra. Las revisiones futuras deberían examinar a fondo el sesgo de publicación. Se necesitan herramientas para investigar el sesgo de publicación y evaluar la certeza en MARC.

Best emollients for eczema (BEE) - comparing four types of emollients in children with eczema: protocol for randomised trial and nested qualitative study.

INTRODUCTION: Atopic dermatitis/eczema affects around 20% of children and is characterised by inflamed, dry, itchy skin. Guidelines recommend 'leave-on' emollients that are applied directly to the skin to add or trap moisture and used regularly, they can soothe, enhance the skin barrier and may prevent disease 'flares'. However, the suitability of the many different emollients varies between people and there is little evidence to help prescribers and parents and carers decide which type to try first. METHODS AND ANALYSIS: Design: pragmatic, multicentre, individually randomised, parallel group superiority trial of four types of emollient (lotions, creams, gel or ointments). SETTING: general practitioner surgeries in England. PARTICIPANTS: children aged over 6 months and less than 12 years with mild-to-severe eczema and no known sensitivity to study emollients. INTERVENTIONS: study-approved lotion, cream, gel or ointment as the only leave-on emollient for 16 weeks, with directions to apply twice daily and as required. Other treatments, such as topical corticosteroids, used as standard care. FOLLOW-UP: 52 weeks. PRIMARY OUTCOME: validated patient-orientated eczema measure measured weekly for 16 weeks. SECONDARY OUTCOMES: eczema signs (Eczema Area Severity Index) by masked researcher, treatment use, parent satisfaction, adverse events, child and family quality of life (Atopic Dermatitis Quality of Life, Child Health Utility 9D and Dermatitis Family Impact). SAMPLE SIZE: 520 participants (130 per group). ANALYSIS: intention-to-treat using linear mixed models for repeated measures.Nested qualitative study: audio-recording of sample of baseline appointments and up to 60 interviews with participants at 4 and 16 weeks, interviews to be transcribed and analysed thematically. ETHICS AND DISSEMINATION: Ethics approval granted by the NHS REC (South West - Central Bristol Research Ethics Committee 17/SW/0089). Findings will be presented at conferences, published in open-access peer-reviewed journals and the study website; and summaries shared with key stakeholders. TRIAL REGISTRATION NUMBER: ISRCTN84540529.

Predictive value of inflammatory markers for cancer diagnosis in primary care: a prospective cohort study using electronic health records.

BACKGROUND: Early identification of cancer in primary care is important and challenging. This study examined the diagnostic utility of inflammatory markers (C-reactive protein, erythrocyte sedimentation rate and plasma viscosity) for cancer diagnosis in primary care. METHODS: Cohort study of 160,000 patients with inflammatory marker testing in 2014, plus 40,000 untested matched controls, using Clinical Practice Research Datalink (CPRD), with Cancer Registry linkage. Primary outcome was one-year cancer incidence. RESULTS: Primary care patients with a raised inflammatory marker have a one-year cancer incidence of 3.53% (95% CI 3.37-3.70), compared to 1.50% (1.43-1.58) in those with normal inflammatory markers, and 0.97% (0.87-1.07) in untested controls. Cancer risk is greater with higher inflammatory marker levels, with older age and in men; risk rises further when a repeat test is abnormal but falls if it normalises. Men over 50 and women over 60 with raised inflammatory markers have a cancer risk which exceeds the 3% NICE threshold for urgent investigation. Sensitivities for cancer were 46.1% for CRP, 43.6% ESR and 49.7% for PV. CONCLUSION: Cancer should be considered in patients with raised inflammatory markers. However, inflammatory markers have a poor sensitivity for cancer and are therefore not useful as 'rule-out' test.

Biomedical risk assessment as an aid for smoking cessation.

BACKGROUND: A possible strategy for increasing smoking cessation rates could be to provide smokers with feedback on the current or potential future biomedical effects of smoking using, for example, measurement of exhaled carbon monoxide (CO), lung function, or genetic susceptibility to lung cancer or other diseases. OBJECTIVES: The main objective was to determine the efficacy of providing smokers with feedback on their exhaled CO measurement, spirometry results, atherosclerotic plaque imaging, and genetic susceptibility to smoking-related diseases in helping them to quit smoking. SEARCH METHODS: For the most recent update, we searched the Cochrane Tobacco Addiction Group Specialized Register in March 2018 and ClinicalTrials.gov and the WHO ICTRP in September 2018 for studies added since the last update in 2012. SELECTION CRITERIA: Inclusion criteria for the review were: a randomised controlled trial design; participants being current smokers; interventions based on a biomedical test to increase smoking cessation rates; control groups receiving all other components of intervention; and an outcome of smoking cessation rate at least six months after the start of the intervention. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We expressed results as a risk ratio (RR) for smoking cessation with 95% confidence intervals (CI). Where appropriate, we pooled studies using a Mantel-Haenszel random-effects method. MAIN RESULTS: We included 20 trials using a variety of biomedical tests interventions; one trial included two interventions, for a total of 21 interventions. We included a total of 9262 participants, all of whom were adult smokers. All studies included both men and women adult smokers at different stages of change and motivation for smoking cessation. We judged all but three studies to be at high or unclear risk of bias in at least one domain. We pooled trials in three categories according to the type of biofeedback provided: feedback on risk exposure (five studies); feedback on smoking-related disease risk (five studies); and feedback on smoking-related harm (11 studies). There was no evidence of increased cessation rates from feedback on risk exposure, consisting mainly of feedback on CO measurement, in five pooled trials (RR 1.00, 95% CI 0.83 to 1.21; I2 = 0%; n = 2368). Feedback on smoking-related disease risk, including four studies testing feedback on genetic markers for cancer risk and one study with feedback on genetic markers for risk of Crohn's disease, did not show a benefit in smoking cessation (RR 0.80, 95% CI 0.63 to 1.01; I2 = 0%; n = 2064). Feedback on smoking-related harm, including nine studies testing spirometry with or without feedback on lung age and two studies on feedback on carotid ultrasound, also did not show a benefit (RR 1.26, 95% CI 0.99 to 1.61; I2 = 34%; n = 3314). Only one study directly compared multiple forms of measurement with a single form of measurement, and did not detect a significant difference in effect between measurement of CO plus genetic susceptibility to lung cancer and measurement of CO only (RR 0.82, 95% CI 0.43 to 1.56; n = 189). AUTHORS' CONCLUSIONS: There is little evidence about the effects of biomedical risk assessment as an aid for smoking cessation. The most promising results relate to spirometry and carotid ultrasound, where moderate-certainty evidence, limited by imprecision and risk of bias, did not detect a statistically significant benefit, but confidence intervals very narrowly missed one, and the point estimate favoured the intervention. A sensitivity analysis removing those studies at high risk of bias did detect a benefit. Moderate-certainty evidence limited by risk of bias did not detect an effect of feedback on smoking exposure by CO monitoring. Low-certainty evidence, limited by risk of bias and imprecision, did not detect a benefit from feedback on smoking-related risk by genetic marker testing. There is insufficient evidence with which to evaluate the hypothesis that multiple types of assessment are more effective than single forms of assessment.

GP and parent dissonance about the assessment and treatment of childhood eczema in primary care: a qualitative study.

OBJECTIVES: To compare parents' and clinicians' perspectives on the assessment and treatment of children with eczema in primary care. DESIGN: Qualitative interview study with purposive and snowball sampling and thematic analysis. SETTING: 14 general practices in the UK. PARTICIPANTS: 11 parents of children with eczema and 15 general practitioners (GPs) took part in semistructured individual interviews. RESULTS: We identified several areas of dissonance between parents and GPs. First, parents sought a 'cause' of eczema, such as an underlying allergy, whereas GPs looked to manage the symptoms of an incurable condition. Second, parents often judged eczema severity in terms of psychosocial impact, while GPs tended to focus on the appearance of the child's skin. Third, parents sought 'more natural' over-the-counter treatments or complementary medicine, which GPs felt unable to endorse because of their unknown effectiveness and potential harm. Fourth, GPs linked poor outcomes to unrealistic expectations of treatment and low adherence to topical therapy, whereas parents reported persisting with treatment and despondency with its ineffectiveness. Consultations were commonly described by parents as being dominated by the GP, with a lack of involvement in treatment decisions. GPs' management of divergent views varied, but avoidance strategies were often employed. CONCLUSIONS: Divergent views between parents and clinicians regarding the cause and treatment of childhood eczema can probably only be bridged by clinicians actively seeking out opinions and sharing rationale for their approach to treatment. Together with assessing the psychosocial as well as the physical impact of eczema, asking about current or intended use of complementary therapy and involving parents in treatment decisions, the management of eczema and patient outcomes could be improved.

Using willingness-to-pay to establish patient preferences for cancer testing in primary care.

BACKGROUND: Shared decision making is a stated aim of several healthcare systems. In the area of cancer, patients' views have informed policy on screening and treatment but there is little information about their views on diagnostic testing in relation to symptom severity. METHODS: We used the technique of willingness-to-pay to determine public preferences around diagnostic testing for colorectal, lung, and pancreatic cancer in primary care in the UK. Participants were approached in general practice waiting rooms and asked to complete a two-stage electronic survey that described symptoms of cancer, the likelihood that the symptoms indicate cancer, and information about the appropriate diagnostic test. Part 1 asked for a binary response (yes/no) as to whether they would choose to have a test if it were offered. Part 2 elicited willingness-to-pay values of the tests using a payment scale followed by a bidding exercise, with the aim that these values would provide a strength of preference not detectable using the binary approach. RESULTS: A large majority of participants chose to be tested for all cancers, with only colonoscopy (colorectal cancer) demonstrating a risk gradient. In the willingness-to-pay exercise participants placed a lower value on an X-ray (lung cancer) than the tests for colorectal or pancreatic cancer and X-ray was the only test where risk was clearly related to the willingness-to-pay value. CONCLUSION: Willingness-to-pay values did not enhance the binary responses in the way intended; participants appeared to be motivated differently when responding to the two parts of the questionnaire. More work is needed to understand how participants perceive risk in this context and how they respond to questions about willingness-to-pay. Qualitative methods could provide useful insights.

Early detection of eukaryotic communities from marine biofilm using high-throughput sequencing: an assessment of different sampling devices.

Marine biofilms are precursors for colonization by larger fouling organisms, including non-indigenous species (NIS). In this study, high-throughput sequencing (HTS) of 18S rRNA metabarcodes was used to investigate four sampling methods (modified syringe, sterilized sponge, underwater tape and sterilized swab) for characterizing eukaryotic communities in marine biofilms. Perspex™ plates were sampled in and out of water. DNA collected with tape did not amplify. Otherwise, there were no statistical differences in communities among the remaining three sampling devices or between the two environments. Sterilized sponges are recommended for ease of use underwater. In-depth HTS analysis identified diverse eukaryotic communities, dominated by Metazoa and Chromoalveolata. Among the latter, diatoms (Bacillariophyceae) were particularly abundant (33% of reads assigned to Chromalveolata). The NIS Ciona savignyi was detected in all samples. The application of HTS in marine biofilm surveillance could facilitate early detection of NIS, improving the probability of successful eradication.

Ethnic differences in patients' preferences for prostate cancer investigation: a vignette-based survey in primary care.

BACKGROUND: Minority ethnic groups in the UK have worse outcomes for some cancer types compared with the white majority. Black males have worse staging at diagnosis of prostate cancer and often present as emergencies, suggesting possible delays in the diagnostic pathway. Delay may arise from lower awareness of cancer symptoms, reluctance to report symptoms, reduced desire for investigation, or a combination of these. Reduced desire for investigation was examined in this study AIM: To investigate whether black males in the UK would choose to be tested for prostate cancer compared with the white majority. DESIGN AND SETTING: A vignette (hypothetical scenario)-based, electronic survey of male patients aged ≥40 years from four general practices in Bristol, UK. METHOD: The vignettes described possible prostate cancer symptoms (equating to risk levels of 2%, 5%, and 10%), investigative procedures, and possible outcomes. Participants indicated whether they would choose investigation in these scenarios. Analysis used logistic regression, with preference for investigation as the outcome variable and ethnicity as the main explanatory variable. RESULTS: In total, 449 (81%) of 555 participants opted for investigation, regardless of risk levels; of these, the acceptance rate was 94% (251 out of 267) among white males and 70% (198 out of 285) among black males. In multivariable analyses, preference for investigation was lower in black males, even after controlling for relevant confounding factors including specific risk level (odds ratio 0.13; 95% confidence interval = 0.07 to 0.25; P<0.001). CONCLUSION: Black males are less likely to opt for investigation at any risk level of prostate cancer compared with white males. This may explain some of their late-stage presentation at diagnosis and subsequent poorer outcomes.

Preferences for cancer investigation: a vignette-based study of primary-care attendees.

BACKGROUND: The UK lags behind many European countries in terms of cancer survival. Initiatives to address this disparity have focused on barriers to presentation, symptom recognition, and referral for specialist investigation. Selection of patients for further investigation has come under particular scrutiny, although preferences for referral thresholds in the UK population have not been studied. We investigated preferences for diagnostic testing for colorectal, lung, and pancreatic cancers in primary-care attendees. METHODS: In a vignette-based study, researchers recruited individuals aged at least 40 years attending 26 general practices in three areas of England between Dec 6, 2011, and Aug 1, 2012. Participants completed up to three of 12 vignettes (four for each of lung, pancreatic, and colorectal cancers), which were randomly assigned. The vignettes outlined a set of symptoms, the risk that these symptoms might indicate cancer (1%, 2%, 5%, or 10%), the relevant testing process, probable treatment, possible alternative diagnoses, and prognosis if cancer were identified. Participants were asked whether they would opt for diagnostic testing on the basis of the information in the vignette. FINDINGS: 3469 participants completed 6930 vignettes. 3052 individuals (88%) opted for investigation in their first vignette. We recorded no strong evidence that participants were more likely to opt for investigation with a 1% increase in risk of cancer (odds ratio [OR] 1·02, 95% CI 0·99-1·06; p=0·189), although the association between risk and opting for investigation was strong when colorectal cancer was analysed alone (1·08, 1·03-1·13; p=0·0001). In multivariable analysis, age had an effect in all three cancer models: participants aged 60-69 years were significantly more likely to opt for investigation than were those aged 40-59 years, and those aged 70 years or older were less likely. Other variables associated with increased likelihood of opting for investigation were shorter travel times to testing centre (colorectal and lung cancers), a family history of cancer (colorectal and lung cancers), and higher household income (colorectal and pancreatic cancers). INTERPRETATION: Participants in our sample expressed a clear preference for diagnostic testing at all risk levels, and individuals want to be tested at risk levels well below those stipulated by UK guidelines. This willingness should be considered during design of cancer pathways, particularly in primary care. The public engagement with our study should encourage general practitioners to involve patients in referral decision making. FUNDING: The National Institute for Health Research Programme Grants for Applied Research programme.

Is healthy eating for obese children necessarily more costly for families?

BACKGROUND: During consultations on weight management in childhood obesity clinics, the additional costs incurred by healthy eating are often cited, as an economic barrier to achieving a better nutritional balance. AIM: To examine whether adopting an improved theoretical, balanced diet compared to current dietary habits in children incurs additional cost. DESIGN AND SETTING: Children aged 5-16 years (body mass index [BMI] ≥98th percentile) recruited to a randomised trial comparing a hospital-based and primary care childhood obesity clinics provided data for this study. METHOD: Three-day dietary diaries collected at baseline were analysed for energy and fat intake and then compared to a theoretical, adjusted healthy-eating diet based on the Food Standards Agency, 'Eatwell plate'. Both were priced contemporaneously using the appropriate portion size, at a neighbourhood, mid-range supermarket, at a budget supermarket, and on the local high street. RESULTS: The existing diet purchased at a budget supermarket was cheapest (£2.48/day). The healthier, alternative menu at the same shop cost an additional 33 pence/day (£2.81). The same exercise in a mid-range supermarket, incurred an additional cost of 4 pence per day (£3.40 versus £3.44). Switching from an unhealthy mid-range supermarket menu to the healthier, budget-outlet alternative saved 59 pence per day. The healthier, alternative menu was cheaper than the existing diet if purchased on the high street (£3.58 versus £3.75), although for both menus this was most expensive. CONCLUSION: For many obese children, eating healthily would not necessarily incur prohibitive, additional financial cost, although a poor diet at a budget supermarket remains the cheapest of all options. Cost is a possible barrier to healthy eating for the most economically disadvantaged.