Clinical and cost-effectiveness of telemedicine among patients with type 2 diabetes in primary care: A systematic review and meta-analysis.

AIMS: Telemedicine has been promoted as an effective way of managing type-2 diabetes (T2DM) in primary care. However, the effectiveness of telemedicine is unclear. We investigated the clinical and cost-effectiveness of different telemedicine interventions for people with T2DM, compared to usual care. METHODS: We searched Medline, Embase, Cochrane, CINHAL, ProQuest and EconLit for randomized controlled trials (RCTs) that examined the effectiveness of telemedicine interventions on clinical outcomes (HbA1c, body mass index [BMI], weight, diastolic blood pressure [DBP], systolic blood pressure [SBP], fasting blood glucose, high-density lipoprotein [HDL] cholesterol, low-density lipoprotein [LDL] cholesterol, total cholesterol and triglyceride) in adults with T2DM, published in English from inception until 31 December 2022. Meta-analyses were conducted using random-effects models pooling mean differences, heterogeneity was quantified using the I2 statistic. Publication bias was assessed using funnel plots, Egger tests and trim and fill. Subgroup analyses included type of telemedicine intervention, telemedicine mode of delivery and type of healthcare professionals. This study was registered with PROSPERO, CRD 42022375128. RESULTS: Of the 4093 records identified, 21 RCTs, 10,732 participants from seven regions, were included. Reported interventions included telephone (k = 16 studies), internet-based (k = 2), videoconference (k = 2) and telephone and emails (k = 1). We observed no statistically significant differences between synchronous or asynchronous telemedicine interventions compared to usual care for HbA1c (-0.08% (-0.88 mmol/mol); 95% CI: -0.18, 0.02), BMI (0.51 kg/m2; 95% CI: -0.21, 1.22), SBP (-1.48 mmHg; 95% CI: -3.22, 0.26), DBP (3.23 mmHg; 95% CI: -0.89, 7.34), HDL-cholesterol (0.01 mmol/L; 95% CI: -0.03, 0.05), LDL-cholesterol (0.08 mmol/L; 95% CI: -0.22, 0.37), triglycerides (-0.08 mmol/L, 95% CI: -0.31, -0.15), total cholesterol (-0.10 mmol/L; 95% CI: -0.25, 0.04) and weight (-0.50 kg; 95% CI: -1.21, 0.21). CONCLUSIONS: Telemedicine was as effective as usual care in improving health outcomes of people with T2DM. They can provide a safe solution in times of rising demands for primary healthcare services, or in extreme events, like a global pandemic. More high-quality RCTs are needed on the cost evaluation of telemedicine.

Investigating attention toward pain-related cues in an Arabic-speaking population with and without chronic pain.

There is some evidence for attentional biases in individuals with chronic pain (CP). Cultural and linguistic differences might affect the manifestation of these processes across populations. However, such attentional biases have not been explored in the Arabic-speaking population. The current study investigated these attentional biases and possible associations with resilience. Two matched groups of Arabic-speaking participants with (58) and without (58) CP were recruited from Jordan and the United Kingdom. They completed emotionally modified versions of the Posner cueing and Stroop tasks, alongside questionnaires. Significant group differences were found for the Posner task, with the CP group exhibiting disengagement revealed by the inhibition of return (IOR) effect for sensory pain-related cues compared to delayed disengagement for the other cue types. The control group showed IOR across cue types. No group differences were found on the Stroop task. The CP group had lower resilience scores than healthy controls, and resilience moderated performance on the Posner task. The study provides preliminary evidence about the attentional processes in the Arabic population; the speed of disengagement is affected in the CP group with early disengagement for sensory pain-related information compared to affect pain and neutral stimuli. Furthermore, resilience levels in the CP and control group moderated the performance on the Posner task, suggesting that it influences attentional allocation. This study can help in understanding how the phenomenon of attention bias intertwines with the cultural and linguistic factors. Future research should further explore attentional dynamics across different time points in this population and the modulatory effect of resilience.

Effectiveness of psychosocial interventions for alcohol use disorder: a systematic review and meta-analysis update.

Background: Given the accumulating research, evolving psychosocial treatment, and equivocal findings, updating WHO's Mental Health Gap Action Programme-2015 was necessary to ensure guidelines reflect effective strategies for alcohol use disorder (AUD).Objective: To estimate the effects of psychosocial interventions on drinking and related outcomes.Methods: We included randomized controlled trials published between January 2015 and June 2022 on adults with alcohol dependence (ICD 10/DSM-IV) and moderate to severe AUD (DSM-5), and those examined psychosocial interventions against treatment-as-usual (TAU) and active controls. Eight databases and registries were searched. Relative Risk (RR) and standardized mean difference (SMD) were used for dichotomous and continuous outcomes. We used Cochrane's risk of bias assessment (RoB2).Results: Of 873 screened records, 14 and 13 studies in the narrative synthesis and meta-analysis. Of the 2,575 participants, 71.5% were men. Thirteen studies used ICD 10/DSM IV diagnosis. Compared to TAU, any psychosocial intervention increased the relative risk of abstinence by 28% [N = 7, RR = 1.28, 95% CI: 1.07 to 1.53, p = .01, NNT = 9]. There were minimal heterogeneity and no evidence of publication bias. Psychosocial interventions were not effective in reducing the drinking frequency (n = 2, Hedge's g = -0.10, 95% CI: -0.46 to 0.26, p = .57) and drinks/drinking days (N = 5, g = -0.10, 95% CI: -0.37 to 0.16, p = .43). Treatment discontinuation did not differ between intervention and control groups [RR = 1.09, 95% CI: 0.66 to 1.80].Conclusion: Psychosocial interventions are effective in improving abstinence but not in reducing drinking frequency or amount. Policymakers must consider this evidence to generate AUD treatment guidelines.Registration: PROSPERO 2022 CRD42022342608.

The mental health needs of healthcare workers: When evidence does not guide policy. A comparative assessment of selected European countries.

BACKGROUND: The healthcare workforce (HCWF) globally is facing high stress levels and deteriorating mental health due to workplace, labour market and policy deficiencies that further exacerbate the existing crisis. However, comprehensive and effective action is missing. AIMS: We adopt a health system and governance perspective to address the mental health needs of healthcare workers (HCWs), considering the nature of interventions and the levels and actors involved in governance. The aim is to move the debate forward by identifying governance gaps hampering the implementation of health workforce policies and exploring strategies to effectively increase mental health support. MATERIAL AND METHODS: A qualitative comparative methodology is applied based on a case study design utilising a multi-level intersectoral governance matrix. We conducted a rapid assessment of HCWF developments in the European context (Germany, Portugal, Romania, Switzerland and the United Kingdom), drawing on secondary sources and country experts. RESULTS AND DISCUSSION: Awareness of mental health threats among HCWs increased, but policy discourse is driven by service delivery and labour market demands. The attention to HCWs' needs is stronger on the international level and weakest at national/regional levels. Although organisations and professions demonstrate varying degrees of activity, their efforts are scattered and lack sustainability. Similar challenges were identified across healthcare systems, including limited action, disconnected actors, missing coordination, and a lack of attention to governance gaps and system weaknesses. CONCLUSION: Adopting a health system approach is important but not sufficient. Successful mental health policy implementation needs multi-level governance and coherent coordination mechanisms.

A culturally adapted manual-assisted problem-solving intervention (CMAP) for adults with a history of self-harm: a multi-centre randomised controlled trial.

BACKGROUND: Self-harm is an important predictor of a suicide death. Culturally appropriate strategies for the prevention of self-harm and suicide are needed but the evidence is very limited from low- and middle-income countries (LMICs). This study aims to investigate the effectiveness of a culturally adapted manual-assisted problem-solving intervention (CMAP) for patients presenting after self-harm. METHODS: This was a rater-blind, multicenter randomised controlled trial. The study sites were all participating emergency departments, medical wards of general hospitals and primary care centres in Karachi, Lahore, Rawalpindi, Peshawar, and Quetta, Pakistan. Patients presenting after a self-harm episode (n = 901) to participating recruitment sites were assessed and randomised (1:1) to one of the two arms; CMAP with enhanced treatment as usual (E-TAU) or E-TAU. The intervention (CMAP) is a manual-assisted, cognitive behaviour therapy (CBT)-informed problem-focused therapy, comprising six one-to-one sessions delivered over three months. Repetition of self-harm at 12-month post-randomisation was the primary outcome and secondary outcomes included suicidal ideation, hopelessness, depression, health-related quality of life (QoL), coping resources, and level of satisfaction with service received, assessed at baseline, 3-, 6-, 9-, and 12-month post-randomisation. The trial is registered on ClinicalTrials.gov. NCT02742922 (April 2016). RESULTS: We screened 3786 patients for eligibility and 901 eligible, consented patients were randomly assigned to the CMAP plus E-TAU arm (n = 440) and E-TAU arm (N = 461). The number of self-harm repetitions for CMAP plus E-TAU was lower (n = 17) compared to the E-TAU arm (n = 23) at 12-month post-randomisation, but the difference was not statistically significant (p = 0.407). There was a statistically and clinically significant reduction in other outcomes including suicidal ideation (- 3.6 (- 4.9, - 2.4)), depression (- 7.1 (- 8.7, - 5.4)), hopelessness (- 2.6 (- 3.4, - 1.8), and improvement in health-related QoL and coping resources after completion of the intervention in the CMAP plus E-TAU arm compared to the E-TAU arm. The effect was sustained at 12-month follow-up for all the outcomes except for suicidal ideation and hopelessness. On suicidal ideation and hopelessness, participants in the intervention arm scored lower compared to the E-TAU arm but the difference was not statistically significant, though the participants in both arms were in low-risk category at 12-month follow-up. The improvement in both arms is explained by the established role of enhanced care in suicide prevention. CONCLUSIONS: Suicidal ideation is considered an important target for the prevention of suicide, therefore, CMAP intervention should be considered for inclusion in the self-harm and suicide prevention guidelines. Given the improvement in the E-TAU arm, the potential use of brief interventions such as regular contact requires further exploration.

Developing the Resident Measure of Safety in Care Homes (RMOS): A Delphi and Think Aloud Study.

OBJECTIVE: This study aimed to develop a measure of contributory factors to safety incidents in care homes to be completed by residents and/or their unpaid carers. INTRODUCTION: Care home residents are particularly vulnerable to patient safety incidents, due to higher likelihood of frailty, multimorbidity and cognitive decline. However, despite residents and their carers wanting to be involved in safety initiatives, there are few mechanisms for them to contribute and make meaningful safety improvements to practice. METHODS: We developed 73 evidence-based items from synthesis and existing measures, which we presented to a panel of stakeholders (residents/carers, health/social care professionals and researchers). We used two online rounds of Delphi to generate consensus (80%) on items important to include in the Resident Measure of Safety in Care Homes (RMOS); a consensus meeting was later held. The draft RMOS developed through the Delphi was presented to participants during 'Think Aloud' interviews using cognitive testing techniques. RESULTS: The 29-item RMOS was developed. Forty-three participants completed Delphi round 1, and 27 participants completed round 2, 11 participants attended the consensus meeting and 12 'Think Aloud' interviews were conducted. Of the 73 original items, 42 items that did not meet consensus in Delphi round 1 were presented in round 2. After the consensus meeting, it was agreed that 35 items would comprise the RMOS questionnaire and were presented in the 'Think Aloud' interviews. Participants suggested numerous changes to items mostly to improve comprehension and ability to answer. CONCLUSION: We have a developed an evidence-based RMOS, with good face validity, to assess contributory factors to safety in care homes from a resident/carer perspective. Future work will involve psychometrically testing the items in a pilot and developing a complementary simplified, dementia-friendly version to promote inclusivity. PATIENT OR PUBLIC INVOLVEMENT: Four patient and public contributors worked with researchers to develop the online questionnaires. Patients (residents) and carers participated on the consensus panel. One member of the research team is an expert by lived experience and was involved in design and analysis decisions. The item list and instructions for the questionnaires were reviewed for face validity, understanding and acceptability by a patient and public involvement group and modified.

Supporting carers to improve patient safety and maintain their well-being in transitions from mental health hospitals to the community: A prioritisation nominal group technique.

INTRODUCTION: Carers of people with mental illness may face distinct challenges, including navigating fragmented health and social services during discharge from mental health hospitals. Currently, limited examples of interventions that support carers of people with mental illness in improving patient safety during transitions of care exist. We aimed to identify problems and solutions to inform future carer-led discharge interventions, which is imperative for ensuring patient safety and the well-being of carers. METHODS: The nominal group technique was used which combines both qualitative and quantitative data collection methods in four distinct phases: (1) problem identification, (2) solution generation, (3) decision making and (4) prioritisation. The aim was to combine expertise from different stakeholder groups (patients, carers and academics with expertise in primary/secondary care, social care or public health) to identify problems and generate solutions. RESULTS: Twenty-eight participants generated potential solutions that were grouped into four themes. The most acceptable solution for each was as follows: (1) 'Carer Involvement and Improving Carer Experience' a dedicated family liaison worker, (2) 'Patient Wellness and Education' adapting and implementing existing approaches to help implement the patient care plan, (3) 'Carer Wellness and Education' peer/social support interventions for carers and (4) 'Policy and System Improvements' understanding the co-ordination of care. CONCLUSION: The stakeholder group concurred that the transition from mental health hospitals to the community is a distressing period, where patients and carers are particularly vulnerable to safety and well-being risks. We identified numerous feasible/acceptable solutions to enable carers to improve patient safety and maintain their own mental wellbeing. PATIENT AND PUBLIC CONTRIBUTION: Patient and public contributors were represented in the workshop and the focus of the workshop was to identify the problems they faced and co-design potential solutions. Patient and public contributors were involved in the funding application and study design.

Forty years on: a new national study of hearing in England and implications for global hearing health policy.

OBJECTIVE: We aimed to update the prevalence estimates of hearing loss in older adults in England using a nationally representative sample of adults aged 50 years old and older. DESIGN: A comparative cross-sectional study design was implemented. Hearing loss was defined as ≥35 dB HL at 3.0 kHz, as measured via Hearcheck in the better-hearing ear. STUDY SAMPLE: We compared the estimates based on the English census in 2015 to estimates from psychoacoustic hearing data available for 8,263 participants in the English Longitudinal Study of Ageing (ELSA) Wave 7 (2014-2015). RESULTS: Marked regional variability in hearing loss prevalence was revealed among participants with similar age profiles. The regional differences in hearing outcomes reached up to 13.53% in those belonging to the 71-80 years old group; the prevalence of hearing loss was 49.22% in the North East of England (95%CI 48.0-50.4), versus 35.69% in the South East (95%CI 34.8-36.50). CONCLUSION: A socio-spatial approach in planning sustainable models of hearing care based on the actual populations' needs and not on age demographics might offer a viable opportunity for healthier lives. Regular assessment of the extent and causality of the population's different audiological needs within the country is strongly supported.

The leaky pipeline of hearing care: primary to secondary care evidence from the English Longitudinal Study of Ageing (ELSA).

OBJECTIVE: The proportions of older adults' transitions through acknowledging their hearing loss to getting access to treatment are unknown. This was examined using data from a nationally representative cohort in England. DESIGN: Patient and healthcare factors associated with referrals were examined cross-sectionally, through primary to secondary care. Non-report predictors identified using multiple logistic regression models. STUDY SAMPLE: 8529 adults with hearing data in the English Longitudinal Study of Ageing Wave 7. RESULTS: Nearly 40% of those with acknowledged hearing loss did not tell a doctor or nurse (n = 857/2249). Women (OR 2.68, 95% CI 2.14-2.98), retirees (OR 1.30, 95% CI 1.17-1.44), those with foreign education (OR 2.74, 95% CI 2.47-3.04), lower education (OR 2.86, 95% CI 2.58-3.18), smokers (OR 4.39, 95% CI 3.95-4.87), and heavy drinkers (OR 1.67, 95% CI 1.58-1.85) were more likely to not report hearing loss. Of those who acknowledged and reported hearing difficulties, willingness to try hearing aid(s) was high (78.9%). CONCLUSIONS: Unacknowledged, or acknowledged but not reported hearing loss by individuals, and non-referrals by primary healthcare professionals, are barriers to accessing hearing healthcare. Future research should report hearing aid use as the proportion of individuals who acknowledge their hearing loss, to avoid an overestimation of the non-use of hearing aids within study samples.

A qualitative study on lived experience of self-harm in South Asians in the UK: From reasons to recovery.

OBJECTIVES: Self-harm rates and clinical presentations differ by ethnicity. South Asian women are at risk of self-harm. Previous research suggested investigating individuals' experiences with self-harm with qualitative studies in developing self-harm prevention strategies. This research aims to explore self-harm experiences among South Asians in the United Kingdom. DESIGN: Qualitative study. METHODS: Participants were recruited via third-sector organizations and online platforms. Semi-structured interviews were conducted with 11 South Asian individuals with a history of self-harm living in the United Kingdom. The data were analysed based on a reflective thematic analysis approach. RESULTS: Results revealed four main themes: (1) reasons for self-harm; (2) recovery journey; (3) culture and mental health; and (4) the transition to suicidal thoughts and behaviours. Reasons for self-harm included negative life circumstances, social life difficulties, challenges faced during COVID-19 and mental health problems. Participants described their recovery journey by acknowledging the role of professional help, self-care, psychoeducation and personal growth, improving social relationships, and faith and spirituality. Cultural factors included generational differences and stigma. Culturally adapted psychological interventions were perceived as promising. The reported transition from self-harm to suicidal behaviours was linked to experiencing major stressful life events and the use of severe methods of self-harm. CONCLUSIONS: The findings suggest that socio-cultural factors impact mental health and recovery processes among South Asians. Mental health services should consider improving culturally sensitive clinical practices in responding to self-harm among South Asian communities.

Effectiveness of cognitive-behavioural therapies of varying complexity in reducing depression in adults: systematic review and network meta-analysis.

BACKGROUND: Cognitive-behavioural therapy (CBT) is frequently used as an umbrella term to include a variety of psychological interventions. It remains unclear whether more complex CBT contributes to greater depression reduction. AIMS: To (a) compare the effectiveness of core, complex and ultra-complex CBT against other psychological intervention, medication, treatment-as-usual and no treatment in reducing depression at post-treatment and in the long term and (b) explore important factors that could moderate the effectiveness of these interventions. METHOD: MEDLINE, PsycInfo, Embase, Web of Science and the Cochrane Register of Controlled Trials were searched to November 2021. Only randomised controlled trials were eligible for the subsequent network meta-analysis. RESULTS: We included 107 studies based on 15 248 participants. Core (s.m.d. = -1.14, 95% credible interval (CrI) -1.72 to -0.55 [m.d. = -8.44]), complex (s.m.d. = -1.24, 95% CrI -1.85 to -0.64 [m.d. = -9.18]) and ultra-complex CBT (s.m.d. = -1.45, 95% CrI -1.88 to -1.02 [m.d. = -10.73]) were all significant in reducing depression up to 6 months from treatment onset. The significant benefits of the ultra-complex (s.m.d. = -1.09, 95% CrI -1.61 to -0.56 [m.d. = -8.07]) and complex CBT (s.m.d. = -0.73, 95% CrI -1.36 to -0.11 [m.d. = -5.40]) extended beyond 6 months. Ultra-complex CBT was most effective in individuals presenting comorbid mental health problems and when delivered by non-mental health specialists. Ultra-complex and complex CBT were more effective for people younger than 59 years. CONCLUSIONS: For people without comorbid conditions healthcare and policy organisations should invest in core CBT. For people <59 years of age with comorbid conditions investments should focus on ultra-complex and complex CBT delivered without the help of mental health professionals.

Beyond the control of the care home: A meta-ethnography of qualitative studies of Infection Prevention and Control in residential and nursing homes for older people.

OBJECTIVE: This study aimed to develop interpretive insights concerning Infection Prevention and Control (IPC) in care homes for older people. DESIGN: This study had a meta-ethnography design. DATA SOURCES: Six bibliographic databases were searched from inception to May 2020 to identify the relevant literature. REVIEW METHODS: A meta-ethnography was performed. RESULTS: Searches yielded 652 records; 15 were included. Findings were categorized into groups: The difficulties of enacting IPC measures in the care home environment; workload as an impediment to IPC practice; the tension between IPC and quality of life for care home residents; and problems dealing with medical services located outside the facility including diagnostics, general practice and pharmacy. Infection was revealed as something seen to lie 'outside' the control of the care home, whether according to origins or control measures. This could help explain the reported variability in IPC practice. Facilitators to IPC uptake involved repetitive training and professional development, although such opportunities can be constrained by the ways in which services are organized and delivered. CONCLUSIONS: Significant challenges were revealed in implementing IPC in care homes including staffing skills, education, workloads and work routines. These challenges cannot be properly addressed without resolving the tension between the objectives of maintaining resident quality of life while enacting IPC practice. Repetitive staff training and professional development with parallel organisational improvements have prospects to enhance IPC uptake in residential and nursing homes. PATIENT OR PUBLIC CONTRIBUTION: A carer of an older person joined study team meetings and was involved in writing a lay summary of the study findings.

The dynamic relationship between hearing loss, quality of life, socioeconomic position and depression and the impact of hearing aids: answers from the English Longitudinal Study of Ageing (ELSA).

PURPOSE: The adverse impact of hearing loss (HL) extends beyond auditory impairment and may affect the individuals' psychosocial wellbeing. We aimed to examine whether there exists a causal psychosocial pathway between HL and depression in later life, via socioeconomic factors and quality of life, and whether hearing aids usage alleviates depressive symptoms over time. METHODS: We examined the longitudinal relationship between HL and depressive symptoms (CES-D) applying dynamic cross-lagged mediation path models. We used the full dataset of participants aged 50-89 years (74,908 person-years), from all eight Waves of the English Longitudinal Study of Ageing (ELSA). Their quality of life (CASP-19) and their wealth were examined as the mediator and moderator of this relationship, respectively. Subgroup analyses investigated differences among those with hearing aids within different models of subjectively and objectively identified HL. All models were adjusted for age, sex, retirement status and social engagement. RESULTS: Socioeconomic position (SEP) influenced the strength of the relationship between HL and depression, which was stronger in the lowest versus the highest wealth quintiles. The use of hearing aids was beneficial for alleviating depressive symptoms. Those in the lowest wealth quintiles experienced a lower risk for depression after the use of hearing aids compared to those in the highest wealth quintiles. CONCLUSION: HL poses a substantial risk for depressive symptoms in older adults, especially those who experience socioeconomic inequalities. The early detection of HL and provision of hearing aids may not only promote better-hearing health but could also enhance the psychosocial wellbeing of older adults, particularly those in a lower SEP.

Association Between Patient Factors and the Effectiveness of Wearable Trackers at Increasing the Number of Steps per Day Among Adults With Cardiometabolic Conditions: Meta-analysis of Individual Patient Data From Randomized Controlled Trials.

BACKGROUND: Current evidence supports the use of wearable trackers by people with cardiometabolic conditions. However, as the health benefits are small and confounded by heterogeneity, there remains uncertainty as to which patient groups are most helped by wearable trackers. OBJECTIVE: This study examined the effects of wearable trackers in patients with cardiometabolic conditions to identify subgroups of patients who most benefited and to understand interventional differences. METHODS: We obtained individual participant data from randomized controlled trials of wearable trackers that were conducted before December 2020 and measured steps per day as the primary outcome in participants with cardiometabolic conditions including diabetes, overweight or obesity, and cardiovascular disease. We used statistical models to account for clustering of participants within trials and heterogeneity across trials to estimate mean differences with the 95% CI. RESULTS: Individual participant data were obtained from 9 of 25 eligible randomized controlled trials, which included 1481 of 3178 (47%) total participants. The wearable trackers revealed that over the median duration of 12 weeks, steps per day increased by 1656 (95% CI 918-2395), a significant change. Greater increases in steps per day from interventions using wearable trackers were observed in men (interaction coefficient -668, 95% CI -1157 to -180), patients in age categories over 50 years (50-59 years: interaction coefficient 1175, 95% CI 377-1973; 60-69 years: interaction coefficient 981, 95% CI 222-1740; 70-90 years: interaction coefficient 1060, 95% CI 200-1920), White patients (interaction coefficient 995, 95% CI 360-1631), and patients with fewer comorbidities (interaction coefficient -517, 95% CI -1188 to -11) compared to women, those aged below 50, non-White patients, and patients with multimorbidity. In terms of interventional differences, only face-to-face delivery of the tracker impacted the effectiveness of the interventions by increasing steps per day. CONCLUSIONS: In patients with cardiometabolic conditions, interventions using wearable trackers to improve steps per day mostly benefited older White men without multimorbidity. TRIAL REGISTRATION: PROSPERO CRD42019143012; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=143012.

Exploring Associations between Stressors and Burnout in Trainee Doctors During the COVID-19 Pandemic in the UK.

OBJECTIVE: The authors examined associations between stressors and burnout in trainee doctors during the COVID-19 pandemic. METHODS: An anonymous online questionnaire including 42 questions on general and pandemic-specific stressors, and the Maslach Burnout Inventory-Health Services Survey (MBI-HSS), was sent to 1000 randomly selected trainee doctors in North-West England. Main outcomes were burnout scores that were stratified into Emotional Exhaustion (EE), Depersonalisation (DP), and reduced Personal Accomplishment (PA) and associations between stressors and burnout using stepwise regression analysis. RESULTS: A total of 362 complete responses were received giving a response rate of 37%. Mean scores for EE, DP, and PA derived from the MBI-HSS were 27.7, 9.8, and 34.3 respectively. Twenty-three stressors were found to be associated with burnout dimensions. "Increase in workload and hours due to COVID-19," "Poor leadership and management in the National Health Service," and "Not feeling valued" were found to have strong associations with burnout dimensions. Only "Not confident in own abilities" was found to be associated with all burnout dimensions. CONCLUSIONS: Associations with burnout were found to be identified in a range of work, pandemic, and non-work-related stressors, supporting the need for multi-level interventions to mitigate burnout.

Benefits and harms of Risperidone and Paliperidone for treatment of patients with schizophrenia or bipolar disorder: a meta-analysis involving individual participant data and clinical study reports.

BACKGROUND: Schizophrenia and bipolar disorder are severe mental illnesses which are highly prevalent worldwide. Risperidone and Paliperidone are treatments for either illnesses, but their efficacy compared to other antipsychotics and growing reports of hormonal imbalances continue to raise concerns. As existing evidence on both antipsychotics are solely based on aggregate data, we aimed to assess the benefits and harms of Risperidone and Paliperidone in the treatment of patients with schizophrenia or bipolar disorder, using individual participant data (IPD), clinical study reports (CSRs) and publicly available sources (journal publications and trial registries). METHODS: We searched MEDLINE, Central, EMBASE and PsycINFO until December 2020 for randomised placebo-controlled trials of Risperidone, Paliperidone or Paliperidone palmitate in patients with schizophrenia or bipolar disorder. We obtained IPD and CSRs from the Yale University Open Data Access project. The primary outcome Positive and Negative Syndrome Scale (PANSS) score was analysed using one-stage IPD meta-analysis. Random-effect meta-analysis of harm outcomes involved methods for coping with rare events. Effect-sizes were compared across all available data sources using the ratio of means or relative risk. We registered our review on PROSPERO, CRD42019140556. RESULTS: Of the 35 studies, IPD meta-analysis involving 22 (63%) studies showed a significant clinical reduction in the PANSS in patients receiving Risperidone (mean difference - 5.83, 95% CI - 10.79 to - 0.87, I2 = 8.5%, n = 4 studies, 1131 participants), Paliperidone (- 6.01, 95% CI - 8.7 to - 3.32, I2 = 4.3%, n = 13, 3821) and Paliperidone palmitate (- 7.89, 95% CI - 12.1 to - 3.69, I2 = 2.9%, n = 5, 2209). CSRs reported nearly two times more adverse events (4434 vs. 2296 publication, relative difference (RD) = 1.93, 95% CI 1.86 to 2.00) and almost 8 times more serious adverse events (650 vs. 82; RD = 7.93, 95% CI 6.32 to 9.95) than the journal publications. Meta-analyses of individual harms from CSRs revealed a significant increased risk among several outcomes including extrapyramidal disorder, tardive dyskinesia and increased weight. But the ratio of relative risk between the different data sources was not significant. Three treatment-related gynecomastia events occurred, and these were considered mild to moderate in severity. CONCLUSION: IPD meta-analysis conclude that Risperidone and Paliperidone antipsychotics had a small beneficial effect on reducing PANSS score over 9 weeks, which is more conservative than estimates from reviews based on journal publications. CSRs also contained significantly more data on harms that were unavailable in journal publications or trial registries. Sharing of IPD and CSRs are necessary when performing meta-analysis on the efficacy and safety of antipsychotics.

Enhancing the multi-dimensional assessment of quality of life: introducing the WHOQOL-Combi.

INTRODUCTION: We revisited the global concept of subjective quality of life (QoL) as assessed by the WHOQOL-BREF to investigate whether it could be elaborated into a conceptually more comprehensive instrument with good psychometric properties. Responding to a growing need for shorter QoL measures with broader social, spiritual and environmental contents, facets from WHOQOL international modules were examined for potential integration into the new WHOQOL-Combi. METHOD: Adults over 65 years, diagnosed with one or more chronic diseases (n = 2833), completed 41 WHOQOL items during the CLASSIC survey; each item represented a WHOQOL facet. This pool of specific QoL facets contained 24 from the WHOQOL-BREF (excluding general items), and 17 from recent international WHOQOL short-form modules, selected for their generic properties. Rasch modelling reduced the final item pool when assessing the WHOQOL-Combi's conceptual structure. Comparisons are made with the WHOQOL-BREF. RESULTS: Modelling confirmed the tenability of a 36-item solution scored as a five-domain profile, comprised of 24 WHOQOL-BREF facets and 12 new facets from modules. Social and psychological domains were strengthened by three facets, spiritual QoL by five, and physical QoL by one. The WHOQOL-Combi showed sound model fit, excellent internal consistency (α = .95), and scores discriminated between socio-demographic categories. Concurrent validity with the EQ-5D-5L was confirmed for physical and psychological domains. Performance was similar to the WHOQOL-BREF. CONCLUSION: The WHOQOL-Combi offers a contemporary, comprehensive, integrated, multi-dimensional subjective QoL instrument with enhanced evaluations of social, spiritual, psychological and physical QoL. Acceptable to older people, future research should evaluate younger age groups and other cultures.

What does safety in mental healthcare transitions mean for service users and other stakeholder groups: An open-ended questionnaire study.

BACKGROUND: Historically, safety mental health research has tended to focus on risks of homicide, suicide and deaths. Although wider safety issues are now recognized in regards to mental health services, the safety of mental health transitions, a key research and policy priority according to World Health Organisation, has not been explored. OBJECTIVE: The purpose of this study was to investigate perceptions of safety in mental health transitions (hospital to community) amongst five stakeholder groups. DESIGN AND SETTING: An online, international cross-sectional, open-ended questionnaire. PARTICIPANTS: There were five stakeholder participant groups: service users; families/carers; mental health-care professionals; researchers; and end users of research. RESULTS: Ninety-three participants from 12 different countries responded. Three overarching themes emerged: 'individual/clinical', 'systems/services' and 'human, behavioural and social' elements of safe mental health transitions. Whilst there was a great focus on clinical elements from researchers and healthcare professionals, service users and carers considered safety in terms of human, behavioural and social elements of transitional safety (ie loneliness, emotional readiness for discharge) and systems/services (ie inter-professional communication). DISCUSSION: Safety in mental health-care transitions is perceived differently by service users and families compared to healthcare professionals and researchers. Traditional safety indicators for care transitions such as suicide, self-harm and risk of adverse drug events are raised as important. However, service users and families in particular have a much wider perception of transitions safety. CONCLUSION: Future quality and safety research and policy should consider including a service user voice and consider integration of psychosocial elements in discharge interventions.

A patient and public involvement workshop using visual art and priority setting to provide patients with a voice to describe quality and safety concerns: Vitamin B12 deficiency and pernicious anaemia.

BACKGROUND: Patient and public involvement and engagement (PPIE) is recognized as important for improved quality in health service provision and research. Vitamin B12 deficiency is one area where PPIE has potential to benefit patients, as patients often report sub-optimal care due to diagnostic delay, insufficient treatment and poor relationships with health professionals. OBJECTIVE: In an effort to engage an understudied patient population in health-care quality and safety discussions, and provide patients with an opportunity to have a voice, contribute to research priorities and express their current quality and safety concerns, we hosted a PPIE workshop. METHODS: One researcher (with lived experience) facilitated a one day workshop with 12 patients with varied demographics. The workshop had four components (a) one-to-one sessions with an artist, (b) quality and safety research/education priority setting, (c) comments on research proposals, and (d) development of a PPIE group for future research. RESULTS: All elements of the workshop elicited a number of quality and safety priorities for the group. Priority setting highlighted issues with interpretation of test results, symptom-based treatment, self-medication and relationship with primary care health-care professionals. One of the major safety issues highlighted in the visual art element was feeling ignored, silenced or not listened too by health-care professionals. DISCUSSION: Visual art methods to express experiences of health, and research priority setting tasks achieved the aim of providing patients with an opportunity to have a voice and express concerns about health-care quality and safety issues. The addition of visual art allowed patients to articulate emotions and impacts on everyday life associated with quality and safety. PATIENT OR PUBLIC CONTRIBUTION: A public contributor was involved in preparation of this manuscript. The event aimed to enable PPIE contribution in future research.

Meta-ethnography in healthcare research: a guide to using a meta-ethnographic approach for literature synthesis.

BACKGROUND: Qualitative synthesis approaches are increasingly used in healthcare research. One of the most commonly utilised approaches is meta-ethnography. This is a systematic approach which synthesises data from multiple studies to enable new insights into patients' and healthcare professionals' experiences and perspectives. Meta-ethnographies can provide important theoretical and conceptual contributions and generate evidence for healthcare practice and policy. However, there is currently a lack of clarity and guidance surrounding the data synthesis stages and process. METHOD: This paper aimed to outline a step-by-step method for conducting a meta-ethnography with illustrative examples. RESULTS: A practical step-by-step guide for conducting meta-ethnography based on the original seven steps as developed by Noblit & Hare (Meta-ethnography: Synthesizing qualitative studies.,1998) is presented. The stages include getting started, deciding what is relevant to the initial interest, reading the studies, determining how the studies are related, translating the studies into one another, synthesising the translations and expressing the synthesis. We have incorporated adaptations and developments from recent publications. Annotations based on a previous meta-ethnography are provided. These are particularly detailed for stages 4-6, as these are often described as being the most challenging to conduct, but with the most limited amount of guidance available. CONCLUSION: Meta-ethnographic synthesis is an important and increasingly used tool in healthcare research, which can be used to inform policy and practice. The guide presented clarifies how the stages and processes involved in conducting a meta-synthesis can be operationalised.