Menopausal hormone therapy and women's health: An umbrella review.

BACKGROUND: There remains uncertainty about the impact of menopausal hormone therapy (MHT) on women's health. A systematic, comprehensive assessment of the effects on multiple outcomes is lacking. We conducted an umbrella review to comprehensively summarize evidence on the benefits and harms of MHT across diverse health outcomes. METHODS AND FINDINGS: We searched MEDLINE, EMBASE, and 10 other databases from inception to November 26, 2017, updated on December 17, 2020, to identify systematic reviews or meta-analyses of randomized controlled trials (RCTs) and observational studies investigating effects of MHT, including estrogen-alone therapy (ET) and estrogen plus progestin therapy (EPT), in perimenopausal or postmenopausal women in all countries and settings. All health outcomes in previous systematic reviews were included, including menopausal symptoms, surrogate endpoints, biomarkers, various morbidity outcomes, and mortality. Two investigators independently extracted data and assessed methodological quality of systematic reviews using the updated 16-item AMSTAR 2 instrument. Random-effects robust variance estimation was used to combine effect estimates, and 95% prediction intervals (PIs) were calculated whenever possible. We used the term MHT to encompass ET and EPT, and results are presented for MHT for each outcome, unless otherwise indicated. Sixty systematic reviews were included, involving 102 meta-analyses of RCTs and 38 of observational studies, with 102 unique outcomes. The overall quality of included systematic reviews was moderate to poor. In meta-analyses of RCTs, MHT was beneficial for vasomotor symptoms (frequency: 9 trials, 1,104 women, risk ratio [RR] 0.43, 95% CI 0.33 to 0.57, p < 0.001; severity: 7 trials, 503 women, RR 0.29, 95% CI 0.17 to 0.50, p = 0.002) and all fracture (30 trials, 43,188 women, RR 0.72, 95% CI 0.62 to 0.84, p = 0.002, 95% PI 0.58 to 0.87), as well as vaginal atrophy (intravaginal ET), sexual function, vertebral and nonvertebral fracture, diabetes mellitus, cardiovascular mortality (ET), and colorectal cancer (EPT), but harmful for stroke (17 trials, 37,272 women, RR 1.17, 95% CI 1.05 to 1.29, p = 0.027) and venous thromboembolism (23 trials, 42,292 women, RR 1.60, 95% CI 0.99 to 2.58, p = 0.052, 95% PI 1.03 to 2.99), as well as cardiovascular disease incidence and recurrence, cerebrovascular disease, nonfatal stroke, deep vein thrombosis, gallbladder disease requiring surgery, and lung cancer mortality (EPT). In meta-analyses of observational studies, MHT was associated with decreased risks of cataract, glioma, and esophageal, gastric, and colorectal cancer, but increased risks of pulmonary embolism, cholelithiasis, asthma, meningioma, and thyroid, breast, and ovarian cancer. ET and EPT had opposite effects for endometrial cancer, endometrial hyperplasia, and Alzheimer disease. The major limitations include the inability to address the varying effects of MHT by type, dose, formulation, duration of use, route of administration, and age of initiation and to take into account the quality of individual studies included in the systematic reviews. The study protocol is publicly available on PROSPERO (CRD42017083412). CONCLUSIONS: MHT has a complex balance of benefits and harms on multiple health outcomes. Some effects differ qualitatively between ET and EPT. The quality of available evidence is only moderate to poor.

The experiences of older adults with a diagnosed functional mental illness, their carers and healthcare professionals in relation to mental health service delivery: An integrative review.

AIMS AND OBJECTIVES: To analyse the experiences of older people with a diagnosed functional mental illness and their carers in relation to mental health service delivery and analyse the experiences of health and social care professionals who care for and treat older people who have a diagnosed functional mental illness. BACKGROUND: The prevalence of functional mental illness in older adults is notable but to date has received less research attention than dementia. Older adults with functional mental illness have life expectancy of up to 20 years less than the rest of the population. Therefore, the experiences of older adults with functional mental illness, their carers and healthcare professionals, in relation to mental health services, need further exploration. DESIGN: Integrative literature review. METHODS: A five-stage process was informed by Whittemore and Knafl. MeSH was used. Keyword searches of MEDLINE, CINAHL, Cochrane Library, PsycINFO, EMBASE and AMED were conducted between January 2000-October 2017. Titles were screened, and data were extracted manually and analysed using narrative synthesis. The PRISMA checklist was used. RESULTS: A total of 342 articles were deemed potentially relevant to this review. Once inclusion and exclusion criteria were applied, 28 articles were included. The literature presented an overarching theme "determinants influencing older people with functional mental illness use of services." The overarching theme is supported by two main themes: inevitable consequences of ageing and variations of the availability of healthcare services for older people with functional mental illness. CONCLUSION: Several determinants influence use of services by older people with functional mental illness. Older people with functional mental illness often perceived they did not have a mental health need. Within the literature, there was little acknowledgement of the experiences of older people with functional mental illness regarding their support needs. RELEVANCE TO CLINICAL PRACTICE: This integrative review has highlighted that some older people with functional mental illness do not seek mental health support because they believe that functional mental illness is an inevitable consequence of ageing; this is mirrored at times by healthcare professionals and carers. In addition to this finding, different views prevail regarding the impact that ageless and age-defined mental health service delivery models have on the needs of older people with functional mental illness. Further research is required to understand these findings.

Supporting rural midwifery practice using a mobile health (mHealth) intervention: a qualitative descriptive study.

INTRODUCTION: Hypertensive disorders in pregnancy account for 12% of all maternal deaths globally. The risks of suboptimal outcomes from these disorders might be greater in rural and remote locations. These potential risks might be related to poor intra- and interprofessional communications due to geographic and digital isolation. Studies in low- and middle-income countries suggest that improving communications is essential and that mobile health (m-health) interventions can improve outcomes. However, for such interventions to be successful they must involve midwives in any design and software development. This study explored how an m-health intervention might support midwives in the management of women with pre-eclampsia in Scottish rural and remote locations. METHODS: A qualitative descriptive approach was adopted. Rural and remote practising community midwives (n=18) were recruited to participate in three focus groups. The data were gathered through digital recordings of conversations at these focus groups. Recordings were transcribed and thematically analysed. Themes were agreed by consensus with the research team in an iterative process. RESULTS: Five principal themes were identified: 'working in isolation', 'encountering women with pre-eclampsia in rural and remote settings', 'learning on the move', 'using audio-visual resources' and 'unease with advances in technology'. CONCLUSION: Geographic and digital isolation pose significant challenges to rural midwifery practice in a high income country such as Scotland. Midwives need to be involved in the development of m-health interventions for them to be acceptable and tailored to their needs in a rural and remote context. The study highlights how m-health interventions can support continuous professional development whilst on the move with no internet connectivity. However, pride in current practice and unease with advances in mobile technology are barriers to the adoption of an m-health intervention. M-health interventions could be of value to other specialised healthcare practitioners in these regions, including general practitioners, to manage women with complications in their pregnancies.

Challenges in accessing and interviewing participants with severe mental illness.

Background Interviews are widely used in qualitative research to collect data. However, little has been written about interviewing people with severe mental illness (SMI). Aim To report and analyse an experience of addressing the ethical and practical challenges of interviewing people with SMI. Discussion Semi-structured interviews were conducted as part of a doctoral study to explore how service users and healthcare professionals built relationships with each other. Conclusion Although interviewing participants with SMI was challenging, rich data illustrating their experiences were gathered. Careful planning around ethical considerations, such as obtaining informed consent, was required to maximise the opportunities to gather in-depth information during the interviews. The relationship established between researcher and the participants assisted with sensitive disclosures and allowed participants to tell their stories. Implications for research This paper provides strategies to help guide researchers planning interviews with vulnerable populations, including those with SMI. These strategies include how to discuss sensitive issues and promote engagement. Listening to participants' life stories is an intense experience, requiring support for the interviewer to stay neutral during interviews. It is also important to be aware of the differences between the roles of nurse and nurse researcher before undertaking in-depth qualitative interviews, particularly with vulnerable participants.

Therapeutic exercises for affecting post-treatment swallowing in people treated for advanced-stage head and neck cancers.

BACKGROUND: Head and neck cancer treatment has developed over the last decade, with improved mortality and survival rates, but the treatments often result in dysphagia (a difficulty in swallowing) as a side effect. This may be acute, resolving after treatment, or remain as a long-term negative sequela of head and neck cancer (HNC) treatment. Interventions to counteract the problems associated with dysphagia include swallowing exercises or modification of diet (bolus texture, size), or both. OBJECTIVES: To determine the effects of therapeutic exercises, undertaken before, during and/or immediately after HNC treatment, on swallowing, aspiration and adverse events such as chest infections, aspiration pneumonia and profound weight loss, in people treated curatively for advanced-stage (stage III, stage IV) squamous cell carcinoma of the head and neck. SEARCH METHODS: The Cochrane ENT Information Specialist searched the ENT Trials Register; Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 6); MEDLINE; PubMed; Embase; CINAHL; LILACS; KoreaMed; IndMed; PakMediNet; Web of Science; ClinicalTrials.gov; ICTRP; speechBITE; Google Scholar; Google and additional sources for published and unpublished trials. The date of the search was 1 July 2016. SELECTION CRITERIA: We selected randomised controlled trials (RCTs) of adults with head and neck cancer (stage III, stage IV) who underwent therapeutic exercises for swallowing before, during and/or immediately after HNC treatment to help produce safe and efficient swallowing. The main comparison was therapeutic exercises versus treatment as usual (TAU). Other possible comparison pairs included: therapeutic exercises versus sham exercises and therapeutic exercises plus TAU versus TAU. TAU consisted of reactive management of a patient's dysphagia, when this occurred. When severe, this included insertion of either a percutaneous endoscopic gastroscopy or nasogastric tube for non-oral feeding. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. Our primary outcomes were: safety and efficiency of oral swallowing, as measured by reduced/no aspiration; oropharyngeal swallowing efficiency (OPSE) measures, taken from videofluoroscopy swallowing studies; and adverse events, such as chest infections, aspiration pneumonia and profound weight loss. Secondary outcomes were time to return to function (swallowing); self-reported changes to quality of life; changes to psychological well-being - depression, anxiety and stress; patient satisfaction with the intervention; patient compliance with the intervention; and cost-effectiveness of the intervention. MAIN RESULTS: We included six studies (reported as seven papers) involving 326 participants whose ages ranged from 39 to 83 years, with a gender bias towards men (73% to 95% across studies), reflecting the characteristics of patients with HNC. The risk of bias in the studies was generally high.We did not pool data from studies because of significant differences in the interventions and outcomes evaluated. We found a lack of standardisation and consistency in the outcomes measured and the endpoints at which they were evaluated.We found no evidence that therapeutic exercises were better than TAU, or any other treatment, in improving the safety and efficiency of oral swallowing (our primary outcome) or in improving any of the secondary outcomes.Using the GRADE system, we classified the overall quality of the evidence for each outcome as very low, due to the limited number of trials and their low quality. There were no adverse events reported that were directly attributable to the intervention (swallowing exercises). AUTHORS' CONCLUSIONS: We found no evidence that undertaking therapeutic exercises before, during and/or immediately after HNC treatment leads to improvement in oral swallowing. This absence of evidence may be due to the small participant numbers in trials, resulting in insufficient power to detect any difference. Data from the identified trials could not be combined due to differences in the choice of primary outcomes and in the measurement tools used to assess them, and the differing baseline and endpoints across studies.Designing and implementing studies with stronger methodological rigour is essential. There needs to be agreement about the key primary outcomes, the choice of validated assessment tools to measure them and the time points at which those measurements are made.

Positioning and spinal bracing for pain relief in metastatic spinal cord compression in adults.

BACKGROUND: This is an updated version of the original Cochrane review published in Issue 3 (Lee 2012) on patient positioning (mobilisation) and bracing for pain relief and spinal stability in adults with metastatic spinal cord compression.Many patients with metastatic spinal cord compression (MSCC) have spinal instability, but their clinician has determined that due to their advanced disease they are unsuitable for surgical internal fixation. Mobilising may be hazardous in the presence of spinal instability as further vertebral collapse can occur. Current guidance on positioning (whether a patient should be managed with bed rest or allowed to mobilise) and whether spinal bracing is helpful, is contradictory. OBJECTIVES: To investigate the correct positioning and examine the effects of spinal bracing to relieve pain or to prevent further vertebral collapse in patients with MSCC. SEARCH METHODS: For this update, we searched for relevant studies from February 2012 to 31 March 2015. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE In Process, EMBASE, AMED, CINAHL, TRIP, SIGN, NICE, UK Clinical Research Network, National Guideline Clearinghouse and PEDro database. We also searched the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov, UK Clinical Trials Gateway (UKCTG), WHO International Clinical Trials Registry Platform (ICTRP) and Australia New Zealand Clinical Trials Registry (ANZCTR).For the original version, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, CANCERLIT, NICE, SIGN, AMED, TRIP, National Guideline Clearinghouse, and PEDro database, in February 2012. SELECTION CRITERIA: We selected randomised controlled trials (RCTs) of adults with MSCC of interventions on positioning (mobilisation) and bracing. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed each possible study for inclusion and quality. MAIN RESULTS: For the original version of the review, we screened 1611 potentially relevant studies. No studies met the inclusion criteria. Many papers identified the importance of mobilisation, but no RCTs of bed rest versus mobilisation have been undertaken. We identified no RCTs of bracing in MSCC.For this update, we identified 347 potential titles. We screened 300 titles and abstracts after removal of duplicates. We did not identify any additional studies for inclusion. AUTHORS' CONCLUSIONS: Since publication of the original version of this review, no new studies were found and our conclusions remain unchanged.There is a lack of evidence-based guidance around how to correctly position and when to mobilise patients with MSCC or if spinal bracing is an effective technique for reducing pain or improving quality of life. RCTs are required in this important area.

Oximetry-supported self-management for chronic obstructive pulmonary disease: mixed method feasibility pilot project.

BACKGROUND: Pulse oximetry could potentially contribute to self-monitoring. NHS Lothian's 'Light Touch' service provided COPD patients with a self-management plan based on symptoms and oximetry. The service was overseen (though not actively monitored) by respiratory-trained community teams who were contactable by a telephone helpline. We aimed to assess the feasibility, perceived utility and impact of the 'Light Touch' service. METHODS: A before-and-after assessment of St George's Respiratory Questionnaire (SGRQ), Hospital Anxiety and Depression Scale (HADS) and use of healthcare resources during the 6-month feasibility study compared to the previous corresponding 6-months. Paired semi-structured interviews with patients at baseline and 6-months, interviews with managers and a focus group of professionals explored perceptions of the service and self-management. Transcripts were coded, and analysed thematically. RESULTS: We recruited 51 participants (mean age 69.7 years (SD 8.4); 21 (46%) male). 46 participants completed quantitative follow up (2 died, 2 were unwell, 1 refused). SGRQ: 21 (46%) participants improved by 4 or more (the minimum important difference); 12 (26%) deteriorated by 4 or more. HADS: more participants had normal scores for anxiety (65%) and depression (80%) at 6-months than at baseline (51 and 64%). More emergency therapy was prescribed during the study period compared to the previous year. Only 18 participants (39%) contacted the Light Touch Helpline during the 6-month study. Twenty patients provided a total of 36 interviews, 8 clinicians contributed to a focus group and 6 managers were interviewed. Patients considered that the oximetry readings heightened awareness of their condition and gave them confidence to make self-management decisions. Healthcare professionals valued oximetry as a tool for teaching people self-management skills, but were concerned that patients rarely contacted the teams for help or advice during the study. CONCLUSIONS: 'Light Touch' shows promise as a low-cost strategy for empowering patients' self-management skills and reducing reliance on clinical supervision.

Nurses' perceptions to alleviate dyspnoea in inpatients with advanced cancer while receiving palliative care.

AIM: To explore nurses' perceptions to alleviate dyspnoea in inpatients with advanced cancer while receiving palliative care. DESIGN: A descriptive qualitative design. METHODS: Seven focus groups were conducted with nurses (n = 27) from five specialized palliative care wards in four hospitals in south and southwest Finland. The focus groups were conducted between June and November 2019, and the transcripts were analysed using inductive analysis. RESULTS: The findings revealed three categories: recognizing dyspnoea is a multi-faceted problem, dealing with the complexity of assessment of dyspnoea and strategies for relieving dyspnoea. Nurses perceived the complexity of dyspnoea as a symptom and emphasized the importance of utilizing patients' subjective experiences and consistent assessment scales to determine its severity. Furthermore, nonpharmacological interventions are as pertinent as pharmacological and medical interventions. The findings can assist nurses in selecting appropriate interventions for dyspnoea care, ultimately enhancing the quality of patient care and patient safety.

Patient positioning (mobilisation) and bracing for pain relief and spinal stability in metastatic spinal cord compression in adults.

BACKGROUND: Many patients with metastatic spinal cord compression (MSCC) have spinal instability but are determined, by their clinician, to be unsuitable for surgical internal fixation due to their advanced disease. Mobilisation may be hazardous in the presence of spinal instability as further vertebral collapse can occur. Current guidance on positioning (or mobilisation) and spinal bracing is contradictory. OBJECTIVES: To investigate the correct positioning (or mobilisation) and examine the effects of spinal bracing to relieve pain or to prevent further vertebral collapse in patients with MSCC. SEARCH METHODS: The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, CANCERLIT, NICE, SIGN, AMED, TRIP, National Guideline Clearinghouse and PEDro database were searched; the last search was run in February 2012. SELECTION CRITERIA: We selected randomised controlled trials (RCTs) of adults with MSCC of interventions on positioning or mobilisation and bracing. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed each possible study for inclusion and quality. MAIN RESULTS: One thousand, six hundred and eleven potentially relevant studies were screened. No studies met the inclusion criteria. Many papers identified the importance of mobilisation but no RCTs have been undertaken. No RCTs of bracing in MSCC were identified. AUTHORS' CONCLUSIONS: There is lack of evidence based guidance around how to correctly position and when to mobilise patients with MSCC or if spinal bracing is an effective technique for reducing pain or improving quality of life. RCTs are required in this important area.

Metastatic spinal cord compression: a review of practice and care.

AIM AND OBJECTIVES: The aim of this review was to address: (1) How is spinal stability assessed? (2) What is the role of bracing/should braces be used? (3) When is it safe to mobilise the patient? (4) What position should the patient be nursed in? BACKGROUND: Controversy surrounds the care for patients with metastatic spinal cord compression (MSCC). There is some evidence to indicate that care for patients with MSCC is based on individual clinician preference rather than evidence-based guidelines which has been shown to cause delays and discrepancies in patient treatment. DESIGN: A structured literature review to synthesise the available evidence about the management of MSCC. METHODS: The following databases were searched: Medline, EMBASE, Cochrane Systematic Reviews Database, SIGN (Scottish Intercollegiate Guidelines Network), NICE (National Institute for Clinical Excellence), AMED (Allied and Complementary Medicine), CINAHL (Cumulative Index to Nursing and Allied Health Literature) and BNI (British Nursing Index). Publications were selected from the past 10 years. The search yielded a total of 1057 hits, 755 abstracts were screened, and 73 articles were retrieved and examined. Thirty-five articles were included. RESULTS: The findings identified a gap and evidence relating to spinal stability, bracing, patient mobilisation, and positioning is limited and may be inconclusive. It is important for patients with a poor prognosis that their preferences and quality of life are considered. CONCLUSION: Currently, the evidence base to underpin care is limited, and further research in this area is necessary for patients and healthcare professionals alike. RELEVANCE TO CLINICAL PRACTICE: Patients who suffer from MSCC suffer numerous physical, psychological and social issues. Because of lack of consensus, the current guidelines to inform clinical decision-making of professional staff are of limited benefit.

Correction: Assessing the facilitators and barriers of interdisciplinary team working in primary care using normalisation process theory: An integrative review.

[This corrects the article DOI: 10.1371/journal.pone.0177026.].

Assessing the facilitators and barriers of interdisciplinary team working in primary care using normalisation process theory: An integrative review.

BACKGROUND: Interdisciplinary team working is of paramount importance in the reform of primary care in order to provide cost-effective and comprehensive care. However, international research shows that it is not routine practice in many healthcare jurisdictions. It is imperative to understand levers and barriers to the implementation process. This review examines interdisciplinary team working in practice, in primary care, from the perspective of service providers and analyses 1 barriers and facilitators to implementation of interdisciplinary teams in primary care and 2 the main research gaps. METHODS AND FINDINGS: An integrative review following the PRISMA guidelines was conducted. Following a search of 10 international databases, 8,827 titles were screened for relevance and 49 met the criteria. Quality of evidence was appraised using predetermined criteria. Data were analysed following the principles of framework analysis using Normalisation Process Theory (NPT), which has four constructs: sense making, enrolment, enactment, and appraisal. The literature is dominated by a focus on interdisciplinary working between physicians and nurses. There is a dearth of evidence about all NPT constructs apart from enactment. Physicians play a key role in encouraging the enrolment of others in primary care team working and in enabling effective divisions of labour in the team. The experience of interdisciplinary working emerged as a lever for its implementation, particularly where communication and respect were strong between professionals. CONCLUSION: A key lever for interdisciplinary team working in primary care is to get professionals working together and to learn from each other in practice. However, the evidence base is limited as it does not reflect the experiences of all primary care professionals and it is primarily about the enactment of team working. We need to know much more about the experiences of the full network of primary care professionals regarding all aspects of implementation work. SYSTEMATIC REVIEW REGISTRATION: International Prospective Register of Systematic Reviews PROSPERO 2015: CRD42015019362.

Effectiveness of mHealth interventions for maternal, newborn and child health in low- and middle-income countries: Systematic review and meta-analysis.

OBJECTIVE: To assess the effectiveness of mHealth interventions for maternal, newborn and child health (MNCH) in low- and middle-income countries (LMIC). METHODS: 16 online international databases were searched to identify studies evaluating the impact of mHealth interventions on MNCH outcomes in LMIC, between January 1990 and May 2014. Comparable studies were included in a random-effects meta-analysis. FINDINGS: Of 8593 unique references screened after de-duplication, 15 research articles and two conference abstracts met inclusion criteria, including 12 intervention and three observational studies. Only two studies were graded at low risk of bias. Only one study demonstrated an improvement in morbidity or mortality, specifically decreased risk of perinatal death in children of mothers who received SMS support during pregnancy, compared with routine prenatal care. Meta-analysis of three studies on infant feeding showed that prenatal interventions using SMS/cell phone (vs routine care) improved rates of breastfeeding (BF) within one hour after birth (odds ratio (OR) 2.01, 95% confidence interval (CI) 1.27-2.75, I(2) = 80.9%) and exclusive BF for three/four months (OR 1.88, 95% CI 1.26-2.50, I(2) = 52.8%) and for six months (OR 2.57, 95% CI 1.46-3.68, I(2) = 0.0%). Included studies encompassed interventions designed for health information delivery (n = 6); reminders (n = 3); communication (n = 2); data collection (n = 2); test result turnaround (n = 2); peer group support (n = 2) and psychological intervention (n = 1). CONCLUSIONS: Most studies of mHealth for MNCH in LMIC are of poor methodological quality and few have evaluated impacts on patient outcomes. Improvements in intermediate outcomes have nevertheless been reported in many studies and there is modest evidence that interventions delivered via SMS messaging can improve infant feeding. Ambiguous descriptions of interventions and their mechanisms of impact present difficulties for interpretation and replication. Rigorous studies with potential to offer clearer evidence are underway.