Long-Term Effect of Salt Substitution for Cardiovascular Outcomes : A Systematic Review and Meta-analysis.

BACKGROUND: Salt substitution is a simple yet increasingly promising strategy to improve cardiovascular outcomes. PURPOSE: To evaluate the long-term effects of salt substitution on cardiovascular outcomes. DATA SOURCES: PubMed, EMBASE, Cochrane CENTRAL, and CINAHL searched from inception to 23 August 2023. Trial registries, citation analysis, and hand-search were also done. STUDY SELECTION: Randomized controlled trials (RCTs) comparing provision of or advice to use a salt substitute with no intervention or use of regular salt among adults for 6 months or longer in total study duration. DATA EXTRACTION: Two authors independently screened articles, extracted data, and assessed risk of bias. Primary outcomes include mortality, major cardiovascular events (MACE), and adverse events at 6 months or greater. Secondary and post hoc outcomes include blood pressure, cause-specific mortality, and urinary excretion at 6 months or greater. Random-effects meta-analyses were done and certainty of effect estimates were assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation). DATA SYNTHESIS: Of the 16 included RCTs, 8 reported on primary outcomes. Most (n = 7 of 8) were done in China or Taiwan, 3 were done in residential facilities, and 7 included populations of older age (average 62 years) and/or with higher-than-average cardiovascular risk. In this population, salt substitute may reduce risk for all-cause mortality (6 RCTs; 27 710 participants; rate ratio [RR], 0.88 [95% CI, 0.82 to 0.93]; low certainty) and cardiovascular mortality (4 RCTs; 25 050 participants; RR, 0.83 [CI, 0.73 to 0.95]; low certainty). Salt substitute may result in a slight reduction in MACE (3 RCTs; 23 215 participants; RR, 0.85 [CI, 0.71 to 1.00]; very low certainty), with very low-certainty evidence of serious adverse events (6 RCTs; 27 995 participants; risk ratio, 1.04 [CI, 0.87 to 1.25]). LIMITATIONS: The evidence base is dominated by a single, large RCT. Most RCTs were from China or Taiwan and involved participants with higher-than-average cardiovascular risk; therefore, generalizability to other populations is very limited. CONCLUSION: Salt substitution may reduce all-cause or cardiovascular mortality, but the evidence for reducing cardiovascular events and for not increasing serious adverse events is uncertain, particularly for a Western population. The certainty of evidence is higher among populations at higher cardiovascular risk and/or following a Chinese diet. PRIMARY FUNDING SOURCE: National Health and Medical Research Council. (PROSPERO: CRD42022327566).

Is an accurate self-perceived health risk beneficial for patients to minimize prehospital delay time at onset of a ST-segment elevated myocardial infarction (STEMI)?

High risk perception (HRP) is fundamental for adequate health behavior. However, its impact on rapid access to cardiac care after the onset of acute myocardial infarction (AMI) is not known. Conflicting evidence exists about sources that promote HRP. Data on sociodemographic and clinical characteristics of 588 AMI patients who participated in the Munich Examination of Delay in Patients Experiencing Acute Myocardial Infarction (MEDEA) study were collected at the bedside. Adjusted multivariate logistic regression models identified factors associated with HRP. Only 13.4% (n = 79) of patients had a favorable HRP level. The HRP patients did not differ from those with low risk perception (LRP) in terms of sex, age, other sociodemographic features, and somatic risk factors. Among the univariate contributors to HRP were prodromal chest pain (p = 0.0004), symptom mismatch during AMI (p < 0.0001), depression (p = 0.01), and anxiety (p = 0.005). However, family history of AMI, a previous AMI, and knowledge of AMI remained significant in the multivariate regression model. Median delay time to reach a hospital-based emergency facility after the onset of AMI was 127 min (interquartile range [IQR]: 83-43, p = 0.02) in HRP patients and 216 min (IQR: 106-721) in LRP patients. An increasing risk perception score was associated with a corresponding stepwise decline in median delay time (p > 0.004). Self-perceived AMI risk is associated in a dose-response relationship with the time needed to reach coronary care emergency facilities. Recurrent AMI, family history of AMI, and sufficient knowledge of MI contribute to risk perception, whereas somatic risk factors do not.

Overuse of medications in low- and middle-income countries: a scoping review.

Objective: To identify and summarize the evidence about the extent of overuse of medications in low- and middle-income countries, its drivers, consequences and potential solutions. Methods: We conducted a scoping review by searching the databases PubMed®, Embase®, APA PsycINFO® and Global Index Medicus using a combination of MeSH terms and free text words around overuse of medications and overtreatment. We included studies in any language published before 25 October 2021 that reported on the extent of overuse, its drivers, consequences and solutions. Findings: We screened 3489 unique records and included 367 studies reporting on over 5.1 million prescriptions across 80 low- and middle-income countries - with studies from 58.6% (17/29) of all low-, 62.0% (31/50) of all lower-middle- and 60.0% (33/55) of all upper-middle-income countries. Of the included studies, 307 (83.7%) reported on the extent of overuse of medications, with estimates ranging from 7.3% to 98.2% (interquartile range: 30.2-64.5). Commonly overused classes included antimicrobials, psychotropic drugs, proton pump inhibitors and antihypertensive drugs. Drivers included limited knowledge of harms of overuse, polypharmacy, poor regulation and financial influences. Consequences were patient harm and cost. Only 11.4% (42/367) of studies evaluated solutions, which included regulatory reforms, educational, deprescribing and audit-feedback initiatives. Conclusion: Growing evidence suggests overuse of medications is widespread within low- and middle-income countries, across multiple drug classes, with few data of solutions from randomized trials. Opportunities exist to build collaborations to rigorously develop and evaluate potential solutions to reduce overuse of medications.

Local corticosteroid injection versus placebo for carpal tunnel syndrome.

BACKGROUND: Carpal tunnel syndrome (CTS) is a very common clinical syndrome manifested by signs and symptoms of irritation of the median nerve at the carpal tunnel in the wrist. Direct and indirect costs of CTS are substantial, with estimated costs of two billion US dollars for CTS surgery in the USA in 1995 alone. Local corticosteroid injection has been used as a non-surgical treatment for CTS many years, but its effectiveness is still debated. OBJECTIVES: To evaluate the benefits and harms of corticosteroids injected in or around the carpal tunnel for the treatment of carpal tunnel syndrome compared to no treatment or a placebo injection. SEARCH METHODS: We used standard, extensive Cochrane search Methods. The searches were 7 June 2020 and 26 May 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs) or quasi-randomised trials of adults with CTS that included at least one comparison group of local injection of corticosteroid (LCI) into the wrist and one group that received a placebo or no treatment. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcome was 1. improvement in symptoms at up to three months of follow-up. Our secondary outcomes were 2. functional improvement, 3. improvement in symptoms at greater than three months of follow-up, 4. improvement in neurophysiological parameters, 5. improvement in imaging parameters, 6. requirement for carpal tunnel surgery, 7. improvement in quality of life and 8. ADVERSE EVENTS: We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS: We included 14 trials with 994 participants/hands with CTS. Only nine studies (639 participants/hands) had useable data quantitatively and in general, these studies were at low risk of bias except for one quite high-risk study. The trials were conducted in hospital-based clinics across North America, Europe, Asia and the Middle East. All trials used participant-reported outcome measures for symptoms, function and quality of life. There is probably an improvement in symptoms measured at up to three months of follow-up favouring LCI (standardised mean difference (SMD) -0.77, 95% confidence interval (CI) -0.94 to -0.59; 8 RCTs, 579 participants; moderate-certainty evidence). Up to six months this was still evident favouring LCI (SMD -0.58, 95% CI -0.89 to -0.28; 4 RCTs, 234 participants/hands; moderate-certainty evidence). There is probably an improvement in function measured at up to three months favouring LCI (SMD -0.62, 95% CI -0.87 to -0.38; 7 RCTs, 499 participants; moderate-certainty evidence). We are uncertain if there is a difference in median nerve DML at up to three months of follow-up (mean difference (MD) -0.37 ms, 95% CI -0.75 to 0.02; 6 RCTs, 359 participants/hands; very low-certainty evidence). The requirement for surgery probably reduces slightly in the LCI group at one year (risk ratio 0.84, 95% CI 0.72 to 0.98; 1 RCT, 111 participants, moderate-certainty evidence). Quality of life, measured at up to three months of follow-up using the Short-Form 6 Dimensions questionnaire (scale from 0.29 to 1.0; higher is better) probably improved slightly in the LCI group (MD 0.07, 95% CI 0.02 to 0.12; 1 RCT, 111 participants; moderate-certainty evidence). Adverse events were uncommon (low-certainty evidence). One study reported 2/364 injections resulted in severe pain which resolved over "several weeks" and 1/364 injections caused a "sympathetic reaction" with a cool, pale hand that completely resolved in 20 minutes. One study (111 participants) reported no serious adverse events, but 65% of LCI-injected and 16% of the placebo-injected participants experienced mild-to-moderate pain lasting less than two weeks. About 9% of participants experienced localised swelling lasting less than two weeks. Four studies (229 participants) reported that they experienced no adverse events in their studies. Three studies (220 participants) did not specifically report adverse events. AUTHORS' CONCLUSIONS: Local corticosteroid injection is effective for the treatment of mild and moderate CTS with benefits lasting up to six months and a reduced need for surgery up to 12 months. Where serious adverse events were reported, they were rare.

Postgraduate training abroad and migration intentions of medical doctors and students in Gaza: a cross-sectional survey.

BACKGROUND: The migration of medical professionals is a global health challenge, as emigration can weaken local health systems. Factors contributing towards this problem include inadequate job opportunities, low job satisfaction, and difficulty in accessing or substandard residency training. Longstanding political instability in Gaza, occupied Palestinian territory, has affected the health-care system. For instance, medical doctors working in governmental hospitals have received less than half of their salaries every few months for the past 10 years. We explored the intentions of medical professionals and students to do their residency training abroad and their career plans afterwards. METHODS: Between September and November, 2018, we surveyed medical doctors and students in Gaza about their migration intentions. We sent emails and used a social media platform to invite potential participants to complete a validated, online, self-administered structured questionnaire administered via Qualtrics (Provo, UT, USA). Questions were included about sociodemographic, educational, and practice characteristics, intention to train abroad, preferred destination, reasons for and barriers to training abroad, and their intentions of returning to Palestine after training. We used Microsoft Excel 2016 to analyse the results. FINDINGS: Of 148 medical doctors and students who responded to our survey, 116 completed the questionnaire and were included in the analysis. 75 (65%) participants were men, 90 (78%) were aged 21-35 years, and 70 (60%) were single. Most participants were either residents in training (n=48 [41%]), interns (n=12 [10%]), or medical students in their final year (n=33 [28%]). 65 (56%) participants preferred surgical specialities, 33 (28%) medical specialties, and the remainder preferred academic research (four [3%]) and family medicine (14 [12%]). 106 participants intended to travel abroad. The top four destination countries were the UK (n=40 [35%]), the USA (n=20 [17%]), Germany (n=20 [17%]), and Australia (n=12 [10%]). 93 (80%) intended to travel for specialty training and 12 (10%) for subspecialty training. 34 (32%) of 106 intended to return to Palestine after working abroad for more than 10 years, 15 (14%) for 5-10 years, 25 (24%) for less than 5 years, and 14 (13%) directly after training, whereas 18 (17%) intended never to return to Palestine. Financial expenses related to travelling, institution examinations, and visa applications were the major barriers to training abroad (listed by 57 [49%] participants). Most respondents (n=83 [72%]) felt that society expects clinicians to be trained abroad and that they are more qualified than those trained in Palestine (n=74 [64%]). INTERPRETATION: A very high proportion of the medical doctors and students we surveyed intended to train abroad and return to Palestine, although a minority intended never to return. Our findings should be interpreted cautiously because of the possibility of selection bias (ie, those intending to migrate were more likely to respond to our survey and because intention might not translate to action). Qualitative research is needed to obtain a greater understanding of the key influences on intention to migrate to inform strategies to retain the health-care workforce. FUNDING: None.

Clinical audit as a quality improvement tool in the Gaza Strip: an audit of audits.

BACKGROUND: Clinical audit plays a fundamental role in improving the quality of patient care and hence, is considered a cornerstone of clinical governance. This quality improvement tool is newly introduced in the health-care system of the Gaza Strip. Although the number of audits completed in Gaza has been increasing over the past few years, little evidence is available of subsequent quality improvements in practice. METHODS: An online survey was used to collect information on the audit team, location, applied methods, outcomes, presentation of data, and reaudit. Medical students and health-care professionals who had conducted audits between 2015 and 2018 were invited to complete the survey from Oct 12 to Nov 2, 2018. FINDINGS: Data on 62 audits were collected. Training in clinical governance was received by 55 auditors (89%) and a senior supervisor was available in 56 audits (90%). Audits were performed across different hospitals and specialties: 18 (29%) in obstetrics, 16 (26%) in medicine, and 11 (18%) in each of surgery and paediatrics, with six (10%) in other specialties. A clear trend of increasing numbers of audits was observed, with four (6%) having been done in 2015, 12 (19%) in 2016, 22 (35%) in 2017, and 24 audits (39%) in 2018. Students were involved in 46 audits (74%) whereas practising doctors were involved in only 29 audits (47%). 17 (27.4%) audits were done at more than one health-care facility and the remaining audits were done at one of 13 other main hospitals or community centres across the Gaza Strip. Clear standards were identified in 54 audits (90%) while eight audits (13%) reported not setting standards at all. Improvement of documentation was recommended in 44 audits (71%), development of national guidelines in 37 (60%), and staff training in 32 (52%). Only 32 audits (51.6%) were presented to the local staff. The audit cycle was completed in 13 projects (20.9%) with only seven of them reporting subsequent improvements in practice. INTERPRETATION: A rise in the numbers of audits reflects a growing awareness of their key role in health care and patients' safety. However, completion of audit cycles and the actual implementation of recommendations are lagging. Therefore, more focused efforts supported by both clinical and administrative leaderships are needed to implement changes and ensure continuous evaluation of their effectiveness. FUNDING: None.

Effect of an Individualized Audit and Feedback Intervention on Rates of Musculoskeletal Diagnostic Imaging Requests by Australian General Practitioners: A Randomized Clinical Trial.

Importance: Audit and feedback can improve professional practice, but few trials have evaluated its effectiveness in reducing potential overuse of musculoskeletal diagnostic imaging in general practice. Objective: To evaluate the effectiveness of audit and feedback for reducing musculoskeletal imaging by high-requesting Australian general practitioners (GPs). Design, Setting, and Participants: This factorial cluster-randomized clinical trial included 2271 general practices with at least 1 GP who was in the top 20% of referrers for 11 imaging tests (of the lumbosacral or cervical spine, shoulder, hip, knee, and ankle/hind foot) and for at least 4 individual tests between January and December 2018. Only high-requesting GPs within participating practices were included. The trial was conducted between November 2019 and May 2021, with final follow-up on May 8, 2021. Interventions: Eligible practices were randomized in a 1:1:1:1:1 ratio to 1 of 4 different individualized written audit and feedback interventions (n = 3055 GPs) that varied factorially by (1) frequency of feedback (once vs twice) and (2) visual display (standard vs enhanced display highlighting highly requested tests) or to a control condition of no intervention (n = 764 GPs). Participants were not masked. Main Outcomes and Measures: The primary outcome was the overall rate of requests for the 11 targeted imaging tests per 1000 patient consultations over 12 months, assessed using routinely collected administrative data. Primary analyses included all randomized GPs who had at least 1 patient consultation during the study period and were performed by statisticians masked to group allocation. Results: A total of 3819 high-requesting GPs from 2271 practices were randomized, and 3660 GPs (95.8%; n = 727 control, n = 2933 intervention) were included in the primary analysis. Audit and feedback led to a statistically significant reduction in the overall rate of imaging requests per 1000 consultations compared with control over 12 months (adjusted mean, 27.7 [95% CI, 27.5-28.0] vs 30.4 [95% CI, 29.8-30.9], respectively; adjusted mean difference, -2.66 [95% CI, -3.24 to -2.07]; P < .001). Conclusions and Relevance: Among Australian general practitioners known to frequently request musculoskeletal diagnostic imaging, an individualized audit and feedback intervention, compared with no intervention, significantly decreased the rate of targeted musculoskeletal imaging tests ordered over 12 months. Trial Registration: ANZCTR Identifier: ACTRN12619001503112.

Self-Management for Men With Lower Urinary Tract Symptoms: A Systematic Review and Meta-Analysis.

PURPOSE: Lower urinary tract symptoms are very common in older men. We conducted a systematic review and meta-analysis to evaluate the effects of self-management interventions on these symptoms. METHODS: We included randomized controlled trials comparing the effect of self-management interventions (alone or combined with drug therapy) with usual care or drug therapy alone in men with lower urinary tract symptoms. Two independent reviewers screened retrieved articles, extracted data, and assessed the risk of bias of included studies. The primary outcome was lower urinary tract symptom severity. Where data were available, we calculated mean differences (MDs) between the interventions. RESULTS: Analyses were based on 8 studies among 1,006 adult men. Seven of these studies were judged to be at high risk in 2 of the 7 domains of bias. The nature of the self-management interventions varied across studies. There was a clinically important reduction in the 35-point International Prostate Symptom Score at 6 months favoring self-management interventions compared with usual care (MD = -7.4; 95% CI, -8.8 to -6.1; 2 studies). The reduction in score with self-management was similar to that achieved with drug therapy at 6 to 12 weeks (MD = 0.0; 95% CI, -2.0 to 2.0; 3 studies). Self-management had a smaller, additional benefit at 6 weeks when added to drug therapy (MD = -2.3; 95% CI, -4.1 to -0.5; 1 study). CONCLUSIONS: We found moderate-quality evidence (suggesting reasonable certainty in estimates) for the effectiveness of self-management for treating lower urinary tract symptoms in men. We therefore recommend the use of self-management interventions for this patient population.

Concerns and potential improvements in end-of-life care from the perspectives of older patients and informal caregivers: a scoping review.

BACKGROUND: Overtreatment in advanced age i.e. aggressive interventions that do not improve survival and are potentially harmful, can impair quality of care near the end of life (EOL). As healthcare provider perspectives on care quality may differ from that of service users, the aim of this study was to explore the views of older patients near EOL or their caregivers about the quality of health care at the EOL based on their lived experience, and to identify healthcare service improvements. METHODS: Medline and backward citation searches were conducted for qualitative or quantitative studies reported on the views of patients and/or informal caregivers about EOL care quality. Thematic analysis was used to summarise qualitative data (primary analysis); narrative and tabulations were used to summarise quantitative data (secondary analysis). RESULTS: Thirty articles met the inclusion criteria. Five main qualitative themes regarding quality care emerged: (1) Effective communication between clinicians and patients/caregivers; (2) Healthcare that values patient preferences and shared decision making; (3) Models of care that support quality of life and death with dignity; (4) Healthcare services that meet patient expectations; and (5) Support for informal caregivers in dealing with EOL challenges. The quantitative articles supported various aspects of the thematic framework. CONCLUSION: The findings of this study show that many of the issues highlighted by patients or bereaved relatives have persisted over the past two decades. There is an urgent need for comprehensive evaluation of care across the healthcare system and targeted redesign of existing EOL care pathways to ensure that care aligns with what patients and informal caregivers consider high-quality patient-centred care at the EOL.

Healthcare workers preparedness for COVID-19 pandemic in the occupied Palestinian territory: a cross-sectional survey.

BACKGROUND: The COVID-19 pandemic threatens to overwhelm the capacity of a vulnerable healthcare system in the occupied Palestinian territory (oPt). We aimed to evaluate the availability of personal protective equipment (PPE) and the level of preparedness among HCWs in the oPt. METHODS: A cross-sectional study was conducted using a validated online questionnaire distributed through convenient sampling between March 30, 2020 and April 12, 2020. Outcomes were availability of PPE, healthcare workers (HCWs) preparedness in oPt for COVID-19 pandemic, and regional and hospital differences in oPt in terms of availability of PPE and HCWs preparedness. Descriptive statistics and univariate analysis were used in this study. RESULTS: Of 138 respondents, only 38 HCWs (27.5%) always had access to facemasks and 15 (10.9%) always had access to isolation gowns. Most HCWs did not find eye protection (n = 128, 92.8%), N95 respirators (n = 132, 95.7%), and face shields (n = 127, 92%) always available. Compared to HCWs in West Bank, those in the Gaza Strip were significantly less likely to have access to alcohol sanitizers (p = 0.03) and gloves (p < 0.001). On average, governmental hospitals were significantly less likely to have all appropriate PPE than non-governmental institutions (p = 0.001). Only 16 (11.6%) surveyed felt confident in dealing with a potential COVID-19 case, 57 (41.3%) having received any COVID-19-related training, and 57 (41.3%) not having a local hospital protocol. CONCLUSION: HCWs in oPt appear to be underprepared and severely lacking adequate PPE provision. The lack of PPE provision will exacerbate spread of COVID-19 and deepen the crisis, whilst putting HCWs at risk.

Head of bed elevation to relieve gastroesophageal reflux symptoms: a systematic review.

BACKGROUND: Overuse of proton pump inhibitors (PPIs) - frequently used for relieving symptoms of gastroesophageal reflux disease (GORD) - raises long-term safety concerns, warranting evidence-based non-drug interventions. We conducted a systematic review to evaluate the effect of head-of-bed elevation on relieving symptoms of GORD in adults. METHODS: We included controlled trials comparing the effect of head-of-bed elevation interventions to control in adults with GORD. Two independent reviewers screened articles, extracted data, and assessed quality of included studies. Primary outcomes were changes in GORD symptoms and use of PPIs. RESULTS: We screened 1206 records; and included five trials (four cross-over and one factorial) comprising 228 patients. All five included trials were judged to be at high-risk of performance bias and four of selection bias. Of five included trials, two used 'bed blocks' under the bed legs; one used 'sleeping on a wedge' pillow, and two used both. High heterogeneity in outcome measures and reported outcomes data precluded meta-analyses. The four studies that reported on GORD symptoms found an improvement among participants in the head-of-bed elevation; a high-quality crossover trial showed a clinical important reduction in symptom scores at 6 weeks (risk ratio of 2.1; 95% CI 1.2 to 3.6). These results are supported by the observed improvement in physiological intra-oesophageal pH measurements. CONCLUSIONS: Methodological and reporting limitations in available literature preclude definitive recommendations. However, head-of-bed elevation could be still considered as a cheap and safe alternative to drug interventions with unfavourable safety profiles. PROTOCOL REGISTRATION: Open Science Framework: http://osf.io/2hz3j.

Workplace pedometer interventions for increasing physical activity.

BACKGROUND: The World Health Organization (WHO) recommends undertaking 150 minutes of moderate-intensity physical activity per week, but most people do not. Workplaces present opportunities to influence behaviour and encourage physical activity, as well as other aspects of a healthy lifestyle. A pedometer is an inexpensive device that encourages physical activity by providing feedback on daily steps, although pedometers are now being largely replaced by more sophisticated devices such as accelerometers and Smartphone apps. For this reason, this is the final update of this review. OBJECTIVES: To assess the effectiveness of pedometer interventions in the workplace for increasing physical activity and improving long-term health outcomes. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Occupational Safety and Health (OSH) UPDATE, Web of Science, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform from the earliest record to December 2016. We also consulted the reference lists of included studies and contacted study authors to identify additional records. We updated this search in May 2019, but these results have not yet been incorporated. One more study, previously identified as an ongoing study, was placed in 'Studies awaiting classification'. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of workplace interventions with a pedometer component for employed adults, compared to no or minimal interventions, or to alternative physical activity interventions. We excluded athletes and interventions using accelerometers. The primary outcome was physical activity. Studies were excluded if physical activity was not measured. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. When studies presented more than one physical activity measure, we used a pre-specified list of preferred measures to select one measure and up to three time points for analysis. When possible, follow-up measures were taken after completion of the intervention to identify lasting effects once the intervention had ceased. Given the diversity of measures found, we used ratios of means (RoMs) as standardised effect measures for physical activity. MAIN RESULTS: We included 14 studies, recruiting a total of 4762 participants. These studies were conducted in various high-income countries and in diverse workplaces (from offices to physical workplaces). Participants included both healthy populations and those at risk of chronic disease (e.g. through inactivity or overweight), with a mean age of 41 years. All studies used multi-component health promotion interventions. Eleven studies used minimal intervention controls, and four used alternative physical activity interventions. Intervention duration ranged from one week to two years, and follow-up after completion of the intervention ranged from three to ten months. Most studies and outcomes were rated at overall unclear or high risk of bias, and only one study was rated at low risk of bias. The most frequent concerns were absence of blinding and high rates of attrition. When pedometer interventions are compared to minimal interventions at follow-up points at least one month after completion of the intervention, pedometers may have no effect on physical activity (6 studies; very low-certainty evidence; no meta-analysis due to very high heterogeneity), but the effect is very uncertain. Pedometers may have effects on sedentary behaviour and on quality of life (mental health component), but these effects were very uncertain (1 study; very low-certainty evidence). Pedometer interventions may slightly reduce anthropometry (body mass index (BMI) -0.64, 95% confidence interval (CI) -1.45 to 0.18; 3 studies; low-certainty evidence). Pedometer interventions probably had little to no effect on blood pressure (systolic: -0.08 mmHg, 95% CI -3.26 to 3.11; 2 studies; moderate-certainty evidence) and may have reduced adverse effects (such as injuries; from 24 to 10 per 100 people in populations experiencing relatively frequent events; odds ratio (OR) 0.50, 95% CI 0.30 to 0.84; low-certainty evidence). No studies compared biochemical measures or disease risk scores at follow-up after completion of the intervention versus a minimal intervention. Comparison of pedometer interventions to alternative physical activity interventions at follow-up points at least one month after completion of the intervention revealed that pedometers may have an effect on physical activity, but the effect is very uncertain (1 study; very low-certainty evidence). Sedentary behaviour, anthropometry (BMI or waist circumference), blood pressure (systolic or diastolic), biochemistry (low-density lipoprotein (LDL) cholesterol, total cholesterol, or triglycerides), disease risk scores, quality of life (mental or physical health components), and adverse effects at follow-up after completion of the intervention were not compared to an alternative physical activity intervention. Some positive effects were observed immediately at completion of the intervention periods, but these effects were not consistent, and overall certainty of evidence was insufficient to assess the effectiveness of workplace pedometer interventions. AUTHORS' CONCLUSIONS: Exercise interventions can have positive effects on employee physical activity and health, although current evidence is insufficient to suggest that a pedometer-based intervention would be more effective than other options. It is important to note that over the past decade, technological advancement in accelerometers as commercial products, often freely available in Smartphones, has in many ways rendered the use of pedometers outdated. Future studies aiming to test the impact of either pedometers or accelerometers would likely find any control arm highly contaminated. Decision-makers considering allocating resources to large-scale programmes of this kind should be cautious about the expected benefits of incorporating a pedometer and should note that these effects may not be sustained over the longer term. Future studies should be designed to identify the effective components of multi-component interventions, although pedometers may not be given the highest priority (especially considering the increased availability of accelerometers). Approaches to increase the sustainability of intervention effects and behaviours over a longer term should be considered, as should more consistent measures of physical activity and health outcomes.

The relation between health research output and burden of disease in Palestine: a systematic review.

BACKGROUND: Highest priority should be given to research on conditions responsible for the greatest disease burden. This is particularly important in settings where resources are scarce. The aim of this study was to assess the association between research output and disease burden in the occupied Palestinian territory and to identify the conditions that are under-investigated or over-investigated, if any. METHODS: We searched PubMed and Scopus for reports of original research relevant to human health or health care that was authored by researchers affiliated with Palestinian institutions and published between Jan 1, 2000, and Dec 31, 2015. We categorised the health condition studied in included articles using the Global Burden of Disease (GBD) taxonomy. Data about the burden of disease (percentage of deaths and disability-adjusted life-years [DALYs]) were obtained from the Palestine profile in the GBD study. We examined the degree of discordance between the observed number of published articles for each disease or health condition with the expected number based on the proportion of disease burden for that disease or health condition. FINDINGS: We identified 2469 records and excluded 1650 records after screening titles and abstracts. We included 511 of the remaining 819 full-text articles in our review. Research output was poorly associated with disease burden, irrespective of whether measured in DALYs (ρ: -0·116; p=0·7) or death (0·217; p=0·5). Cardiovascular disease, maternal and neonatal health, and cancer accounted for 212 (67%) deaths per 100 000 population in the occupied Palestinian territory, but this was addressed in only 117 (23%) articles. INTERPRETATION: We found evidence of research waste, as measured by a mismatch between the health burden of disease or health condition and the number of published research reports about that disease or condition in Palestine. National research priority setting should be developed to meet the local community's need of quality evidence in order to develop independent and informed health policies. FUNDING: None.

Inpatient management of community-acquired pneumonia at the European Gaza Hospital: a clinical audit.

BACKGROUND: Disease severity scores such as CURB-65 are often used to guide the management of patients with community-acquired pneumonia. Early and adequate empirical antibiotic treatment reduces mortality. The aim of this study was to examine the severity assessment and management of patients presenting with community-acquired pneumonia at the European Gaza Hospital in the Gaza Strip and to compare this to the best available evidence. METHODS: Medical records of all patients admitted to the European Gaza Hospital with a diagnosis of community-acquired pneumonia between Dec 1, 2015, and March 31, 2016, were reviewed retrospectively. Clinical practice was compared with recommendations for severity assessment and the management of community-acquired pneumonia, as reported in guidelines by the National Institute for Health and Care Excellence and the American Thoracic Society. Ethical approval was obtained from the General Directorate of Human Resources. FINDINGS: 141 patients were admitted to the European Gaza Hospital with community-acquired pneumonia during the study period. Records of 41 patients were missing or could not be retrieved. The mean age of patients was 55·9 years (SD 20·2). Blood urea and nitrogen concentrations were not documented for 48 (48%) patients, and respiratory rate was not documented for 73 (73%) patients. The CURB-65 score was determined only for 12 (12%) patients. Microbiological testing was done only for two (2%) patients. Although 18 different antibiotic regimens were used, 81 (81%) patients received a ß-lactam plus macrolide combination therapy, either given alone (49 [49%] patients) or with another antibiotic (32 [32%] patients), which is in line with the recommendations for patients admitted to hospital with community-acquired pneumonia. 43 (43%) patients received anti-viral drugs, and 41 (41%) patients received corticosteroids. INTERPRETATION: Clinicians were poorly adherent to current standards of care in severity assessment and management of community-acquired pneumonia. Moreover, the broad range of antibiotic regimes used, without microbiological guidance, was inappropriate and will have increased the risk of antibiotic resistance. A local evidence-based clinical practice guideline should be developed and implemented. Furthermore, the documentation system should be improved to enhance the continuity of care and clinical auditing. FUNDING: None.

Management of acute ischaemic stroke at Nasser Hospital, Gaza Strip: a clinical audit.

BACKGROUND: Stroke is a leading cause of morbidity and mortality worldwide. The aim of this study was to assess the standard of care for patients with acute ischaemic stroke at the internal medicine department of Nasser Hospital, Gaza Strip. METHODS: For this retrospective clinical audit, we selected a random sample of 100 medical records for patients with stroke who were admitted to Nasser Hospital between January and August, 2016. Clinical practice was compared with the recommendations in the 2013 American Heart Association and American Stroke Association guidelines. Patient confidentiality was maintained, and ethical approval was obtained from the Palestinian Ministry of Health. FINDINGS: Five patient records were not coded and therefore excluded. Of the remaining 95 patients, 51 (54%) were men with a mean age of 67 years (SD 14). 53 patients presented with dysarthria. The duration of stroke symptoms before admission was not reported in 86 (91%) records. A complete blood count and renal function tests were done for all patients, lipid profiling for 87 (92%) patients, electrocardiography for 85 (89%) patients, carotid duplex ultrasound for 32 (34%) patients, and CT scan for all patients. None of the patients had continuous cardiac monitoring or an assessment of swallowing function, and 70 (74%) patients received immediate anti-platelet therapy (325 mg aspirin). 80 (85%) patients received venous thromboembolism prophylaxis. 41 (43%) patients were given antibiotics without a recorded indication. None of the patients received thrombolytic therapy. As recommended in the guidelines, 41 (43%) patients did not receive anti-hypertensive agents on the first day of hospitalisation. 46 (48%) patients had diabetes, and glycaemic control was achieved by day 3 in 26 (57%) patients. INTERPRETATION: No Palestinian guidelines exist for the management of patients with acute ischaemic stroke, and in most cases management was based on personal experience rather than evidence. The development of evidence-based guidelines is mandatory to improve management of ischaemic stroke. Furthermore, implementing staff education activities, regular clinical audit, and team feedback would encourage adherence to such guidelines. Combined with the establishment of a specialised stroke unit and development of a multidisciplinary team approach, patient outcome could be improved further. FUNDING: None.

Montreal Cognitive Assessment (MoCA) for HIV-Associated Neurocognitive Disorders.

This study aims to systematically review the evidence on the accuracy of the Montreal Cognitive Assessment (MoCA) test for diagnosing HIV-associated neurocognitive disorders (HAND) and to outline the quality and quantity of research evidence available about the accuracy of MoCA in populations infected with HIV. We conducted a systematic literature review, searching five databases from inception until January 2019. We extracted dichotomized positive and negative test results at various thresholds and calculated the sensitivity and specificity of MoCA. Quality assessment was performed according to the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) criteria. Eight cross-sectional studies met the inclusion criteria for meta-analysis. Overall, 1014 patients were included but most studies recruited small samples. Recruitment period ranged from 2009 to 2015. We assessed most studies as being applicable to the review question though we had concerns about the selection of participants in three studies. The accuracy of MoCA for diagnosing HAND was reported at six cut-off points (scores 22-27). The MoCA test provides information about general cognitive functioning disturbances that contribute to a diagnosis of HAND. A lower threshold than the original cut-off of 26 is probably more useful for optimal screening of HAND, as it lowers false positive rates and improves diagnostic accuracy. Nonetheless, the choice of cut-off always comes with a sensitivity-specificity trade-off, the preferred cut point depending on whether sensitivity or specificity is more valuable in a given context.

External validation and comparison of four cardiovascular risk prediction models with data from the Australian Diabetes, Obesity and Lifestyle study.

OBJECTIVES: To evaluate the performance of the 2013 Pooled Cohort Risk Equation (PCE-ASCVD) for predicting cardiovascular disease (CVD) in an Australian population; to compare this performance with that of three frequently used Framingham-based CVD risk prediction models. DESIGN: Prospective national population-based cohort study. SETTING: 42 randomly selected urban and non-urban areas in six Australian states and the Northern Territory. PARTICIPANTS: 5453 adults aged 40-74 years enrolled in the Australian Diabetes, Obesity and Lifestyle study and followed until November 2011. We excluded participants who had CVD at baseline or for whom data required for risk model calculations were missing. MAIN OUTCOME MEASURES: Predicted and observed 10-year CVD risks (adjusted for treatment drop-in); performance (calibration and discrimination) of four CVD risk prediction models: 1991 Framingham, 2008 Framingham, 2008 office-based Framingham, 2013 PCE-ASCVD. RESULTS: The performance of the 2013 PCE-ASCVD model was slightly better than 1991 Framingham, and each was better the two 2008 Framingham risk models, both in men and women. However, all four models overestimated 10-year CVD risk, particularly for patients in higher deciles of predicted risk. The 2013 PCE-ASCVD (7.5% high risk threshold) identified 46% of men and 18% of women as being at high risk; the 1991 Framingham model (20% threshold) identified 17% of men and 2% of women as being at high risk. Only 16% of men and 11% of women identified as being at high risk by the 2013 PCE-ASCVD experienced a CV event within 10 years. CONCLUSIONS: The 2013 PCE-ASCVD or 1991 Framingham should be used as CVD risk models in Australian. However, the CVD high risk threshold for initiating CVD primary preventive therapy requires reconsideration.

Role of professional networks on social media in addressing clinical questions at general practice: a cross-sectional study of general practitioners in Australia and New Zealand.

BACKGROUND: Clinicians frequently have questions about patient care. However, for more than half of the generated questions, answers are never pursued, and if they are, often not answered satisfactorily. We aimed to characterise the clinical questions asked and answers provided by general practitioners (GP) through posts to a popular professional social media network. METHODS: In this cross-sectional study, we analysed clinical questions and answers posted between January 20th and February 10th 2018 on a popular GP-restricted (Australia, New Zealand) Facebook group. Each clinical question was categorised according to 'background' or 'foreground' question; type (e.g. treatment, diagnosis); and the clinical topic (e.g. cardiovascular). Each answer provided in response to included questions was categorised into: (i) short answer (e.g. agree/disagree); (ii) provided an explanation to justify the answer; and (iii) referred to a published relevant evidence resource. RESULTS: Of 1060 new posts during the study period, 204 (19%) included a clinical question. GPs most commonly asked about treatment (n = 87; 43%) and diagnosis (n = 59; 29%). Five major topics (23% skin, 10% psychology, 9% cardiovascular, 8% female genital, and 7% musculoskeletal) accounted for 118 (58%) questions. Each question received on average 10 (SD = 9) answers: 42% were short; 51% provided an explanation; and only 6% referred to relevant research evidence. Only 3 answers referred to systematic reviews. CONCLUSIONS: In this sample of Australian and New Zealand GPs, who were members of a GP social media group, GPs asked clinical questions that can be organised into a limited number of question types and topics. This might help guide the development of GP learning programs.

The range and nature of reproductive health research in the occupied Palestinian territory: a scoping review.

BACKGROUND: In order to set research priorities for reproductive health in the occupied Palestinian territory, it is vital to know what current research has been done in the field of reproductive health. The purpose of this scoping review is to examine the range and nature of reproductive health research in the occupied Palestinian territory and to identify research gaps in the existing literature. METHODS: We searched four databases: EMBASE, PubMed, CINAHL, and Popline. We included studies that: (i) are published (with an abstract); (ii) relevant to reproductive health; (iii) Palestinians living in Palestine; (iv) participants over the age of 15 years; and (v) restricted to human research. Three independent reviewers screened title and abstracts, and extracted data from included articles. We conducted quantitative and qualitative analyses. RESULTS: Of 1025 titles and abstracts screened, 145 articles were included. 52 (36%) articles were conducted in community setting and 34 (24%) were conducted in hospitals. There were 5 (3%) experimental studies. 15 articles had more than one main theme; 160 subthemes overall were identified. The most frequently studied theme was labor and delivery (n = 19; 12%). One article discussed adolescent reproductive health and menopause while no articles discussed men's reproductive health. CONCLUSIONS: 91% of the research conducted is observational. The focus of reproductive health research was to understand the topic, community and providers' perceptions and knowledge. Articles related to the quality of services were limited. It is also important to research the reproductive health of women outside of reproductive age, men, and adolescents.