The impact of reduced routine community mental healthcare on people from minority ethnic groups during the COVID-19 pandemic: qualitative study of stakeholder perspectives.

BACKGROUND: Enduring ethnic inequalities exist in mental healthcare. The COVID-19 pandemic has widened these. AIMS: To explore stakeholder perspectives on how the COVID-19 pandemic has increased ethnic inequalities in mental healthcare. METHOD: A qualitative interview study of four areas in England with 34 patients, 15 carers and 39 mental health professionals from National Health Service (NHS) and community organisations (July 2021 to July 2022). Framework analysis was used to develop a logic model of inter-relationships between pre-pandemic barriers and COVID-19 impacts. RESULTS: Impacts were largely similar across sites, with some small variations (e.g. positive service impacts of higher ethnic diversity in area 2). Pre-pandemic barriers at individual level included mistrust and thus avoidance of services and at a service level included the dominance of a monocultural model, leading to poor communication, disengagement and alienation. During the pandemic remote service delivery, closure of community organisations and media scapegoating exacerbated existing barriers by worsening alienation and communication barriers, fuelling prejudice and division, and increasing mistrust in services. Some minority ethnic patients reported positive developments, experiencing empowerment through self-determination and creative activities. CONCLUSIONS: During the COVID-19 pandemic some patients showed resilience and developed adaptations that could be nurtured by services. However, there has been a reduction in the availability of group-specific NHS and third-sector services in the community, exacerbating pre-existing barriers. As these developments are likely to have long-term consequences for minority ethnic groups' engagement with mental healthcare, they need to be addressed as a priority by the NHS and its partners.

Trends in the Intraindividual Double Burden of Overweight/Obesity and Anemia among Adult Women Living in 33 Low- and Middle-Income Countries: A Secondary Analysis of Demographic and Health Surveys from 2000-2019.

BACKGROUND: Changes in overweight/obesity and anemia among women have been investigated in multiple studies, but the rate at which their coexistence at the individual level has evolved remains unknown. OBJECTIVES: We aimed to 1) document trends in the magnitude and inequalities of the co-occurrence of overweight/obesity and anemia; and 2) compare these with overall trends in overweight/obesity, anemia, and the co-occurrence of anemia with normal weight or underweight. METHODS: For this cross-sectional series study, we used 96 Demographic and Health Surveys from 33 countries with available anthropometric and anemia data among nonpregnant adult women (20-49 y old; n = 1,648,308). The primary outcome was defined as the coexistence of overweight or obesity (BMI ≥25kg/m2) and anemia (hemoglobin concentrations <12.0 g/dL) within the same individual. We computed overall and regional trends through multilevel linear regression models and by sociodemographic characteristics (i.e., wealth, education, and residence). Estimates at the country level were calculated through ordinary least square regression models. RESULTS: From 2000 to 2019, the co-occurrence of overweight/obesity and anemia increased modestly at an annual rate of 0.18 percentage points (95% CI: 0.08, 0.28 percentage points; P < 0.001), ranging from 0.73 percentage points in Jordan to -0.56 percentage points in Peru. This trend occurred in parallel with overall increases in overweight/obesity and reductions in anemia. The co-occurrence of anemia with normal weight or underweight was reducing in all countries, except Burundi, Sierra Leone, Jordan, Bolivia, and Timor-Leste. Stratified analyses yielded an upward trend in the co-occurrence of overweight/obesity and anemia across all subgroups but particularly in women from the 3 middle wealth groups, no education, and capital city or rural residents. CONCLUSIONS: The rising trend in the intraindividual double burden suggests that efforts to reduce anemia among women living with overweight/obesity may need to be revisited to accelerate progress toward the 2025 global nutrition target of halving anemia.

The Use of Digital Health Interventions for Cardiometabolic Diseases Among South Asian and Black Minority Ethnic Groups: Realist Review.

BACKGROUND: Digital health interventions (DHIs) for the prevention and management of cardiometabolic diseases have become increasingly common. However, there is limited evidence for the suitability of these approaches in minority ethnic populations, who are at an increased risk of these diseases. OBJECTIVE: This study aimed to investigate the use of DHIs for cardiovascular disease and type 2 diabetes among minority ethnic populations in countries with a majority of White, English-speaking populations, focusing on people who identified as South Asian, Black, or African American. METHODS: A realist methodology framework was followed. A literature search was conducted to develop context-mechanism-outcome configurations, including the contexts in which DHIs work for the target minority ethnic groups, mechanisms that these contexts trigger, and resulting health outcomes. After systematic searches, a qualitative analysis of the included studies was conducted using deductive and inductive coding. RESULTS: A total of 15 studies on the uptake of DHIs for cardiovascular disease or diabetes were identified, of which 13 (87%) focused on people with an African-American background. The review found evidence supporting the use of DHIs in minority ethnic populations when specific factors are considered in implementation and design, including patients' beliefs, health needs, education and literacy levels, material circumstances, culture, social networks, and wider community and the supporting health care systems. CONCLUSIONS: Our context-mechanism-outcome configurations provide a useful guide for the future development of DHIs targeted at South Asian and Black minority ethnic populations, with specific recommendations for improving cultural competency and promoting accessibility and inclusivity of design.

The impact of diarrhoea measurement methods for under 5s in low- and middle-income countries on estimated diarrhoea rates at the population level: A systematic review and meta-analysis of methodological and primary empirical studies.

OBJECTIVE: We systematically reviewed all studies published between 2000 and June 2021 that estimated under 5 diarrhoea rates in low- and middle-income countries and extracted data on diarrhoea rates, measurement methods and reactivity. METHODS: We summarised data from studies that performed direct comparisons of methods, and indirectly compared studies which utilised only one method using meta-regression to determine the association between methods and estimated diarrhoea rates. RESULTS: In total, 288 studies met our inclusion criteria: 4 direct comparisons and 284 studies utilising only one measurement method. Meta-regression across all studies showed that diarrhoea rates were sensitive to method of measurement. We estimated that passive surveillance methods were associated with a 97% lower estimated rate than active surveillance (IRR = 0.03, 95% CI [0.02, 0.06]). Among active surveillance studies, a doubling of recall period was associated with a 48% lower rate (IRR = 0.52 [0.46, 0.60]), while decreased questioning frequency was associated with a higher estimated rate: at the extreme, one time questioning yielded an over 4× higher rate than daily questioning (IRR = 4.22 [2.73, 6.52]). CONCLUSIONS: Estimated diarrhoea rates are sensitive to their measurement methods. There is a need for a standardisation of diarrhoea measurement methods, and for the use of other outcomes in the measurement of population-level gastrointestinal health.

Adolescent undernutrition in South Asia: a scoping review.

Undernutrition is a growing public health challenge affecting growth and development during adolescence in many low- and middle-income countries. This scoping review maps the evidence on adolescent undernutrition (stunting, thinness and micronutrient deficiencies) in South Asia and highlights gaps in knowledge. Using Arksey and O'Malley's framework and the Joanna Briggs Institute Reviewers' Manual, the search included electronic bibliographic databases (Medline (OVID), Embase, Cochrane Library, Web of Science, CINAHL, PsycInfo, and Scopus) as well as various grey literature sources published up to March 2019. In total, 131 publications met the inclusion criteria of this review. All the included evidence used quantitative data and 115 publications used a cross-sectional design. Nearly 70% (n = 86) of the included publications were conducted in India. Prevalence of undernutrition was reported based on different growth references and cut-offs. Evidence is divided into publications that included an intervention component (n = 12) and publications that did not include an intervention component (n = 116), and presented in a narrative synthesis. This scoping review provides a wide range of publications on adolescent undernutrition in South Asia and identifies future research priorities in the field.

The co-occurrence of overweight/obesity and anaemia among adult women, adolescent girls and children living in fifty-two low- and middle-income countries.

OBJECTIVE: To investigate the magnitude and distribution of concurrent overweight/obesity and anaemia among adult women, adolescent girls and children living in low- and middle-income countries (LMIC). DESIGN: We selected the most recent Demographic and Health Surveys with anthropometric and Hb level measures. Prevalence estimates and 95 % CI of concurrent overweight/obesity and anaemia were calculated for every country, overall and stratified by household wealth quintile, education level, area of residence and sex (for children only). Regional and overall pooled prevalences were estimated using a random-effects model. We measured gaps, expressed in percentage points, to display inequalities in the distribution of the double burden of malnutrition (DBM). SETTING: Nationally representative surveys from fifty-two LMIC. PARTICIPANTS: Adult women (n 825 769) aged 20-49 years, adolescent girls (n 192 631) aged 15-19 years and children (n 391 963) aged 6-59 months. RESULTS: The pooled prevalence of concurrent overweight/obesity and anaemia was 12·4 % (95 % CI 11·1, 13·7) among adult women, 4·5 % (95 % CI 4·0, 5·0) among adolescent girls and 3·0 % (95 % CI 2·7, 3·3) among children. Overall, the DBM followed an inverse social gradient, with a higher prevalence among the richest quintile, most educated groups and in urban areas; however, important variations exist. The largest inequality gaps were observed among adult women in Yemen by household wealth (24·0 percentage-points) and in Niger by education level (19·6 percentage-points) and area of residence (11·9 percentage-points). Differences were predominantly significant among adult women, but less among girls and children. CONCLUSIONS: Context-specific, multifaceted, responses with an equity lens are needed to reduce all forms of malnutrition.

Risk factors for upper limb fractures due to unintentional injuries among adolescents: a case control study from Sri Lanka.

BACKGROUND: Injuries are the number one cause for morbidity and mortality among adolescents. Adolescent fractures are a hidden public health problem in Sri Lanka. Upper limb fractures are common in adolescents due to various risk factors. Many injuries are predictable and can be prevented by identifying the risk factors. The aim of the study was to determine the risk factors for upper limb fractures among adolescents in Sri Lanka. METHODS: A case control study was undertaken with 450 cases and 450 controls. Cases were recruited consecutively from all major hospitals among the adolescent victims who had admitted with newly diagnosed upper limb fractures in the district of Colombo. Controls were apparently healthy adolescents from the same district and excluded who had previous upper limb fractures. The age and gender were not matched in selecting controls since these two factors were potential risk factors for adolescent fractures according to previous literature. Risk factors for upper limb fractures were assessed by odds ratio (OR) with 95% confidence interval (CI) and adjusted for possible confounding by performing logistic regression analysis. RESULTS: The mean age of the cases was 13.62 years with a Standard Deviation (SD) of 2.8 and controls was 12.75 years (SD = 2.7) respectively. Having a high standard of living index (OR = 3.52; 95%CI: 2.3-5.2, p < 0.001), being in a high social class category (social class I & II) (OR = 2.58, 95%CI: 1.7-3.92, p < 0.001), engage in physical or sports activity (OR = 9.36; 95%CI: 3.31-26.47, p < 0.001), watching television (OR = 1.95; 95%CI: 1.18 -3.22, p = 0.009), playing video or computer games (OR = 2.35; 95%CI: 1.7-3.24, p < 0.001), and attending extra classes (OR = 1.82; 95%CI: 1.2-2.7, p = 0.007) were risk factors for having a upper limb fracture. Risk factors for upper limb fractures following adjusted for confounders were siblings in the family (aOR = 11.62, 95% CI: 6.95-41.29, p = 0.03) and attend extra classes after school hours (aOR = 2.51, 95%CI: 0.68-0.93, p = 0.04). Two significant effect modifications between being a Buddhist and low standard of living index (p < 0.001) and having one sibling in the family and attend extra classes after school hours (p = 0.01) were observed. CONCLUSIONS: Modifiable risk factors in relation to lifestyle factors and socioeconomic position were important determinants of upper limb fracture risk in adolescents. Many fractures can be prevented by strengthening awareness programmes in the community.

Socioeconomic inequality in different phenotypes of childhood obesity and its determinants in Iran: a Blinder-Oaxaca decomposition method.

BACKGROUND: Childhood obesity has become a significant public health issue worldwide. Socioeconomic status is among its key determinants. This study examined the socioeconomic inequality in different phenotypes of childhood obesity at the national level in Iran. METHODS: This national, multistage school cross-sectional study was undertaken in 2015 on 14,400 students aged 7-18 years from urban and rural areas of 30 provinces of Iran. Using principal component analysis, socioeconomic status (SES) was categorized into tertiles. SES inequality in different phenotypes of obesity (i.e., generalized obesity", "abdominal obesity", and combined obesity) was estimated using the concentration index. The determinants of this inequality were assessed by the Blinder-Oaxaca decomposition method. RESULTS: Overall, 14,274 students completed the study (response rate: 99%). The mean age was 12.28 years, 50.6% were boys, and 71.42% lived in urban areas. The prevalence of generalized obesity and abdominal obesity was 20.8% and 11.3%, respectively. The concentration index for different phenotypes of obesity was positive, indicating that inequality is more common amongst the low SES groups. High SES, being male, living in a rural, and having a positive family history of obesity were associated with general obesity. Moderate physical activity and living in a rural area were associated with abdominal obesity. In addition, living in a rural area, having a high SES, being male, and having a positive family history of obesity were associated with combined obesity. CONCLUSION: According to the present study findings, all childhood obesity phenotypes were more prevalent in Iranian children with high SES. Therefore, due to obesity and other diseases, it is essential to implement environmental changes in addition to designing macro-educational programs and prevention strategies.

Intra-household double burden of overweight/obesity and anaemia: Evidence from 49 low-and middle-income countries.

Globally, overweight/obesity is rising rapidly while anaemia persists. Nevertheless, evidence on their coexistence at the household level remains limited. Using data from the Demographic and Health Surveys, we quantified the magnitude, distribution and inequalities (i.e., estimates by wealth, education level and residence) in the intra-household double burden (DBM) of overweight/obesity and anaemia among mothers and their children living in 49 low- and middle-income countries (LMICs). The pooled prevalence of total intra-household DBM was 17.2% (95% confidence interval [CI]: 15.6, 18.8); 16.2% (95% CI: 14.6, 17.9) for mothers with overweight/obesity and children with anaemia; and 2.8% (95% CI: 2.5, 3.1) for mothers with anaemia and children with overweight/obesity. South Africa had the highest prevalence of total DBM at the household level, affecting almost one in three households. Households with mothers with overweight/obesity and children with anaemia followed an inverse social gradient, with higher estimates found in the richest quintile, highest maternal education level and in urban areas; although with some variation across regions. The opposite was observed for mothers with anaemia and children with overweight/obesity. The largest inequality gaps were found for mothers with overweight/obesity and children with anaemia in Togo by household wealth (29.3%-points; p < 0.001), in Ghana by maternal education level (28.0%-points; p = 0.001) and in Niger by area of residence (25.2%-points; p < 0.001). Although double-duty actions might help accelerate action towards reducing malnutrition in all its forms, a comprehensive assessment of the causes of anaemia is first warranted to design effective country-specific programmes.

Evaluation of a self-help intervention to promote the health and wellbeing of marginalised people including those living with leprosy in Nepal: a prospective, observational, cluster-based, cohort study with controls.

BACKGROUND: People affected by leprosy are at increased risk of ulcers from peripheral nerve damage. This in turn can lead to visible impairments, stigmatisation and economic marginalisation. Health care providers suggest that patients should be empowered to self-manage their condition to improve outcomes and reduce reliance on services. Self-care involves carrying out personal care tasks with the aim of preventing disabilities or preventing further deterioration. Self-help, on the other hand, addresses the wider psychological, social and economic implications of leprosy and incorporates, for example, skills training and microfinance schemes. The aim of this study, known as SHERPA (Self-Help Evaluation for lepRosy and other conditions in NePAl) is to evaluate a service intervention called Integrated Mobilization of People for Active Community Transformation (IMPACT) designed to encourage both self-care and self-help in marginalised people including those affected by leprosy. METHODS: A mixed-method evaluation study in Province 5, Nepal comprising two parts. First, a prospective, cluster-based, non-randomised controlled study to evaluate the effectiveness of self-help groups on ulcer metrics (people affected by leprosy only) and on four generic outcome measures (all participants) - generic health status, wellbeing, social integration and household economic performance. Second, a qualitative study to examine the implementation and fidelity of the intervention. IMPACT: This research will provide information on the effectiveness of combined self-help and self-care groups, on quality of life, social integration and economic wellbeing for people living with leprosy, disability or who are socially and economically marginalised in low- and middle- income countries.

Optimising an intervention to support home-living older adults at risk of malnutrition: a qualitative study.

BACKGROUND: In the UK, about 14% of community-dwelling adults aged 65 and over are estimated to be at risk of malnutrition. Screening older adults in primary care and treating those at risk may help to reduce malnutrition risk, reduce the resulting need for healthcare use and improve quality of life. Interventions are needed to raise older adults' risk awareness, offer relevant and meaningful strategies to address risk and support general practices to deliver treatment and support. METHODS: Using the Person-based Approach and input from Patient and Public Involvement representatives, we developed the 'Eat well, feel well, stay well' intervention. The intervention was optimised using qualitative data from think aloud and semi-structured process evaluation interviews with 23 and 18 older adults respectively. Positive and negative comments were extracted to inform rapid iterative modifications to support engagement with the intervention. Data were then analysed thematically and final adjustments made, to optimise the meaningfulness of the intervention for the target population. RESULTS: Participants' comments were generally positive. This paper focuses predominantly on participants' negative reactions, to illustrate the changes needed to ensure that intervention materials were optimally relevant and meaningful to older adults. Key factors that undermined engagement included: resistance to the recommended nutritional intake among those with reduced appetite or eating difficulties, particularly frequent eating and high energy options; reluctance to gain weight; and a perception that advice did not align with participants' specific personal preferences and eating difficulties. We addressed these issues by adjusting the communication of eating goals to be more closely aligned with older adults' beliefs about good nutrition, and acceptable and feasible eating patterns. We also adjusted the suggested tips and strategies to fit better with older adults' everyday activities, values and beliefs. CONCLUSIONS: Using iterative qualitative methods facilitated the identification of key behavioural and contextual elements that supported engagement, and issues that undermined older adults' engagement with intervention content. This informed crucial revisions to the intervention content that enabled us to maximise the meaningfulness, relevance and feasibility of the key messages and suggested strategies to address malnutrition risk, and therefore optimise engagement with the intervention and the behavioural advice it provided.

Social networks, health and identity: exploring culturally embedded masculinity with the Pakistani community, West Midlands, UK.

BACKGROUND: Migrants from South Asia living in developed countries have an increased risk for developing cardiovascular disease (CVD), with limited research into underlying social causes. METHODS: We used social capital as an interpretive lens to undertake analysis of exploratory qualitative interviews with three generations of at-risk migrant Pakistani men from the West Midlands, UK. Perceptions of social networks, trust, and cultural norms associated with access to healthcare (support and information) were the primary area of exploration. RESULTS: Findings highlighted the role of social networks within religious or community spaces embedded as part of ethnic enclaves. Local Mosques and gyms remained key social spaces, where culturally specific gender differences played out within the context of a diaspora community, defined ways in which individuals navigated their social spheres and influenced members of their family and community on health and social behaviours. CONCLUSIONS: There are generational and age-based differences in how members use locations to access and develop social support for particular lifestyle choices. The pursuit of a healthier lifestyle varies across the diverse migrant community, determined by social hierarchies and socio-cultural factors. Living close to similar others can limit exposure to novel lifestyle choices and efforts need to be made to promote wider integration between communities and variety of locations catering to health and lifestyle.

Cultural adaptation of a children's weight management programme: Child weigHt mANaGement for Ethnically diverse communities (CHANGE) study.

BACKGROUND: Childhood obesity prevalence continues to be at high levels in the United Kingdom (UK). South Asian children (mainly Pakistani and Bangladeshi origin) with excess adiposity are at particular risk from the cardiovascular consequences of obesity. Many community-based children's weight management programmes have been delivered in the UK, but none have been adapted for diverse cultural communities. The aim of the Child weigHt mANaGement for Ethnically diverse communities (CHANGE) study, was to culturally adapt an existing children's weight management programme for children aged 4-11 years so that the programme was more able to meet the needs of families from South Asian communities. METHODS: The adaptation process was applied to First Steps, an evidence informed programme being delivered in Birmingham (a large, ethnically diverse city). A qualitative study was undertaken to obtain the views of South Asian parents of children with excess weight, who had fully or partially attended, or who had initially agreed but then declined to attend the First Steps programme. The resulting data were integrated with current research evidence and local programme information as part of a cultural adaptation process that was guided by two theoretical frameworks. RESULTS: Interviews or focus groups with 31 parents in their preferred languages were undertaken. Themes arising from the data included the need for convenient timing of a programme in a close familiar location, support for those who do not speak English, the need to focus on health rather than weight, nutritional content that focuses on traditional and Western diets, more physical activity content, and support with parenting skills. The data were mapped to the Behaviour Change Wheel framework and Typology of Cultural Adaptation to develop an intervention programme outline. The research evidence and local programme information was then used in the detailed planning of the programme sessions. CONCLUSIONS: The process of cultural adaptation of an existing children's weight management programme resulted in a theoretically underpinned programme that is culturally adapted at both the surface and deep structural levels. TRIAL REGISTRATION: ISRCTN81798055 , registered: 13/05/2014.

Using recruitment and selection to build a primary care workforce for the future.

Recruitment and selection are critical components of human resource management. They influence both the quantity and quality of the healthcare workforce. In this article, we use two different examples of primary care workers, General Practitioners in the UK and Community Health Workers in low- and middle- income countries, to illustrate how recruitment and selection are, and could be, used to enhance the primary care workforce in each setting. Both recruitment and selection can be costly, so when funding is limited, decisions on how to spend the human resources budget must be made. It could be argued that human resource management should focus on recruitment in a seller's market (an insufficient supply of applicants) and on selection in a buyer's market (sufficient applicants but concerns about their quality). We use this article to examine recruitment and selection in each type of market and highlight the interactions between these two human resource management decisions. Recruitment and selection, we argue, must be considered in both types of market; particularly in sectors where workers' labour impacts upon population health. We note the paucity of high-quality research in recruitment and selection for primary care and the need for rigorous study designs such as randomised trials.

Harnessing genomics to improve outcomes for women with cancer in India: key priorities for research.

Cumulatively, breast, cervical, ovarian, and uterine cancer account for more than 70% of cancers in women in India. Distinct differences in the clinical presentation of women with cancer suggest underlying differences in cancer biology and genetics. The peak age of onset of breast and ovarian cancer appears to be a decade earlier in India (age 45-50 years) than in high-income countries (age >60 years). Understanding these differences through research to develop diagnosis, screening, prevention, and treatment frameworks that ar e specific to the Indian population are critical and essential to improving women's health in India. Since the sequencing of the human genome in 2001, applications of advanced technologies, such as massively parallel sequencing, have transformed the understanding of the genetic and environmental drivers of cancer. How can advanced technologies be harnessed to provide health-care solutions at a scale and to a budget suitable for a country of 1·2 billion people? What research programmes are necessary to answer questions specific to India, and to build capacity for innovative solutions using these technologies? In order to answer these questions, we convened a workshop with key stakeholders to address these issues. In this Series paper, we highlight challenges in tackling the growing cancer burden in India, discuss ongoing genomics research and developments in infrastructure, and suggest key priorities for future research in cancer in India.

Risk of chronic kidney disease in young adults with impaired glucose tolerance/impaired fasting glucose: a retrospective cohort study using electronic primary care records.

BACKGROUND: The risk of chronic kidney disease (CKD) is known to be elevated in patients with diabetes mellitus but the risk of young adults aged 18 to 40 years with impaired glucose tolerance/impaired fasting glucose (IGT/IFG) developing CKD is not well characterised. Furthermore, progression of IGT/IFG to diabetes and subsequent CKD development is not well understood. METHODS: A retrospective cohort study was undertaken using The Health Improvement Network (THIN) database, a large dataset of electronic patient records. THIN database is jointly managed by IMS Health Real World Evidence Solution ( http://www.epic-uk.org/index.html ) and In Practice System (InPs). Cases were aged 18 to 40, with a diagnosis of IGT/IFG and registered at a practice contributing to THIN between 2000 and 2015. The study population consisted of 40,092 patients, including 21,454 (53.5%) female and 18,638 (46.5%) male. The median follow-up was approximately 2 years. The outcome was a diagnosis of CKD determined from either clinical coding or laboratory results. For the primary analysis the unadjusted and adjusted relative risk of CKD in IGT/IFG was compared to age, sex and practice matched controls with normoglycaemia. For the secondary analysis we compared the incidence of CKD before to after a diagnosis of type 2 diabetes (T2DM) in the IGT/IFG study cohort. RESULTS: The Incidence Rate Ratio (IRR) for CKD for IGT/IFG compared to normoglycaemia was 4.0 [95% confidence interval (CI), 3.2 to 5.1, P < 0.001]. The adjusted IRR was 2.6 [95% CI, 2.0 to 3.4, P < 0.001]. The unadjusted IRR was 8.8 [95% CI, 7.7 to 10.0, P < 0.001] after IGT/IFG patients had developed T2DM and the adjusted IRR was 6.3 [95% CI, 5.5 to 7.2, P < 0.001]. CONCLUSION: Our results show that young IGT/IFG subjects are also at higher risk of developing CKD. This risk is modulated by the degree of baseline renal function and glucose tolerance, being higher in those developing T2DM.

Incidence and impact on outcomes of acute kidney injury after a stroke: a systematic review and meta-analysis.

BACKGROUND: Patients with chronic kidney disease have worse outcomes after stroke. However, the burden of acute kidney injury after stroke has not been extensively investigated. METHODS: We used MEDLINE and Embase to conduct a systematic review and meta-analysis of published studies that provided data on the risk of AKI and outcomes in adults after ischemic and hemorrhagic stroke. Pooled incidence was examined using the Stuart-Ord method in a DerSimonian-Laird model. Pooled Odds Ratios and 95% confidence intervals were calculated for outcomes using a random effects model. This review was registered with PROSPERO (CRD42017064588). RESULTS: Eight studies were included, five from the United States, representing 99.9% of included patients. Three studies used established acute kidney injury criteria based on creatinine values to define acute kidney injury and five used International Classification of Diseases coding definitions. Overall pooled incidence was 9.61% (95% confidence interval 8.33-10.98). Incidence for studies using creatinine definitions was 19.51% (95% confidence interval 12.75-27.32%) and for studies using coding definitions 4.63% (95% confidence interval 3.65-5.72%). Heterogeneity was high throughout. Mortality in stroke patients who sustained acute kidney injury was increased (Odds Ratio 2.45; 95% confidence interval 1.47-4.10). Three studies reported risk factors for acute kidney injury. There was sparse information on other outcomes. CONCLUSIONS: Mortality in stroke patients who develop acute kidney injury is significantly increased. However the reported incidence of AKI after stroke varies widely and is underestimated using coding definitions. Larger international studies are required to identify potentially preventable factors to reduce acute kidney injury after stroke and improve outcomes.

Influences on the adoption of patient safety innovation in primary care: a qualitative exploration of staff perspectives.

BACKGROUND: Primary care is changing rapidly to meet the needs of an ageing and chronically ill population. New ways of working are called for yet the introduction of innovative service interventions is complicated by organisational challenges arising from its scale and diversity and the growing complexity of patients and their care. One such intervention is the multi-strand, single platform, Patient Safety Toolkit developed to help practices provide safer care in this dynamic and pressured environment where the likelihood of adverse incidents is increasing. Here we describe the attitudes of staff toward these tools and how their implementation was shaped by a number of contextual factors specific to each practice. METHODS: The Patient Safety Toolkit comprised six tools; a system of rapid note review, an online staff survey, a patient safety questionnaire, prescribing safety indicators, a medicines reconciliation tool, and a safe systems checklist. We implemented these tools at practices across the Midlands, the North West, and the South Coast of England and conducted semi-structured interviews to determine staff perspectives on their effectiveness and applicability. RESULTS: The Toolkit was used in 46 practices and a total of 39 follow-up interviews were conducted. Three key influences emerged on the implementation of the Toolkit these related to their ease of use and the novelty of the information they provide; whether their implementation required additional staff training or practice resource; and finally factors specific to the practice's local environment such as overlapping initiatives orchestrated by their CCG. CONCLUSIONS: The concept of a balanced toolkit to address a range of safety issues proved popular. A number of barriers and facilitators emerged in particular those tools that provided relevant information with a minimum impact on practice resource were favoured. Individual practice circumstances also played a role. Practices with IT aware staff were at an advantage and those previously utilising patient safety initiatives were less likely to adopt additional tools with overlapping outputs. By acknowledging these influences we can better interpret reaction to and adoption of individual elements of the toolkit and optimise future implementation.

Measurement of blood pressure for the diagnosis and management of hypertension in different ethnic groups: one size fits all.

BACKGROUND: Hypertension is a major risk factor for cardiovascular disease and prevalence varies by ethnic group. The diagnosis and management of blood pressure are informed by guidelines largely based on data from white populations. This study addressed whether accuracy of blood pressure measurement in terms of diagnosis of hypertension varies by ethnicity by comparing two measurement modalities (clinic blood pressure and home monitoring) with a reference standard of ambulatory BP monitoring in three ethnic groups. METHODS: Cross-sectional population study (June 2010 - December 2012) with patients (40-75 years) of white British, South Asian and African Caribbean background with and without a previous diagnosis of hypertension recruited from 28 primary care practices. The study compared the test performance of clinic BP (using various protocols) and home-monitoring (1 week) with a reference standard of mean daytime ambulatory measurements using a threshold of 140/90 mmHg for clinic and 135/85 mmHg for out of office measurement. RESULTS: A total of 551 participants had complete data of whom 246 were white British, 147 South Asian and 158 African Caribbean. No consistent difference in accuracy of methods of blood pressure measurement was observed between ethnic groups with or without a prior diagnosis of hypertension: for people without hypertension, clinic measurement using three different methodologies had high specificity (75-97%) but variable sensitivity (33-65%) whereas home monitoring had sensitivity of 68-88% and specificity of 64-80%. For people with hypertension, detection of a raised blood pressure using clinic measurements had sensitivities of 34-69% with specificity of 73-92% and home monitoring had sensitivity (81-88%) and specificity (55-65%). CONCLUSIONS: For people without hypertension, ABPM remains the choice for diagnosing hypertension compared to the other modes of BP measurement regardless of ethnicity. Differences in accuracy of home monitoring and clinic monitoring (higher sensitivity of the former; higher specificity of the latter) were also not affected by ethnicity.