Competitions and incentives for smoking cessation.

BACKGROUND: Material or financial incentives may be used in an attempt to reinforce behaviour change, including smoking cessation. They have been widely used in workplace smoking cessation programmes, and to a lesser extent within community programmes. Quit and Win contests are the subject of a companion review. OBJECTIVES: To determine whether competitions and incentives lead to higher long-term quit rates. We also set out to examine the relationship between incentives and participation rates. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE (January 1966 to September 2004), EMBASE (1980 to 2004/8), CINAHL (1982 to 2004/8) and PsycINFO (1872 to 2004/6). Search terms included incentive*, competition*, contest*, reward*, prize*, contingent payment*, deposit contract*. SELECTION CRITERIA: We considered randomized controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures. DATA COLLECTION AND ANALYSIS: Data were extracted by one author and checked by the second. We contacted study authors for additional data where necessary. The main outcome measure was abstinence from smoking for at least six months from the start of the intervention. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Where possible we performed meta-analysis using a generic inverse variance model, grouped by timed endpoints, but not pooled across the subgroups. MAIN RESULTS: Fifteen studies met our inclusion criteria. None of the studies demonstrated significantly higher quit rates for the incentives group than for the control group beyond the six-month assessment. There was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that different types of incentives were more or less effective. There is some evidence that although cessation rates have not been shown to differ significantly, recruitment rates can be improved by rewarding participation, which may be expected to deliver higher absolute numbers of successful quitters. Cost effectiveness analysis is not appropriate to this review, since the efficacy of the intervention has not been demonstrated. AUTHORS' CONCLUSIONS: Incentives and competitions do not appear to enhance long-term cessation rates, with early success tending to dissipate when the rewards are no longer offered. Rewarding participation and compliance in contests and cessation programmes may have more potential to deliver higher absolute numbers of quitters.

Quit and Win contests for smoking cessation.

BACKGROUND: Quit and Win contests were developed in the 1980s by the Minnesota Heart Health Program, and have been widely used since then as a population-based smoking cessation intervention at local, national and international level. Since 1994 an international contest has been held every two years in as many as 80 countries (2002). OBJECTIVES: To determine whether quit and win contests can deliver higher long-term quit rates than baseline community quit rates. To assess the impact of such programmes, we considered both the quit rates achieved by participants, and the population impact, which takes into account the proportion of the target population entering the contest. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Group specialized register, with additional searches of MEDLINE (January 1966 to September 2004), EMBASE (180 to 2004/8), CINAHL (1982 to 2004/8) and PsycINFO (1872 to 2004/6). Search terms included competition*, quit and win, quit to win, contest*, prize*. SELECTION CRITERIA: We considered randomized controlled trials, allocating individuals or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures. DATA COLLECTION AND ANALYSIS: Data were extracted by one author and checked by the second. We contacted study authors for additional data where necessary. The main outcome measure was abstinence from smoking for at least six months from the start of the intervention. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. We decided against performing a meta-analysis, because of the heterogeneity of the included studies, and the small number of scientifically valid studies. MAIN RESULTS: Four studies met our inclusion criteria. Three demonstrated significantly higher quit rates (8% to 20%) for the quit and win group than for the control group at the 12-month assessment. However, the population impact measure, where available, suggests that the effect of contests on community prevalence of smoking is small, with fewer than one in 500 smokers quitting because of the contest. Levels of deception, where they could be quantified, were high. Although surveys suggest that international quit and win contests may be effective, especially in developing countries, the lack of controlled studies precludes any firm conclusions from this review. AUTHORS' CONCLUSIONS: Quit and win contests at local and regional level appear to deliver quit rates above baseline community rates, although the population impact of the contests seems to be relatively low. Contests may be subject to levels of deception which could compromise the validity of the intervention. International contests may prove to be an effective mechanism, particularly in developing countries, but a lack of well-designed comparative studies precludes any firm conclusions.

Workplace interventions for smoking cessation.

BACKGROUND: The workplace has potential as a setting through which large groups of people can be reached to encourage smoking cessation. OBJECTIVES: To categorize workplace interventions for smoking cessation tested in controlled studies and to determine the extent to which they help workers to stop smoking or to reduce tobacco consumption. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Group Specialized Register in October 2004, MEDLINE (1966 - October 2004), EMBASE (1985 - October 2004) and PsycINFO (to October 2004). We searched abstracts from international conferences on tobacco and we checked the bibliographies of identified studies and reviews for additional references. SELECTION CRITERIA: We categorized interventions into two groups: a) Interventions aimed at the individual to promote smoking cessation and b) interventions aimed at the workplace as a whole. We applied different inclusion criteria for the different types of study. For interventions aimed at helping individuals to stop smoking, we included only randomized controlled trials allocating individuals, workplaces or companies to intervention or control conditions. For studies of smoking restrictions and bans in the workplace, we also included controlled trials with baseline and post-intervention outcomes and interrupted times series studies. DATA COLLECTION AND ANALYSIS: Information relating to the characteristics and content of all kinds of interventions, participants, outcomes and methods of the study was abstracted by one author and checked by two others. Because of heterogeneity in the design and content of the included studies, we did not attempt formal meta-analysis, and evaluated the studies using qualitative narrative synthesis. MAIN RESULTS: Workplace interventions aimed at helping individuals to stop smoking included ten studies of group therapy, seven studies of individual counselling, nine studies of self-help materials and five studies of nicotine replacement therapy. The results were consistent with those found in other settings. Group programmes, individual counselling and nicotine replacement therapy increased cessation rates in comparison to no treatment or minimal intervention controls. Self-help materials were less effective.Workplace interventions aimed at the workforce as a whole included 14 studies of tobacco bans, two studies of social support, four studies of environmental support, five studies of incentives, and eight studies of comprehensive (multi-component) programmes. Tobacco bans decreased cigarette consumption during the working day but their effect on total consumption was less certain. We failed to detect an increase in quit rates from adding social and environmental support to these programmes. There was a lack of evidence that comprehensive programmes reduced the prevalence of smoking. Competitions and incentives increased attempts to stop smoking, though there was less evidence that they increased the rate of actual quitting. AUTHORS' CONCLUSIONS: We found: 1. Strong evidence that interventions directed towards individual smokers increase the likelihood of quitting smoking. These include advice from a health professional, individual and group counselling and pharmacological treatment to overcome nicotine addiction. Self-help interventions are less effective. All these interventions are effective whether offered in the workplace or elsewhere. Although people taking up these interventions are more likely to stop, the absolute numbers who quit are low. 2. Limited evidence that participation in programmes can be increased by competitions and incentives organized by the employer. 3. Consistent evidence that workplace tobacco policies and bans can decrease cigarette consumption during the working day by smokers and exposure of non-smoking employees to environmental tobacco smoke at work, but conflicting evidence about whether they decrease prevalence of smoking or overall consumption of tobacco by smokers. 4. A lack of evidence that comprehensive approaches reduce the prevalence of smoking, despite the strong theoretical rationale for their use. 5. A lack of evidence about the cost-effectiveness of workplace programmes.

Use of local neural tube defect registers to interpret national trends.

To conduct a number of studies into the prevalence of neural tube defects (NTD) in the area covered by the Oxford Record Linkage Study (ORLS), multiple sources were used to build a local register of cases occurring in Oxfordshire and West Berkshire between 1968-1990. One source of potential cases--namely, termination and congenital malformation monitoring data available for the locality from the Office of Population Censuses and Surveys (OPCS) data--were kept separate. Comparison of the local cases recorded by OPCS and those known to the register from 1974-1990, using the method of capture-recapture, suggested that national data are only about two thirds complete, but that this underreporting is likely to be reasonably consistent from year to year. OPCS data can therefore be used to study NTD trends if not absolute risks. The local register seemed, by the same yardstick, to be very complete and is being used in a variety of studies of the occurrence of NTD. Survival to one year in this area, over the period 1968-1990, has only improved in the recent past, if at all. Most NTD pregnancies now end in termination rather than birth, and there has been a true decline in the occurrence of NTDs, and likewise the different subtypes.

Neural tube defects 1974-94--down but not out.

AIMS: To describe accurately the total prevalence of neural tube defects (NTDs) in England and Wales over time, and to provide a benchmark up to 1994. METHODS: National data about NTDs reported as births or terminations are available from 1974-94, but reporting is incomplete. A local register of NTDs covering Oxfordshire/west Berkshire from 1965-94 was used to validate national data for the locality, using the method of capture and recapture, and hence to estimate incompleteness of reporting nationally. RESULTS: National underreporting is consistent at about two thirds of the true number of cases reaching at least the second trimester. The local register is much more complete, but time trends locally and nationally are similar. In England and Wales total prevalence declined from about 34 per 10000 live and stillbirths in 1974 to a plateau of just under 8 per 10000 in the 1990s. CONCLUSIONS: The decline in NTD prevalence is real and seems to have stopped. How this relates to changes in diet or the practice of vitamin supplementation is unknown, and the implications of the plateau are uncertain. OPCS figures of 500 NTDs annually in England and Wales represent about two thirds of the true number of cases.

Workplace interventions for smoking cessation.

BACKGROUND: The workplace has potential as a setting through which large groups of people can be reached to encourage smoking cessation. OBJECTIVES: To categorise workplace interventions for smoking cessation tested in controlled studies and to determine the extent to which they help workers to stop smoking or to reduce tobacco consumption. SEARCH STRATEGY: We searched the Tobacco Addiction Review Group trials register in November 2002, Medline (1966 - November 2002), EMBASE (1985 - November 2002) and PsycINFO (to November 2002). We searched abstracts from international conferences on tobacco and we checked the bibliographies of identified studies and reviews for additional references. SELECTION CRITERIA: We categorised interventions into two groups: a) Interventions aimed at the individual to promote smoking cessation and b) interventions aimed at the workplace as a whole. We applied different inclusion criteria for the different types of study. For interventions aimed at helping individuals to stop smoking, we included only randomised controlled trials allocating individuals, workplaces or companies to intervention or control conditions. For studies of smoking restrictions and bans in the workplace, we also included controlled trials with baseline and post-intervention outcomes and interrupted times series studies. DATA COLLECTION AND ANALYSIS: Information relating to the characteristics and content of all kinds of interventions, participants, outcomes and methods of the study was abstracted by one reviewer and checked by two others. Because of heterogeneity in the design and content of the included studies, we did not attempt formal meta-analysis, and evaluated the studies using qualitative narrative synthesis. MAIN RESULTS: Workplace interventions aimed at helping individuals to stop smoking included nine studies of group therapy, three studies of individual counselling, eight studies of self-help materials and four studies of nicotine replacement therapy. The results were consistent with those found in other settings. Group programmes, individual counselling and nicotine replacement therapy increased cessation rates in comparison to no treatment or minimal intervention controls. Self-help materials were less effective. Workplace interventions aimed at the workforce as a whole included 13 studies of tobacco bans, two studies of social support, four studies of environmental support, four studies of incentives, six studies of comprehensive (multi-component) programmes and two studies of competitions and recruitment. Tobacco bans decreased cigarette consumption during the working day but their effect on total consumption was less certain. We failed to detect an increase in quit rates from adding social and environmental support to these programmes. There was a lack of evidence that comprehensive programmes reduced the prevalence of smoking. Competitions and incentives increased attempts to stop smoking, though there was less evidence that they increased the rate of actual quitting. REVIEWER'S CONCLUSIONS: We found 1. Strong evidence that interventions directed towards individual smokers increase the likelihood of quitting smoking. These include advice from a health professional, individual and group counselling and pharmacological treatment to overcome nicotine addiction. Self-help interventions are less effective. All these interventions are effective whether offered in the workplace or elsewhere. Although people taking up these interventions are more likely to stop, the absolute numbers who quit are low. 2. Limited evidence that participation in programmes can be increased by competitions and incentives organised by the employer. 3. Consistent evidence that workplace tobacco policies and bans can decrease cigarette consumption during the working day by smokers and exposure of non-smoking employees to environmental tobacco smoke at work, but conflicting evidence about whether they decrease prevalence of smoking or overall consumption of tobacco by smokers. 4. A lack of evidence that comprehensive approaches reduce the prevalence of smoking, despite the strong theoretical rationale for their use. 5. A lack of evidence about the cost-effectiveness of workplace programmes.

Validation of a brief symptom questionnaire (ReQuest in Practice) for patients with gastro-oesophageal reflux disease.

BACKGROUND: A clinical need exists for a means of assessing symptom control in patients with gastro-oesophageal reflux disease. The ReQuest questionnaire has been extensively validated for symptom assessment in both erosive and non-erosive gastro-oesophageal reflux disease but was designed for research purposes. We derived a shorter version (ReQuest in Practice) that would be more convenient for clinical practice. AIM: To validate ReQuest in Practice in patients suffering from gastro-oesophageal reflux disease. METHODS: Multicentre, non-interventional, crossover comparison. Patients completed ReQuest in Practice followed by ReQuest or vice versa. Before and after a planned endoscopy, patients completed the health-related quality of life questionnaire GERDyzer. Internal consistency and the Intraclass Correlation Coefficient were calculated. Construct validity was evaluated by correlation with ReQuest and GERDyzer. RESULTS: There was high internal consistency of ReQuest in Practice (Cronbach's alpha: 0.9) and a high Intraclass Correlation Coefficient of 0.99. The measurement error of ReQuest in Practice was 4.1. High correlation between ReQuest in Practice and ReQuest (Spearman correlation coefficient: 0.9) and GERDyzer (Spearman correlation coefficient: 0.8) demonstrated construct validity. CONCLUSIONS: ReQuest in Practice was proven to be valid and reliable. Its close correlation with ReQuest makes it a promising tool to guide the clinical management of patients across the full spectrum of both erosive and non-erosive gastro-oesophageal reflux disease.

[Epidemiology of chronic hepatitis C in Germany--an analysis of 10,326 patients in hepatitis centres and outpatient units]. / Epidemiologie der chronischen Hepatitis C in Deutschland--Eine Analyse von 10,326 Hepatitis-C-Virus-Infizierten aus Schwerpunktpraxen und -ambulanzen.

Little is known about the epidemiology of chronic hepatitis C (CHC) in Germany and especially about the importance of transmission, duration of infection, genotypes, symptoms and quality of life of the patients. The current study prospectively evaluates epidemiological and clinical data of patients infected with the hepatitis C virus (HCV). Using online data entry, various characteristics of 10,326 untreated patients with CHC were documented from March 2003 until May 2006 in 352 centres all over Germany. Mean age of patients was 43.4 years. Patients infected by i.v. drug abuse were considerably younger (36.5 years) than the remaining patients (49.2 years). As indicated by their native language, 64.4% of the patients came from Germany and 19.2% from Russia. 61.7% were infected with genotype 1 and 34.9% with genotype 2 or 3. 45.5% of the patients had been infected by i.v. drug abuse. In at least 5.4% of the patients liver cirrhosis had been proved by biopsy. 63.5% of the patients felt an impairment of quality of life caused by CHC. In many patients infected with hepatitis C socio-economic issues are existent. This is reflected, i.e., in very high rates of unemployment in special subpopulations. Coinfections with hepatitis B and HIV occurred in 1.5% and 4.7%, respectively. Nearly 80% of patients were managed near their homes. The data of the 10 326 patients represent about 2% of all German patients with CHC. This database is up to now the largest of its kind and gives a representative insight into the epidemiological situation of CHC in Germany.

Clinical guidelines and hospital discharges of children with acute urinary tract infections.

In order to evaluate the effect of the introduction of recent similar guidelines on the treatment of acute urinary tract infection (UTI) in children, and possible changes in its epidemiology, we analyzed the records of hospital discharge for acute UTI under the age of 15 years in England and Wales between 1979 and 1993 and in Finland between 1978 and 1994. Cases were defined by the ICD9 diagnostic codes 590.1 (acute pyelonephritis) and 599.0 (UTI, site not specified) for males and females according to three age groups (0-4, 5-9, and 10-14 years). We also compared the registry data on kidney transplants due to end-stage renal disease caused by recurrent pyelonephritis in the United Kingdom and Finland. In England the rate of attack of symptomatic UTI per 1,000 girls under 15 years increased from 0.74 (95% confidence interval 0.71-0.76) in 1987 to 1.32 (1.29-1.35) in 1993 (P < 0.001, test for trend). The respective figures for Finnish girls were 1.74 (1.62-1.86) in 1987 and 1.62 (1.51-1.74) in 1993 (P = 0.72). In English boys, the increase in the attack rate was from 0.38 (0.36-0.40) in 1987 to 0.70 (0.68-0.73) in 1993 (P < 0.001). In Finnish boys the respective figures were 0.74 (0.66-0.82) in 1987 and 0.88 (0.80-0.97) in 1993 (P < 0.02). The observed increases in the attack rates of UTI most probably relate to increased referral of acute UTI patients to hospitals for the recommended imaging studies rather than changing occurrence. Publication of guidelines for treatment of UTI in children, consolidating more-general awareness, may have contributed to this. The mean annual numbers of kidney transplants in the United Kingdom and Finland during 1989-1995 due to end-stage renal disease caused by pyelonephritis were of similar magnitude, i.e., 1.9 (1.6-2.3) transplants per million inhabitants in the United Kingdom and 2.8 (1.5-4.7) transplants per million inhabitants in Finland. The decreasing trend in these figures in both countries, although statistically significant only in the United Kingdom (P < 0.05, test for trend), suggests improved longterm outcome of these patients induced by better diagnosis and treatment of pyelonephritis and the diseases related to it, such as congenital malformations. According to our data, valid clinical guidelines are effective in changing clinical practice.

Family history taking and genetic counselling in primary care.

OBJECTIVES: We aimed to evaluate the feasibility and acceptability of taking routine family histories and subsequent counselling. METHODS: The study was set in primary care in the UK. The subjects were patients between the ages of 20 and 34 years registered at one general practice. Patients were invited by letter to attend a clinic in their GP surgery, run by a GP and health visitor. A family history was constructed and counselling undertaken for any identified problems. A telephone survey of a sample of nonattenders was also performed. The outcome measures were attendance rate, patient views, patient anxiety as measured by the short form of the Spielberger State-Trait Anxiety Inventory and referrals to secondary care. RESULTS: In total, 16.1% patients attended the clinic; 40.3 % had a family history of at least one disease with a possible genetic component. Anxiety levels fell immediately after the consultation and rose to pre-clinic levels at 12 weeks. The clinic generated three referrals to secondary care and a further seven patients who were counselled by the investigators following advice from a consultant geneticist. CONCLUSIONS: It is possible to take detailed family histories and provide genetic counselling advice in primary care with minimal training of clinical primary care staff. The service is acceptable to patients, does not induce anxiety and has little effect on numbers of patients referred.

Reproductive factors, subfertility, and risk of neural tube defects: a case-control study based on the Oxford Record Linkage Study Register.

Periconceptual exposure to subfertility treatments is increasingly common, raising concerns about the possibility of malformations in the offspring. The authors conducted a case-control study to determine whether subfertility or its treatment was associated with increased risk of neural tube defects (NTDs). Cases were 694 women diagnosed with an NTD-affected pregnancy in Oxfordshire or West Berkshire, England, between 1970 and 1987. Cases were individually matched on maternal year of birth and year of index pregnancy to controls randomly selected from a computerized database. Data on demographic, reproductive, and obstetric factors were abstracted from patient hospital records. Overall, the period prevalences of subfertility and of subfertility treatment were 7% and 3%, respectively, No evidence was found that the risk of NTD-affected pregnancies was increased by either subfertility (odds ratio (OR) = 1.2, 95% confidence interval (CI): 0.7, 2.1) or its treatment (OR = 0.9, 95% CI: 0.4, 2.0). After adjustment, NTD-affected pregnancies were associated with female offspring (OR = 2.3, 95% CI: 1.8, 3.1), multiple birth (OR = 4.8, 95% CI: 1.2, 18.8), and higher numbers of pregnancies (p for trend = 0.005). The findings from this large, population-based study were wholly consistent with those from smaller studies that found no increased risk of NTD associated with exposure to fertility treatments but reported associations with various pregnancy outcomes.

Infertility treatment and multiple birth rates in Britain, 1938-94.

Trends in multiple birth rates are thought to have been substantially affected by subfertility treatments in the last 25 years, but there are few quantitative assessments of this. This paper examines trends in twin and higher multiple birth rates separately in Scotland, England and Wales and compares their course with corresponding multiple birth rates in the Oxford Record Linkage Study area, where the proportions following subfertility treatment are documented. National data on prescriptions for subfertility treatments reinforce the view that they have had a major effect on the trends, and currently perhaps 60% of triplet and higher order births and 15% of twins follow their use in Britain.

Crosslinked fibrous collagen for use as a dermal implant: control of the cytotoxic effects of glutaraldehyde and dimethylsuberimidate.

Collagen intended for use as a dermal implant may be crosslinked to increase its strength and persistence in vivo. Sheets of rat fibrous dermal collagen were crosslinked with either glutaraldehyde or dimethylsuberimidate and the cytotoxicity to human dermal fibroblasts resulting from these treatments was measured by following the inhibition of [3H]leucine incorporation into protein. Both agents were cytotoxic at the concentrations required to effect adequate crosslinking (0.005% and 25 mM, respectively). This cytotoxicity could be limited by extensive washing and by incubation with 5 mM L-lysine, with 66 mM (0.25% w/v) sodium borohydride, or with 71.3 mM (1% w/v) dimedone. However, cytotoxicity was most efficiently controlled by treatment with a combination of 66 mM sodium borohydride and 5 mM L-lysine or 66 mM sodium borohydride and 71.3 mM dimedone. [3H]Leucine incorporation by cells exposed to crosslinked collagen treated with these combinations approached 100% of the values recorded with cells exposed to uncrosslinked collagen.

Bromocriptine use is associated with decreased smoking rates.

Dopaminergic transmission in the central nervous system is thought to underlie addictive behaviours, including smoking. One effective smoking cessation drug, bupropion, enhances dopaminergic transmission; conversely, antipsychotic drugs, which are dopamine antagonists, are associated with increased smoking. Thus we hypothesized that subfertile women treated with the potent dopamine agonist bromocriptine might smoke less as a consequence of their treatment. Among 4,608 subfertile women those conceiving on bromocriptine were half as likely to smoke as those taking other drugs or those conceiving without medication (p < 0.0001). This observation supports the role of dopamine in nicotine addiction, and suggests that bromocriptine-like drugs could be used effectively by pregnant women to aid cessation.

Does smoking status influence the prognosis of bladder cancer? A systematic review.

OBJECTIVE: To summarize, in a systematic review, the evidence for the effect of stopping smoking on recurrence, cancer-specific and all cause-mortality among smokers with newly diagnosed bladder cancer. MATERIALS AND METHODS: Two electronic databases and the reference lists of identified primary studies and reviews were searched. Studies were included if a hazard ratio and its confidence intervals could be extracted. A predefined set of study characteristics was extracted which defined whether studies were giving valid prognostic data on the effects of smoking in reasonably homogenous cohorts. The results of studies were synthesized qualitatively. RESULTS: Fifteen relevant studies were identified; former and current smokers were combined in many studies. Many studies produced information on prognosis that was confounded by the mixing of incident and prevalent cases. Only three studies examined the influence of smoking on prognosis in only incident cases, most of whom had superficial disease. Of these, only one was of high quality. These three studies and the other 12 showed suggestive evidence that continued smoking or a lifetime of smoking constitutes a moderate risk factor for recurrence and death, and that stopping smoking could favourably change this. However, the evidence base for this is weak because of the methodological shortcomings and because most studies' results were not statistically significant. A life-table model showed that if stopping smoking altered the prognosis, the size of the benefit would be clinically worthwhile. CONCLUSION: There is suggestive evidence that stopping smoking might favourably alter the course of bladder cancer, but this is insufficient for clinicians to inform patients that doing so will improve their prognosis, and for providing specialized services to assist in stopping smoking to patients with bladder cancer.

Childhood cancer incidence in a cohort of twin babies.

We studied childhood cancer incidence in a population-based twin cohort using record linkage to the National Registry of Childhood Tumours. After correcting for mortality, an incidence deficit was observed (Standardized Incidence Ratio (SIR) 79; 95% Confidence Interval (CI) 39-120). Pooled analysis with data from published cohort studies indicates a similar significant incidence reduction (SIR 81, 95% CI 67-96). Further studies are warranted.