A systematic review of active case-finding strategies for tuberculosis in homeless populations.

SETTING: Tuberculosis (TB) is prevalent in the homeless population, and can create health inequalities and challenges for eradication. Evidence-based approaches to active case finding (ACF) are needed. OBJECTIVES: To determine the effectiveness of ACF for TB control, and identify strategies to improve uptake of screening and the diagnostic pathway in homeless populations in low- and medium-burden settings. Secondary objectives were to assess the yield of screening and participant characteristics. DESIGN: A systematic search of electronic databases and grey literature sources identified ACF studies that reported population measures (prevalence or incidence) of TB control, and/or uptake and/or yield of screening for latent tuberculous infection (LTBI) or active TB affecting any site. Studies were described using narrative synthesis. RESULTS: Twenty studies met the inclusion criteria. Studies were heterogeneous across multiple elements, including programme design, which likely contributed to variability in outcomes. ACF was associated with reductions in TB rates in three time-trend analyses. The strongest evidence for improving uptake of screening was for incentives, with mixed evidence for peer educators. At the observational level, professional support and mandatory screening may also improve uptake, and additional community support enhanced completion of the diagnostic pathway. Those most likely to be diagnosed with TB appeared less likely to accept screening. Yield of screening was 1.5-57% (41 684 participants) for LTBI, and 0-3.1% (91 771 participants) for active TB. CONCLUSION: Observational evidence suggests that ACF is effective. Strategies to improve screening uptake were identified. Variability in uptake and yield necessitates programmes tailored to local populations; areas for further research were identified.

Anti-TNF therapy is not associated with an increased risk of post-colectomy complications, a population-based study.

AIM: Previous studies have raised concerns that the use of anti-tumour necrosis factor (anti-TNF) therapy in patients with ulcerative colitis (UC) undergoing surgery may increase the risk of postoperative complications. We have taken a population-based approach to investigate whether there is an association between anti-TNF therapy and postoperative complications in UC patients undergoing subtotal colectomy. METHOD: Hospital Episode Statistics (HES) data and procedural coding were used to identify all patients in England between April 2006 and March 2015 undergoing subtotal colectomy for UC. Patients were grouped into those who received anti-TNF therapy within 12 or 4 weeks of surgery and those who did not. The incidence of postoperative complications was evaluated by HES coding and compared between groups. RESULTS: In all, 6225 UC patients underwent subtotal colectomy. 753 patients received anti-TNF therapy within 12 weeks prior to surgery (418 within 4 weeks). There was no difference in postoperative complications between groups although groups were not comparable for age and comorbidities. Logistic regression with complications as the outcome variable did not show any significant association between anti-TNF therapy and complications. Colectomy performed during an unplanned admission (vs planned admission) and smoking were associated with complications. CONCLUSION: This large population-based study does not demonstrate any association between preoperative anti-TNF therapy and postoperative complications in UC patients undergoing subtotal colectomy. The only variables associated with complications were colectomy performed during an unplanned admission and smoking.

Pre-existing diabetes is a risk factor for increased rates of cellular rejection after kidney transplantation: an observational cohort study.

AIM: To investigate whether people with diabetes have an elevated risk of kidney allograft rejection in a well characterized clinical cohort in the setting of contemporary immunosuppression. METHODS: We conducted a retrospective cohort study including all kidney allograft recipients at a single centre between 2007 and 2015, linking clinical, biochemical and histopathological data from electronic patient records. RESULTS: Data were analysed for 1140 kidney transplant recipients. The median follow-up was 4.4 years post-transplantation, and 117 of the kidney transplant recipients (10.2%) had diabetes at time of transplantation. Kidney allograft recipients with vs without diabetes were older (53 vs 45 years; P<0.001) and more likely to be non-white (41.0% vs 26.4%; P=0.001). Kidney allograft recipients with vs without diabetes had a higher risk of cellular rejection (19.7% vs 12.4%; P=0.024), but not of antibody-mediated rejection (3.4% vs 3.7%; P=0.564). Graft function and risk of death-censored graft loss were similar in the two groups, but kidney allograft recipients with diabetes had a higher risk of death and overall graft loss than those without diabetes. In a Cox regression model of non-modifiable risk factors at time of transplantation, diabetes was found to be an independent risk factor for cellular rejection (hazard ratio 1.445, 95% CI 1.023-1.945; P=0.042). CONCLUSIONS: Kidney allograft recipients with diabetes at transplantation should be counselled regarding their increased risk of cellular rejection but reassured regarding the lack of any adverse impact on short-to-medium term allograft function or survival.

Sex-related Outcome Inequalities in Endovascular Aneurysm Repair.

OBJECTIVE/BACKGROUND: Women are known to have a higher rate of postoperative complications and mortality following open abdominal aortic aneurysm (AAA) repair. It is less clear whether this remains true of endovascular aneurysm repair (EVAR). This study examines the association between sex and hospital length of stay (LoS), readmission rates, and mortality following elective EVAR in the population of England between April 2006 and March 2015. METHODS: Retrospective analysis of Hospital Episode Statistics (HES) was performed, including regression analysis of potential factors that may affect the primary outcomes (age, sex, deprivation, comorbidities and Trust volume). RESULTS: In total, 20,780 EVARs were performed in the time period, 11.2% (n = 2,304) on women. The women were older (78 years [interquartile range {IQR} 74-82 years] vs. 76 years [IQR 70-80 years]; p < .001) and had a longer LoS (5 days [IQR 3-8 days] vs. 4 days [IQR 3-6 days]; p < .001). Women also had a higher readmission rate and mortality rate at both 30 days and 1 year. Following multivariate logistic regression, being female remained significantly related to poor outcome on all outcomes: LoS (odds ratio [OR] 1.86, 95% confidence interval [CI] 1.69-2.05), 30-day readmission (OR 1.23, 95% CI 1.09-1.40), 1-year readmission (OR 1.16, 95% CI 1.06-1.28); 30-day mortality (OR 1.54, 95% CI 1.15-2.07), 1-year mortality (OR 1.24, 95% CI 1.06-1.45). Advancing age and increased comorbidity score were significantly related to longer LoS, higher readmission rates, and higher mortality. Deprivation score was associated with LoS and 1-year readmission rate but not with 30-day readmission and with increased mortality. Higher-volume Trusts (>50 EVARs per year) had higher readmission rates and 1-year mortality. CONCLUSION: These population-based data show that, following EVAR, women have a longer LoS and higher readmission and mortality than men. This reflects the same disparity in outcomes that is found in open AAA repair. Further work to clarify the cause of this is needed.

Lessons learned from the AFLY5 RCT process evaluation: implications for the design of physical activity and nutrition interventions in schools.

BACKGROUND: Systematic reviews have highlighted that school-based diet and physical activity (PA) interventions have had limited effects. This study used qualitative methods to examine how the effectiveness of future primary (elementary) school diet and PA interventions could be improved. METHODS: Data are from the Active For Life Year 5 (AFLY5) study, which was a cluster randomised trial conducted in 60 UK primary schools. Year 5 (8-9 years of age) pupils in the 30 intervention schools received a 12-month intervention. At the end of the intervention period, interviews were conducted with: 28 Year 5 teachers (including 8 teachers from control schools); 10 Headteachers (6 control); 31 parents (15 control). Focus groups were conducted with 70 year 5 pupils (34 control). Topics included how the AFLY5 intervention could have been improved and how school-based diet and PA interventions should optimally be delivered. All interviews and focus groups were transcribed and thematically analysed across participant groups. RESULTS: Analysis yielded four themes. Child engagement: Data suggested that programme success is likely to be enhanced if children feel that they have a sense of autonomy over their own behaviour and if the activities are practical. School: Finding a project champion within the school would enhance intervention effectiveness. Embedding diet and physical activity content across the curriculum and encouraging teachers to role model good diet and physical activity behaviours were seen as important. Parents and community: Encouraging parents and community members into the school was deemed likely to enhance the connection between schools, families and communities, and "create a buzz" that was likely to enhance behaviour change. Government/Policy: Data suggested that there was a need to adequately resource health promotion activity in schools and to increase the infrastructure to facilitate diet and physical activity knowledge and practice. DISCUSSION AND CONCLUSIONS: Future primary school diet and PA programmes should find ways to increase child engagement in the programme content, identify programme champions, encourage teachers to work as role models, engage parents and embed diet and PA behaviour change across the curriculum. However, this will require adequate funding and cost-effectiveness will need to be established. TRIAL REGISTRATION: ISRCTN50133740.

The feasibility of using local general practice data to estimate the prevalence of childhood disabling conditions.

AIMS: This study aimed to assess the feasibility of using general practice data to estimate the prevalence of potentially disabling conditions in young people aged 0-18 years. BACKGROUND: There are limited data that estimate the prevalence of disabling conditions in children and young people and are suitable to inform service planning. This has been highlighted by several government documents and parent groups. The current study analysed anonymized data from 5 general practices in Bristol, UK (n = 10 756 children and young people aged 0-18 years). A comprehensive Read Code list was created to identify children and young people with potentially disabling conditions and the severity of conditions was compared with General Practitioner completed free text within the computerized system. RESULTS: Across these practices an average 4.9% (95% confidence intervals 4.5-5.3) of children and young people had a significant physical or mental difficulty that could impact on their daily living. The most common disabling conditions in our sample were in the ICF category of mental function 36% (including general and specific developmental delays and mental health diagnoses). CONCLUSION: This study suggests that routinely collected data may provide much needed robust information to inform service provision for some of the most vulnerable children and young people in our communities. It also highlights the need for improved data systems for disability services.

Unintentional injuries in school-aged children and adolescents: lessons from a systematic review of cohort studies.

OBJECTIVES: To critically synthesise current knowledge of the patterns of injuries and risk factors for injury in school-aged children, to summarise the evidence and support effective child injury prevention initiatives. DESIGN: Systematic review. Selection criteria and METHODS: Prospective cohort studies reporting unintentional injuries in healthy children aged 5-18 years were identified by searching 15 electronic databases and additional grey literature sources. A narrative synthesis was conducted of papers meeting quality criteria, with risk factors analysed at individual, family and environmental levels. Limitations of existing evidence were considered. RESULTS: 44 papers from 18 different cohort studies met the inclusion criteria. There were broad and consistent patterns of injury across time and place. Male sex, psychological, behavioural and risk-taking behaviour problems, having a large number of siblings, and a young mother were all associated with increased injury occurrence across more than one cohort and setting. CONCLUSIONS: Descriptive epidemiology and risk factors for injury were derived from prospective cohort studies, but few studies used the full potential of their design. Opportunities to use repeated measures to assess temporal changes in injury occurrence, and the exploration of risk factors, particularly those related to the child's environment, have rarely been undertaken. Few studies were conducted in low/middle-income countries where the burden of injury is greatest. These findings should be considered when planning future research and prevention initiatives.

An evaluation of the recording of folic acid use in the South West Congenital Anomaly Register.

OBJECTIVE: Some congenital anomaly registers are collecting data on risk factors for pregnancies affected by anomalies; yet the quality of that information is rarely assessed. We assessed the quality of the risk factor data in the South West Congenital Anomaly Register (SWCAR) through a review of the data held on folic acid use, in cases of neural tube defect (NTD). METHODS: We reviewed all cases of NTD reported to SWCAR over 2 years and compared information held in the register with that in handwritten and computerised prenatal records, where available. RESULTS: Data on folic acid use was recorded in only 41 (36.9%) of the prenatal records of the 111 cases of NTDs reviewed. Information on any folic acid use in the prenatal records was transferred to the register in all instances where it existed. Information on the time of taking folic acid or not taking folic acid was rarely recorded in prenatal records. CONCLUSION: Incomplete recording of folic acid use and timing in prenatal records has limited the ability of SWCAR to collect accurate information on folic acid use in cases of NTDs. Minimal recording information on folic acid use in prenatal records is suggested.

Estimating infectious disease in UK asylum seekers and refugees: a systematic review of prevalence studies.

BACKGROUND: The prevalence of infectious diseases such as tuberculosis (TB), HIV and hepatitis B in the UK asylum seeker and refugee population is currently uncertain. METHODS: Systematic review of published and unpublished studies. RESULTS: Five studies met the inclusion criteria. Three studies reported the prevalence of TB with rates ranging from 1.33 to 10.42 per 1000. The three studies reporting hepatitis B estimated rates from 57 to 118 per 1000. One study reported a prevalence rate for HIV of 38.19 per 1000. CONCLUSION: A small number of studies have been identified reporting prevalence rates for TB, hepatitis B and HIV that vary widely where comparisons are available. These differences may reflect true variation in risk between study populations, but are likely to be affected by sampling difficulties encountered when researching these population groups. Efforts are required to improve these difficulties which are currently limiting the validity of prevalence findings and generalizability to comparable asylum seeker and refugee populations.

School-based secondary prevention programmes for preventing violence.

BACKGROUND: Early aggressive behaviour is a risk factor for later violence and criminal behaviour. Despite over 20 years of violence prevention interventions being delivered in the school setting, questions remain regarding the effectiveness of different interventions for children exhibiting aggressive behaviour. OBJECTIVES: To examine the effect of school based violence prevention programmes for children identified as aggressive or at risk of being aggressive. SEARCH STRATEGY: We searched CENTRAL, Cochrane Injuries Group specialised register, MEDLINE, EMBASE, other specialised databases and reference lists of articles. We also contacted authors and organisations to identify any further studies. SELECTION CRITERIA: We included trials meeting the following criteria; 1) participants were randomly assigned to intervention and control groups; 2) outcome data were collected concurrently; 3) participants comprised children in mandatory education identified as exhibiting, or at risk of, aggressive behaviour; 4) interventions designed to reduce aggression, violence, bullying, conflict or anger; 5) school based interventions; 6) outcomes included aggressive behaviour, school and agency responses to acts of aggression, or violent injuries. DATA COLLECTION AND ANALYSIS: Data were collected on design, participants, interventions, outcomes and indicators of study quality. Results of any intervention to no intervention were compared immediately post-intervention and at 12 months using meta-analysis where appropriate. MAIN RESULTS: Of 56 trials identified, none reported data on violent injuries. Aggressive behaviour was significantly reduced in intervention groups compared to no intervention groups immediately post intervention in 34 trials with data, (Standardised Mean Difference (SMD) = -0.41; 95% confidence interval (CI) -0.56 to -0.26). This effect was maintained in the seven studies reporting 12 month follow-up (SMD = -0.40, (95% CI -0.73 to -0.06)). School or agency disciplinary actions in response to aggressive behaviour were reduced in intervention groups for nine trials with data, SMD = -0.48; 95% CI -1.16 to 0.19, although this difference may have been due to chance and was not maintained, based on two studies reporting follow-up to two to four months (SMD = 0.03; 95% CI -0.42 to 0.47). Subgroup analyses suggested that interventions designed to improve relationship or social skills may be more effective than interventions designed to teach skills of non-response to provocative situations, but that benefits were similar when delivered to children in primary versus secondary school, and to groups of mixed sex versus boys alone. AUTHORS' CONCLUSIONS: School-based secondary prevention programmes to reduce aggressive behaviour appear to produce improvements in behaviour greater than would have been expected by chance. Benefits can be achieved in both primary and secondary school age groups and in both mixed sex groups and boys-only groups. Further research is required to establish whether such programmes reduce the incidence of violent injuries or if the benefits identified can be maintained beyond 12 months.

Review of the teaching of medical ethics in London medical schools.

The study examined the influence of the Pond Report on the teaching of medical ethics in the London medical schools. A questionnaire was given to both medical students and college officers. All medical colleges reported that ethics was included in the curriculum. However, from students' replies, it seems that attendance of optional courses is low and that not all current final year medical students have had any formal teaching in medical ethics. Stronger guidelines are necessary to ensure appropriate ethical training in London medical schools.