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ObjectivesTemporary doctors, known as locum doctors, play an important role in the delivery of care in the National Health Service (NHS); however, little is known about the extent of locum use in NHS trusts. This study aimed to quantify and describe locum use for all NHS trusts in England in 2019–2021.SettingDescriptive analyses of data on locum shifts from all NHS trusts in England in 2019–2021. Weekly data were available for the number of shifts filled by agency and bank staff and the number of shifts requested by each trust. Negative binomial models were used to investigate the association between the proportion of medical staffing provided by locums and NHS trust characteristics.ResultsIn 2019, on average 4.4% of total medical staffing was provided by locums, but this varied substantially across trusts (25th–75th centile=2.2%–6.2%). Over time, on average two-thirds of locum shifts were filled by locum agencies and a third by trusts’ staff banks. On average, 11.3% of shifts requested were left unfilled. In 2019–2021, the mean number of weekly shifts per trust increased by 19% (175.2–208.6) and the mean number of weekly unfilled shifts per trust increased by 54% (32.7 to 50.4). Trusts rated by the Care Quality Commission (CQC) as inadequate or requiring improvement (incidence rate ratio=1.495; 95% CI 1.191 to 1.877), and smaller trusts had a higher use of locums. Large variability was observed across regions for use of locums, proportion of shifts filled by locum agencies and unfilled shifts.ConclusionsThere were large variations in the demand for and use of locum doctors in NHS trusts. Trusts with poor CQC ratings and smaller trusts appear to use locum doctors more intensively compared with other trust types. Unfilled shifts were at a 3-year high at the end of 2021 suggesting increased demand which may result from growing workforce shortages in NHS trusts.

PurposeThe POPPY II cohort is an Australian state-based cohort linking data for a population of individuals prescribed opioid medicines, constructed to allow a robust examination of the long-term patterns and outcomes of prescription opioid use.ParticipantsThe cohort includes 3 569 433 adult New South Wales residents who initiated a subsidised prescription opioid medicine between 2003 and 2018, identified through pharmacy dispensing data (Australian Pharmaceutical Benefits Scheme) and linked to 10 national and state datasets and registries including rich sociodemographic and medical services data.Findings to dateOf the 3.57 million individuals included in the cohort, 52.7% were female and 1 in 4 people were aged ≥65 years at the time of cohort entry. Approximately 6% had evidence of cancer in the year prior to cohort entry. In the 3 months prior to cohort entry, 26.9% used a non-opioid analgesic and 20.5% used a psychotropic medicine. Overall, 1 in 5 individuals were initiated on a strong opioid (20.9%). The most commonly initiated opioid was paracetamol/codeine (61.3%), followed by oxycodone (16.3%).Future plansThe POPPY II cohort will be updated periodically, both extending the follow-up duration of the existing cohort, and including new individuals initiating opioids. The POPPY II cohort will allow a range of aspects of opioid utilisation to be studied, including long-term trajectories of opioid use, development of a data-informed method to assess time-varying opioid exposure, and a range of outcomes including mortality, transition to opioid dependence, suicide and falls. The duration of the study period will allow examination of population-level impacts of changes to opioid monitoring and access, while the size of the cohort will also allow examination of important subpopulations such as people with cancer, musculoskeletal conditions or opioid use disorder.

ObjectivesAn estimated 1.7 billion children around the world do not have access to safe, affordable and timely surgical care, with the financing through out-of-pocket (OOP) expenses being one of the main barriers to care. Our study modelled the impact of reducing OOP costs related to surgical care for children in Somaliland on the risk of catastrophic expenditures and impoverishment.Design and settingThis cross-sectional nationwide economic evaluation modelled several different approaches to reduction of paediatric OOP surgical costs in Somaliland.Participants and outcome measuresA surgical record review of all procedures on children up to 15 years old was conducted at 15 surgically capable hospitals. We modelled two rates of OOP cost reduction (reduction of OOP proportion from 70% to 50% and from 70% to 30% reduction in OOP costs) across five wealth quintiles (poorest, poor, neutral, rich, richest) and two geographical areas (urban and rural). The outcome measures of the study are catastrophic expenditures and risk of impoverishment due to surgery. We followed the Consolidated Health Economic Evaluation Reporting Standards.ResultsWe found that the risk of catastrophic and impoverishing expenditures related to OOP expenditures for paediatric surgery is high across Somaliland, but most notable in the rural areas and among the poorest quintiles. Reducing OOP expenses for surgical care to 30% would protect families in the richest wealth quintiles while minimally affecting the risk of catastrophic expenditure and impoverishment for those in the lowest wealth quintiles, particularly those in rural areas.ConclusionOur models suggest that the poorest communities in Somaliland lack protection against the risk of catastrophic health expenditure and impoverishment, even if OOP payments are reduced to 30% of surgical costs. A comprehensive financial protection in addition to reduction of OOP costs is required to prevent risk of impoverishment in these communities.

IntroductionPregnant women are currently considered a vulnerable population to SARS-CoV-2 infection, with increased risk of severe COVID-19, preterm birth and maternal mortality. There is, however, a paucity of data on the burden of maternal SARS-CoV-2 infection in sub-Saharan countries. The objective of this study is to determine the prevalence and health effects of maternal SARS-CoV-2 infection in selected sites from Gabon and Mozambique.Methods and analysisMA-CoV (MAternal CoVid) is an observational, multicentre prospective cohort study where 1000 pregnant women (500 per country) will be enrolled at the antenatal clinic visits. Participants will undergo monthly follow-up at each antenatal care visit, delivery and postpartum visit. The primary study outcome is the prevalence of SARS-CoV-2 infection during pregnancy. The clinical presentation of COVID-19 in pregnancy will also be characterised, and incidence of infection during pregnancy will be evaluated, as well as the risk factors of maternal and neonatal morbidity and mortality associated with SARS-CoV-2 infection and the risk of mother to child transmission of SARS-CoV-2. SARS-CoV-2 infection screening will be performed through PCR diagnosis.Ethics and disseminationThe protocol was reviewed and approved by theComité National d’Éthique pour la Recherche au Gabon,Comité Nacional de Bioética para Saúde de Moçambiqueand the Ethics Committee of the Hospital Clinic of Barcelona (Spain). Project results will be presented to all stakeholders and published in open access journals.Trial registration numberNCT05303168.

ObjectivesAmong nationally representative cross-sections of women in need of contraception from Burkina Faso, Côte d'Ivoire and Kenya, we aimed to: (1) examine the intersection of past-year physical/sexual intimate partner violence (IPV), emotional IPV and reproductive coercion (RC) and (2) assess the impact of physical/sexual IPV, emotional IPV and RC on women’s contraceptive use outcomes, including current contraceptive use, method type and covert use.DesignThe present analysis uses cross-sectional female data collected in Burkina Faso (December 2020–March 2021), Côte d'Ivoire (October–November 2021) and Kenya (November–December 2020).SettingsBurkina Faso, Côte d'Ivoire and KenyaParticipantsAnalytical samples were restricted to partnered women with contraceptive need who completed a violence module (Burkina Faso n=1863; Côte d'Ivoire n=1105; Kenya n=3390).Primary and secondary outcome measuresThe exposures of interest—past-year emotional IPV, physical/sexual IPV and RC—were assessed using abridged versions of the Revised Conflict and Tactics Scale-2 and Reproductive Coercion Scale, respectively. Outcomes of interest included current contraceptive use, contraceptive method type (female controlled vs male compliant), and covert contraceptive use, and used standard assessments.ResultsAcross sites, 6.4% (Côte d'Ivoire) to 7.8% (Kenya) of women in need of contraception experienced RC; approximately one-third to one-half of women experiencing RC reported no other violence forms (31.7% in Burkina Faso to 45.8% in Côte d'Ivoire), whereas physical/sexual IPV largely occurred with emotional IPV. In multivariable models, RC was consistently associated with covert use (Burkina Faso: aOR 2.84 (95% CI 1.21 to 6.64); Côte d'Ivoire: aOR 4.45 (95% CI 1.76 to 11.25); Kenya: aOR 5.77 (95% CI 3.51 to 9.46)). Some IPV in some settings was also associated with covert use (emotional IPV, Burkina Faso: aOR 2.99 (95% CI 1.56 to 5.74); physical/sexual, Kenya: aOR 2.35 (95% CI 1.33 to 4.17)).ConclusionsAcross settings, covert use is a critical strategy for women experiencing RC. Country policies must recognise RC as a unique form of violence with profound implications for women’s reproductive health.

IntroductionBoth B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-pro-BNP) are used to identify patients at risk of perioperative vascular events, but prognostic thresholds have been established in a large prospective cohort for NT-pro-BNP only. We designed this study to inform perioperative risk interpretation of BNP values. Our primary objective is to validate a formula to convert BNP to NT-pro-BNP concentrations before non-cardiac surgery. The secondary objective is to determine the association between BNP categories (established based on conversion from NT-pro-BNP categories) and a composite outcome of myocardial injury after non-cardiac surgery (MINS) and vascular death.Methods and analysisThis is a single-centre, prospective cohort study in patients undergoing non-cardiac surgery who are >65 years old, Revised Cardiac Risk Index ≥1 or >45 years old with significant cardiovascular disease. BNP and NT-pro-BNP will be measured preoperatively, and troponin measurements will be analysed on postoperative days 1, 2 and 3. MINS and vascular death will be ascertained up to 30 days after surgery. The primary analyses will compare measured NT-pro-BNP values to those predicted by an existing formula (from a non-surgical population) based on BNP concentrations and patient characteristics, and recalibrate and update the formula with additional variables. Secondary analyses will estimate the relationship between categories of measured BNP (corresponding to established NT-pro-BNP thresholds) and the composite of MINS and vascular death. The target sample size of 431 patients is based on our primary analysis (assessing the conversion formula).Ethics and disseminationEthics approval has been obtained by the Queen’s University Health Sciences Research Ethics Board, and all participants will provide informed consent for participation in the study. The results will be submitted for publication in conferences and in a peer-reviewed journal, and will inform perioperative vascular risk interpretation of preoperative BNP.Trial registration numberNCT05352698.

ObjectivePast studies on intensive care unit (ICU) patient transfers compare the efficacy of using standardised checklists against unstructured communications. Less studied are the experiences of clinicians in enacting bidirectional (send/receive) transfers. This study reports on the differences in protocols and data elements between receiving and sending transfers in the ICU, and the elements constituting readiness for transfer.MethodsMixed-methods study of a 574-bed general hospital in Singapore with a 74-bed ICU for surgical and medical patients. Six focus group discussions (FGDs) with 34 clinicians comprising 15 residents and 19 nurses, followed by a structured questionnaire survey of 140 clinicians comprising 21 doctors and 119 nurses. FGD transcripts were analysed according to the standard qualitative research guidelines. Survey data were analysed using Student’s t-test with Bonferroni corrections.ResultsGeneral ward (GW) clinicians are more likely to receive ICU patients with complete discharge summaries while ICU clinicians receiving GW patients get significantly less data. Emergency department (ED), GW and operating theatre physicians accompany their patients to the ICU while ICU nurses accompany their patients to the GW. Not all units, such as the ED, experience bidirectional transfers.ConclusionThe protocols and supporting data elements of an ICU transfer vary by the type of transfer and transferring unit. Readiness for transfer means that sending unit protocols affirmatively consider the needs of the receiving unit’s data needs and resource constraints.

ObjectivesThe shortage of healthcare staff is a global problem. UK mental health services have, on average, a higher turnover of staff than the NHS. Factors affecting retention of this staff group need to be explored in more depth to understand what is working for whom, for what reasons and in what circumstances. This review aims to conduct a realist synthesis to explore evidence from published studies, together with stakeholder involvement to develop programme theories that hypothesise how and why retention occurs in the mental health workforce and identify additional evidence to explore and test these theories thereby highlighting any persistent gaps in understanding. This paper develops programme theories that hypothesise why retention occurs and in what context and tests these theories thereby highlighting any persistent gaps in understanding.MethodsRealist synthesis was used to develop programme theories for factors affecting retention of UK mental health staff. This involved: (1) stakeholder consultation and literature scoping to develop initial programme theories; (2) structured searches across six databases to identify 85 included relevant literature relating to the programme theories; and (3) analysis and synthesis to build and refine a final programme theory and logic model.ResultsPhase I combined findings from 32 stakeholders and 24 publications to develop six initial programme theories. Phases II and III identified and synthesised evidence from 88 publications into three overarching programme theories stemming from organisational culture: interconnectedness of workload and quality of care, investment in staff support and development and involvement of staff and service users in policies and practice.ConclusionsOrganisational culture was found to have a key underpinning effect on retention of mental health staff. This can be modified but staff need to be well supported and feel involved to derive satisfaction from their roles. Manageable workloads and being able to deliver good quality care were also key.

ObjectivesDespite the high prevalence of child marriage in Africa, little is known about the current state of the evidence on interventions to prevent and respond to child marriage in the region. The objectives of this systematic scoping review are to describe the breadth of existing evidence on child marriage prevention and response interventions, analyze where these interventions have been implemented, and identify research gaps and priorities for moving forward.MethodsThe inclusion criteria incorporated publications that: (1) focused on Africa, (2) described interventions to address child marriage, (3) were published 2000–2021 and (4) were published as peer-reviewed articles or reports in English. We searched seven databases (PubMed, PsychINFO, Embase, Cinahl Plus, Popline, Web of Science and Cochrane Library), hand-searched the websites of 15 organisations and used Google Scholar to identify research published in 2021. Two authors independently screened titles and abstracts followed by full-text reviews and data extraction for included studies.ResultsOur analysis of the 132 intervention studies identified highlights important disparities by intervention type, sub-region, and intervention activities, focus populations and impact. The greatest number of intervention studies focused on Eastern Africa. Health and empowerment approaches were most represented, followed by education and laws and policies. Norms or livelihoods approaches were least represented.ConclusionOur review finds few high-quality impact evaluations, most of which assess cash transfer programmes. There is a need to strengthen evaluative evidence on other intervention approaches including empowerment and norms change interventions, in particular. Given the linguistic and cultural diversity of the continent, more country-specific studies and research published in languages other than English are needed, particularly in high-prevalence Middle African countries.

Funding: This study is supported by an Early Diagnosis Advisory Group (EDAG) Project Grant from Cancer Research UK (C9227/A27877 - Increasing uptake of faecal immunochemical test (FIT) bowel screening: trial of providing a suggested deadline for FIT kit return, PI KAR, Co-investigators: CMC, AM, GJH, RJCS) and by a Response Mode Grant from the Scottish Chief Scientist Office (HIPS/17/23 - Increasing uptake of bowel cancer screening: development of a FIT planning support tool, PI: KAR, Co-investigators: SM, REOC, RCOC, AI, RJCS, MK). Introduction Screening can reduce deaths from colorectal cancer (CRC). Despite high levels of public enthusiasm, participation rates in population CRC screening programmes internationally remain persistently below target levels. Simple behavioural interventions such as completion goals and planning tools may support participation among those inclined to be screened but who fail to act on their intentions. This study aims to evaluate the impact of: (a) a suggested deadline for return of the test; (b) a planning tool and (c) the combination of a deadline and planning tool on return of faecal immunochemical tests (FITs) for CRC screening. Methods and analysis A randomised controlled trial of 40 000 adults invited to participate in the Scottish Bowel Screening Programme will assess the individual and combined impact of the interventions. Trial delivery will be integrated into the existing CRC screening process. The Scottish Bowel Screening Programme mails FITs to people aged 50–74 with brief instructions for completion and return. Participants will be randomised to one of eight groups: (1) no intervention; (2) suggested deadline (1 week); (3) suggested deadline (2 weeks); (4) suggested deadline (4 weeks); (5) planning tool; (6) planning tool plus suggested deadline (1 week); (7) planning tool plus suggested deadline (2 weeks); (8) planning tool plus suggested deadline (4 weeks). The primary outcome is return of the correctly completed FIT at 3 months. To understand the cognitive and behavioural mechanisms and to explore the acceptability of both interventions, we will survey (n=2000) and interview (n=40) a subgroup of trial participants. Ethics and dissemination The study has been approved by the National Health Service South Central—Hampshire B Research Ethics Committee (ref. 19/SC/0369). The findings will be disseminated through conference presentations and publication in peer-reviewed journals. Participants can request a summary of the results. Trial registration number clinicaltrials.govNCT05408169. Publisher PDF

ObjectivesPeople’s adherence to preventive practices for COVID-19 is fundamental to controlling the transmission of the virus. Therefore, this study is aimed at assessing adherence to preventive practices for COVID-19 and associated factors among the general population in Gurage zone, Ethiopia.MethodsA community-based cross-sectional study was conducted to assess preventive practices and associated factors for COVID-19 among adults in the Gurage zone. The study is based on health belief model constructs. The study involved 398 participants. A multistage sampling technique was employed to recruit study participants. An interviewer-administered, close-ended, structured questionnaire was used to collect data. Binary and multivariable logistic regressions were used to identify independent predictors of the outcome variable.ResultsThe overall adherence to all recommended preventive behaviours of COVID-19 was 17.7%. The majority of respondents (73.1%) practice at least one of the recommended preventive behaviours for COVID-19. Among adults’ COVID-19 preventive behaviours score, wearing a face mask was the highest (82.3%) and social distancing was the lowest (35.4%). Residence adjusted OR (AOR)) 3.42 (95% CI 1.6 to 7.31), marital status AOR 0.33 (95% CI (0.15 to 0.71)), knowledge of the absence/presence of the COVID-19 vaccine AOR 0.45 (95% CI (0.21 to 0.95)) and self-rated level of knowledge as poor AOR 0.052 (95% CI 0.036 to 0.18) and self-rated level of knowledge as not bad AOR 0.14 (95% CI 0.09 to 0.82) were significantly associated with social distancing practice. Factors affecting other COVID-19 preventive behaviours are described in the ‘Results’ section.ConclusionPrevalence of good adherence to recommended preventive behaviours for COVID-19 was very low. Residence, marital status, knowledge of vaccine presence, knowledge of curative drug presence, knowledge of the incubation period, the self-rated level of knowledge and perceived risk to be infected with COVID-19 are significantly associated factors with adherence to preventive behaviours.

ObjectivesDisease-modifying therapies (DMTs) can slow disease progression in multiple sclerosis (MS). The objective of this study was to explore the cost-of-illness (COI) progression among newly diagnosed people with MS in relation to the first DMT received.Design and settingA cohort study using data from nationwide registers in Sweden.ParticipantsPeople with MS (PwMS) in Sweden first diagnosed in 2006–2015, when aged 20–55, receiving first-line therapy with interferons (IFN), glatiramer acetate (GA) or natalizumab (NAT). They were followed up through 2016.Outcome measuresOutcomes (in Euros, €) were: (1) secondary healthcare costs: specialised outpatient and inpatient care including out-of-pocket expenditure, DMTs including hospital-administered MS therapies, and prescribed drugs, and (2) productivity losses: sickness absence and disability pension. Descriptive statistics and Poisson regression were computed, adjusting for disability progression using the Expanded Disability Status Scale.Results3673 newly diagnosed PwMS who were treated with IFN (N=2696), GA (N=441) or NAT (N=536) were identified. Healthcare costs were similar for the INF and GA groups, while the NAT group had higher costs (p value0.05), driven by fewer sickness absence days. NAT had a trend towards lower disability pension costs compared with GA (p value>0.05).ConclusionsSimilar trends over time for healthcare costs and productivity losses were identified across the DMT subgroups. PwMS on NAT maintained their work capacity for a longer time compared with those on GA, potentially leading to lower disability pension costs over time. COI serves as an objective measure to explore the importance of DMTs in maintaining low levels of progression of MS over time.

ObjectivesTo assess the feasibility of using a natural language processing (NLP) application for extraction of free-text online activity mentions in adolescent mental health patient electronic health records (EHRs).SettingThe Clinical Records Interactive Search system allows detailed research based on deidentified EHRs from the South London and Maudsley NHS Foundation Trust, a large south London Mental Health Trust providing secondary and tertiary mental healthcare.Participants and methodsWe developed a gazetteer of online activity terms and annotation guidelines, from 5480 clinical notes (200 adolescents, aged 11–17 years) receiving specialist mental healthcare. The preprocessing and manual curation steps of this real-world data set allowed development of a rule-based NLP application to automate identification of online activity (internet, social media, online gaming) mentions in EHRs. The context of each mention was also recorded manually as: supportive, detrimental or neutral in a subset of data for additional analysis.ResultsThe NLP application performed with good precision (0.97) and recall (0.94) for identification of online activity mentions. Preliminary analyses found 34% of online activity mentions were considered to have been documented within a supportive context for the young person, 38% detrimental and 28% neutral.ConclusionOur results provide an important example of a rule-based NLP methodology to accurately identify online activity recording in EHRs, enabling researchers to now investigate associations with a range of adolescent mental health outcomes.

IntroductionPremenstrual syndrome (PMS) includes a range of physical, behavioural and psychological symptoms and decreases women’s health-related quality of life (HRQoL). It has been proposed that increased body mass index (BMI) is associated with menstrual problems and decreased HRQoL. The body fat amount plays a role in menstrual cycles by altering the oestrogen/progesterone ratio. Alternate day fasting as an unusual diet results in the improvement of anthropometric indices and reduction of body weight. This study aims to investigate the effect of a daily calorie restriction diet and a modified alternate day fasting diet on PMS and HRQoL.Methods and analysisThis 8-week open-label parallel randomised controlled trial examines the impact of a modified alternate-day fasting diet and daily caloric restriction on the severity of PMS and HRQoL in obese or overweight women. Using simple random sampling, women between the ages of 18 years and 50 years and 25 ≤ BMI ˂ 40 who meet the inclusion and exclusion criteria will be chosen from the Kashan University of Medical Sciences Centre. Patients will be randomised, based on BMI and age through stratified randomisation. Then by the random numbers table, they are allocated to fasting (intervention) or daily calorie restriction (control) groups. Outcomes are chosen for the trial: the difference in the severity of PMS, HRQoL, BMI, body fat mass, fat-free mass, waist-to-hip ratio, waist circumference, hip circumference, per cent body fat, skeletal muscle mass and visceral fat area from baseline to 8 weeks.Ethics and disseminationThe Kashan University of Medical Sciences Ethics Committee has approved the trial (IR.KAUMS.MEDNT.REC.1401.003) (17 April 2022). Results will be published in peer-reviewed academic journals and the participants will be informed via phone calls.Trial registration numberIRCT20220522054958N1.

ObjectiveWe described epidemiological characteristics of pulmonary tuberculosis (PTB) among students and evaluated susceptible populations and areas in Guizhou province and also to provide scientific suggestions for prevention and control.SettingGuizhou, China.DesignThis is a retrospective epidemiological study on PTB in students.MethodsData are from the China Information System for Disease Control and Prevention. We collected all PTB cases among the student population from 2010 to 2020 in Guizhou. Incidence, composition ratio and hotspot analysis were used to describe epidemiological and some clinical characteristics.ResultsA total of 37 147 new student PTB cases were registered among the population aged 5–30 years during 2010–2020. The proportions of men and women were 53.71% and 46.29%, respectively. Cases aged 15–19 years dominated (63.91%), and the proportion of ethnic groups was increasing during the period. Generally, the raw annual incidence of PTB among the population was increasing from 32.585 per 100 000 persons in 2010 to 48.872 per 100 000 persons in 2020 (c2trend=1283.230, pConclusionsThe population aged 15–19 years is the vulnerable population, and Bijie city is the susceptible area. BCG vaccination and promotion for active screening should be the priority of futural PTB prevention and control. Tuberculosis laboratory capacity should be improved.

IntroductionPatients undergoing major spine surgery usually experience moderate-to-severe postoperative pain. It has been shown that dexamethasone as an adjunct to local anaesthesia (LA) infiltration presented a superior analgesic benefit compared with LA alone in various types of surgeries. However, a recent meta-analysis reported that the overall benefits of dexamethasone infiltration were marginal. Dexamethasone palmitate (DXP) emulsion is a targeted liposteroid. Compared with dexamethasone, DXP has a stronger anti-inflammatory effect, longer duration of action and fewer adverse effects. We hypothesised that the additive analgesic effects of DXP on local incisional infiltration in major spine surgery may have better postoperative analgesic effect, compared with local anaesthetic alone. However, no study has evaluated this so far. The purpose of this trial is to determine whether pre-emptive coinfiltration of DXP emulsion and ropivacaine at surgical site incision will further reduce postoperative opioid requirements and pain scores after spine surgery than that with ropivacaine alone.Methods and analysisThis is a prospective, randomised, open-label, blinded endpoint, multicentre study. 124 patients scheduled for elective laminoplasty or laminectomy with no more than three levels will be randomly allocated in a 1:1 ratio into two groups: the intervention group will receive local incision site infiltration with ropivacaine plus DXP; the control group will receive infiltration with ropivacaine alone. All participants will complete a 3 months follow-up. The primary outcome will be the cumulative sufentanil consumption within 24 hours after surgery. The secondary outcomes will include further analgesia outcome assessments, steroid-related side effects and other complications, within the 3 months follow-up period.Ethics and disseminationThis study protocol has been approved by the Institutional Review Board of Beijing Tiantan Hospital (KY-2019-112-02-3). All participants will provide a written informed consent. The results will be submitted for publication in a peer-reviewed journals.Trial registration numberNCT05693467.

ObjectivesTo describe mortality due to opioid toxicity among people who experienced incarceration in Ontario between 2015 and 2020, during the fentanyl-dominant era.DesignIn this retrospective cohort study, we linked Ontario coronial data on opioid toxicity deaths between 2015 and 2020 with correctional data for adults incarcerated in Ontario provincial correctional facilities.SettingOntario, Canada.ParticipantsWhole population data.Main outcomes and measuresThe primary outcome was opioid toxicity death and the exposure was any incarceration in a provincial correctional facility between 2015 and 2020. We calculated crude death rates and age-standardised mortality ratios (SMR).ResultsBetween 2015 and 2020, 8460 people died from opioid toxicity in Ontario. Of those, 2207 (26.1%) were exposed to incarceration during the study period. Among those exposed to incarceration during the study period (n=1 29 152), 1.7% died from opioid toxicity during this period. Crude opioid toxicity death rates per 10 000 persons years were 43.6 (95% CI=41.8 to 45.5) for those exposed to incarceration and 0.95 (95% CI=0.93 to 0.97) for those not exposed. Compared with those not exposed, the SMR for people exposed to incarceration was 31.2 (95% CI=29.8 to 32.6), and differed by sex, at 28.1 (95% CI=26.7 to 29.5) for males and 77.7 (95% CI=69.6 to 85.9) for females. For those exposed to incarceration who died from opioid toxicity, 10.6% died within 14 days of release and the risk was highest between days 4 and 7 postrelease, at 288.1 per 10 000 person years (95% CI=227.8 to 348.1).ConclusionsThe risk of opioid toxicity death is many times higher for people who experience incarceration compared with others in Ontario. Risk is markedly elevated in the week after release, and women who experience incarceration have a substantially higher SMR than men who experience incarceration. Initiatives to prevent deaths should consider programmes and policies in correctional facilities to address high risk on release.

ObjectivesTo evaluate the impact and feasibility of multisource feedback compared with traditional feedback for trauma team captains (TTCs).DesignA mixed-methods, non-randomised prospective study.SettingA level one trauma centre in Ontario, Canada.ParticipantsPostgraduate medical residents in emergency medicine and general surgery participating as TTCs. Selection was based on a convenience sampling method.InterventionPostgraduate medical residents participating as TTCs received either multisource feedback or standard feedback following trauma cases.Main outcome measuresTTCs completed questionnaires designed to measure the self-reported intention to change practice (catalytic effect), immediately following a trauma case and 3 weeks later. Secondary outcomes included measures of perceived benefit, acceptability, and feasibility from TTCs and other trauma team members.ResultsData were collected following 24 trauma team activations: TTCs from 12 activations received multisource feedback and 12 received standard feedback. The self-reported intention for practice change was not significantly different between groups initially (4.0 vs 4.0, p=0.57) and at 3 weeks (4.0 vs 3.0, p=0.25). Multisource feedback was perceived to be helpful and superior to the existing feedback process. Feasibility was identified as a challenge.ConclusionsThe self-reported intention for practice change was no different for TTCs who received multisource feedback and those who received standard feedback. Multisource feedback was favourably received by trauma team members, and TTCs perceived multisource feedback as useful for their development.

IntroductionTransition from paediatric to adult care can be challenging for youth living with type 1 diabetes (T1D), as many youth feel unprepared to transfer to adult care and are at high risk for deterioration of glycaemic management and acute complications. Existing strategies to improve transition experience and outcomes are limited by cost, scalability, generalisability and youth engagement. Text messaging is an acceptable, accessible and cost-effective way of engaging youth. Together with adolescents and emerging adults and paediatric and adult T1D providers, we co-designed a text message-based intervention, Keeping in Touch (KiT), to deliver tailored transition support. Our primary objective is to test the effectiveness of KiT on diabetes self-efficacy in a randomised controlled trial.Methods and analysisWe will randomise 183 adolescents with T1D aged 17–18 years within 4 months of their final paediatric diabetes visit to the intervention or usual care. KiT will deliver tailored T1D transition support via text messages over 12 months based on a transition readiness assessment. The primary outcome, self-efficacy for diabetes self-management, will be measured 12 months after enrolment. Secondary outcomes, measured at 6 and 12 months, include transition readiness, perceived T1D-related stigma, time between final paediatric and first adult diabetes visits, haemoglobin A1c, and other glycaemia measures (for continuous glucose monitor users), diabetes-related hospitalisations and emergency department visits and the cost of implementing the intervention. The analysis will be intention-to-treat comparing diabetes self-efficacy at 12 months between groups. A process evaluation will be conducted to identify elements of the intervention and individual-level factors influencing implementation and outcomes.Ethics and disseminationThe study protocol version 7 July 2022 and accompanying documents were approved by Clinical Trials Ontario (Project ID: 3986) and the McGill University Health Centre (MP-37-2023-8823). Study findings will be presented at scientific conferences and in peer-reviewed publications.Trial registration numberNCT05434754.

ObjectivesTo examine the prevalence of institutional delivery and postnatal care after home delivery and to identify their determinants in Myanmar mothers who received at least four antenatal care visits.DesignThe study used the Myanmar Demographic and Health Survey data (2015–2016), a nationally representative cross-sectional study.ParticipantsThe study included women aged 15–49 years who had at least one birth within the 5 years preceding the survey and completed four or more antenatal visits.Outcome measuresInstitutional delivery and postnatal care after home delivery were used as outcomes. We used two separate samples, that is, 2099 women for institutional delivery and 380 mothers whose most recent birth was within 2 years before the survey and delivered at home for postnatal care utilisation. We used multivariable binary logistic regression analyses.SettingFourteen states/regions and Nay Pyi Taw Union Territory in Myanmar.ResultsThe prevalence of institutional delivery was 54.7% (95% CI: 51.2%, 58.2%) and postnatal care utilisation was 76% (95% CI: 70.2%, 80.9%). Women who lived in urban areas, women who had higher education, women who had higher wealth status, women who had educated husbands and women having their first childbirth were more likely to have institutional delivery than their counterparts. The institutional delivery was lower among women who live in rural areas, poor women and women with husbands who worked in agriculture than their counterparts. Postnatal care utilisation was significantly higher among women living in central plains and coastal regions, women who received all seven components of antenatal care and women who had skilled assistance at birth than their counterparts.ConclusionsPolicymakers should address the identified determinants to improve the service continuum and reduce maternal mortality in Myanmar.

IntroductionObservational studies suggest both low and high iodine intakes in pregnancy are associated with poorer neurodevelopmental outcomes in children. This raises concern that current universal iodine supplement recommendations for pregnant women in populations considered to be iodine sufficient may negatively impact child neurodevelopment. We aim to determine the effect of reducing iodine intake from supplements for women who have adequate iodine intake from food on the cognitive development of children at 24 months of age.Methods and analysisA multicentre, randomised, controlled, clinician, researcher and participant blinded trial with two parallel groups. Using a hybrid decentralised clinical trial model, 754 women (377 per group) less than 13 weeks’ gestation with an iodine intake of ≥165 µg/day from food will be randomised to receive either a low iodine (20 µg/day) multivitamin and mineral supplement or an identical supplement containing 200) µg/day (amount commonly used in prenatal supplements in Australia), from enrolment until delivery. The primary outcome is the developmental quotient of infants at 24 months of age assessed with the Cognitive Scale of the Bayley Scales of Infant Development, fourth edition. Secondary outcomes include infant language and motor development; behavioural and emotional development; maternal and infant clinical outcomes and health service utilisation of children. Cognitive scores will be compared between groups using linear regression, with adjustment for location of enrolment and the treatment effect described as a mean difference with 95% CI.Ethics and disseminationEthical approval has been granted from the Women’s and Children’s Health Network Research Ethics Committee (HREC/17/WCHN/187). The results of this trial will be presented at scientific conferences and published in peer-reviewed journals.Trial registration numberNCT04586348.

IntroductionHistoric disruption in health infrastructure combined with data from a recent vaccine coverage survey suggests there are likely significant immunity gaps to vaccine preventable diseases and high risk of outbreaks in Timor-Leste. Community-based serological surveillance is an important tool to augment understanding of population-level immunity achieved through vaccine coverage and/or derived from prior infection.Methods and analysisThis national population-representative serosurvey will take a three-stage cluster sample and aims to include 5600 individuals above one year of age. Serum samples will be collected by phlebotomy and analysed for measles immunoglobulin G (IgG), rubella IgG, severe acute respiratory syndrome coronavirus-2 anti-spike protein IgG, hepatitis B surface antibody and hepatitis B core antigen using commercially available chemiluminescent immunoassays or enzyme-linked immunosorbent assays. In addition to crude prevalence estimates and to account for differences in Timor-Leste’s age structure, we will calculate stratified age-standardised prevalence estimates, using Asia in 2013 as the standard population. Additionally, this survey will derive a national asset of serum and dried blood spot samples which can be used for further investigation of infectious disease sero-epidemiology and/or validation of existing and novel serological assays for infectious diseases.Ethics and disseminationEthical approval has been obtained from the Research Ethics and Technical Committee of the Instituto Nacional da Saúde,Timor-Leste and the Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research, Australia. Co-designing this study with Timor-Leste Ministry-of-Health and other relevant partner organisations will allow immediate translation of findings into public health policy (which may include changes to routine immunisation service delivery and/or plans for supplementary immunisation activities).STRENGTHS AND LIMITATIONS OF THIS STUDYThis project is one of very few large-scale, community-based, population-representative serosurveys to be conducted in low-middle income countries.It will provide accurate seroprevalence estimates for multiple vaccine-preventable diseases, which will immediately inform public health policy and support an ongoing programme of vaccine research in Timor-Leste and the surrounding region.A national asset of bio-banked serum samples will be derived, which can be used in cross-sectional and prospective studies of infectious disease epidemiology, including those which evaluate disease control interventions.Diverse, remote communities across Timor-Leste will be visited, with primary sample analysis occurring at the National Health Laboratory in Timor-Leste. Therefore, fieldwork and laboratory-related logistical challenges will need to be overcome.

IntroductionThe prevalence of traumatic brain injury (TBI) among older adults is increasing exponentially. The sequelae can be severe in older adults and interact with age-related conditions such as multimorbidity. Despite this, TBI research in older adults is sparse. Minder, an in-home monitoring system developed by the UK Dementia Research Institute Centre for Care Research and Technology, uses infrared sensors and a bed mat to passively collect sleep and activity data. Similar systems have been used to monitor the health of older adults living with dementia. We will assess the feasibility of using this system to study changes in the health status of older adults in the early period post-TBI.Methods and analysisThe study will recruit 15 inpatients (>60 years) with a moderate-severe TBI, who will have their daily activity and sleep patterns monitored using passive and wearable sensors over 6 months. Participants will report on their health during weekly calls, which will be used to validate sensor data. Physical, functional and cognitive assessments will be conducted across the duration of the study. Activity levels and sleep patterns derived from sensor data will be calculated and visualised using activity maps. Within-participant analysis will be performed to determine if participants are deviating from their own routines. We will apply machine learning approaches to activity and sleep data to assess whether the changes in these data can predict clinical events. Qualitative analysis of interviews conducted with participants, carers and clinical staff will assess acceptability and utility of the system.Ethics and disseminationEthical approval for this study has been granted by the London-Camberwell St Giles Research Ethics Committee (REC) (REC number: 17/LO/2066). Results will be submitted for publication in peer-reviewed journals, presented at conferences and inform the design of a larger trial assessing recovery after TBI.

ObjectiveThis study aimed to assess the prevalence and determinants of the triple burden of malnutrition among mother–child pairs in low-income and middle-income countries.DesignCross-sectional study.SettingLow-income and middle-income countries.ParticipantsWomen and children.Primary outcomeTriple burden of malnutrition (overweight/obese mother with undernourished and anaemic under 5 years child).MethodsData for this study were drawn from recent 22 low-income and middle-income countries Demographic and Health Surveys. A total weighted sample of 116 795 mother–child pairs was included in the study. STATA V.14.2 was used to clean, code and analyse the data. Multilevel logistic regression was employed to identify factors associated with the problem. Adjusted OR (AOR) with 95% CI and a pResultThe pooled prevalence of the triple burden of malnutrition among mother–child pairs was 11.39%. It showed statistically significant positive associations with mothers aged ≥35 years (AOR 2.25, 95% CI 2.08 to 2.44), family size >10 (AOR 1.17, 95% CI 1.08 to 1.26), delivery by caesarean section (AOR 1.93, 95% CI 1.83 to 2.03), the richest household (AOR 1.72, 95% CI 1.56 to 1.88), grand multiparous (AOR 1.62, 95% CI 1.46 to 1.81), age of child 36–47 months (AOR 1.77, 95% CI 1.64 to 1.90), at a pConclusionAbout 1 out of 10 households suffer from the triple burden of malnutrition in low-income and middle-income countries. This study revealed that several maternal, child, household and community-level factors have a significant impact on the triple burden of malnutrition among mother–child pairs.

IntroductionNeurological complications after surgery for acute type A aortic dissection (ATAAD) increase patient morbidity and mortality. Carbon dioxide flooding is commonly used in open-heart surgery to reduce the risk of air embolism and neurological impairment, but it has not been evaluated in the setting of ATAAD surgery. This report describes the objectives and design of the CARTA trial, investigating whether carbon dioxide flooding reduces neurological injury following surgery for ATAAD.Methods and analysisThe CARTA trial is a single-centre, prospective, randomised, blinded, controlled clinical trial of ATAAD surgery with carbon dioxide flooding of the surgical field. Eighty consecutive patients undergoing repair of ATAAD, and who do not have previous neurological injuries or ongoing neurological symptoms, will be randomised (1:1) to either receive carbon dioxide flooding of the surgical field or not. Routine repair will be performed regardless of the intervention. The primary endpoints are size and number of ischaemic lesions on brain MRI performed after surgery. Secondary endpoints are clinical neurological deficit according to the National Institutes of Health Stroke Scale, level of consciousness using the Glasgow Coma Scale motor score, brain injury markers in blood after surgery, neurological function according to the modified Rankin Scale and postoperative recovery 3 months after surgery.Ethics and disseminationEthical approval has been granted by Swedish Ethical Review Agency for this study. Results will be disseminated through peer-reviewed media.Trial registration numberNCT04962646.

IntroductionNon-pharmacological approaches have shown promising results in improving symptoms and quality of life of patients with fibromyalgia. However, these approaches may not be easily accessible or feasible for everyone. eHealth interventions may offer a more convenient and cost-effective approach to reach a wider range of patients with fibromyalgia and improve their outcomes. As eHealth tools become more prevalent in clinical practice, it is crucial to understand their effectiveness, limitations and how they can be integrated into standard care to optimise clinical outcomes. This systematic review aims to evaluate the effectiveness of eHealth therapeutic education interventions in managing fibromyalgia.Methods and analysisRandomised controlled trials including eHealth therapeutic education interventions for individuals ≥18 years old with fibromyalgia, published in English or Spanish, will be retrieved by searching the databases PubMed, CINAHL Plus, EMBASE, Scopus, ISI Web of Science, PsycINFO and the Cochrane Central Register of Controlled Trials. Covidence software will be used for the selection of studies and data extraction. The risk of bias and the certainty of evidence will be assessed using the Cochrane Risk of Bias Assessment tool. We plan to perform a meta-analysis contingent on the number of studies retrieved and the interstudy heterogeneity, which will be explored with I2statistics.Ethics and disseminationThis protocol and the subsequent systematic review will not collect individual-level data and do not require approval by an ethical committee. We intend to disseminate the study results via peer-reviewed scientific journals and relevant (inter)national conferences.PROSPERO registration numberCRD42022343373.

IntroductionDue to the increased prevalence of chronic conditions, multimorbidity and an increased complexity of care, the burden on healthcare teams is high resulting in unmet needs of patients and their family and a high workload on healthcare professionals. To respond to these challenges, care models integrating nurse practitioners were introduced. Despite the proven benefits, implementation in Belgium is at an early stage. The aim of this study is to develop, implement and evaluate nurse practitioner roles in a Belgian university hospital. Insights into development and implementation processes can inform healthcare managers and policymakers for future (nationwide) implementation.Methods and analysisFor the development, implementation and (process-)evaluation of nurse practitioner roles in three departments in a Belgian university hospital, a participatory action research approach involving interdisciplinary teams of healthcare professionals, healthcare managers and researchers will be used. To investigate the effectiveness at patient (eg, quality of care), healthcare providers (eg, team effectiveness) and organisational level (eg, utility) a longitudinal (matched controlled) pre–post mixed methods study will be set up. Quantitative data (surveys, data from electronic patient files, administrative files) will be analysed using SPSS V.28.0. Qualitative data will be collected throughout the whole process and will consist of the meetings, (focus group) interviews and field notes. All qualitative data will be analysed thematically both across-case and within-case. This study is designed and will be reported based on the Standard Protocol Items: Recommendations for Interventional Trials 2013 statement.Ethics and disseminationEthical approval for all parts of this study was obtained from the Ethics Committee of the participating university hospital (February–August 2021). All participants throughout the study parts will receive written and verbal information and will be asked written consent. All data will be stored on a secured server. Only the primary researchers will have access to the data set.Trial registration numberNCT05520203.

PurposeThe Cook Stove Pregnancy Cohort Study (CSPCS) was designed to assess the effects of biomass fuel use on household air pollution (HAP) as well as the effects of HAP (fine particulate matter, PM2.5) on birth outcomes and acute lower respiratory infection (ALRI) among infants in Bangladesh.ParticipantsWe recruited 903 women within 18 weeks of pregnancy from rural and semiurban areas of Bangladesh between November 2016 and March 2017. All women and their infants (N=831 pairs) were followed until 12 months after delivery and a subset have undergone respiratory and gut microbiota analysis.MethodsQuestionnaires were administered to collect detailed sociodemographic, medical, nutritional and behavioural information on the mother–child dyads. Anthropometric measurements and biological samples were also collected, as well as household PM2.5concentrations.Findings to datePublished work in this cohort showed detrimental effects of biomass fuel and health inequity on birth outcomes. Current analysis indicates high levels of household PM2.5being associated with cooking fuel type and infant ALRI. Lastly, we identified distinct gut and respiratory microbial communities at 6 months of age.Future plansThis study provides an economical yet effective framework to conduct pregnancy cohort studies determining the health effects of adverse environmental exposures in low-resource countries. Future analyses in this cohort include assessing the effect of indoor PM2.5levels on (1) physical growth, (2) neurodevelopment, (3) age of first incidence and frequency of ALRI in infants and (4) the development of the respiratory and gut microbiome. Additional support has allowed us to investigate the effect of in utero exposure to metals on infant neurodevelopment in the first year of life.

IntroductionParents of children hospitalised in a burn unit experience psychological trauma and later post-traumatic stress. Aboriginal and Torres Strait Islander families whose child has been admitted to a burn unit encounter additional burdens through a culturally unsafe healthcare system. Psychosocial interventions can help reduce anxiety, distress and trauma among children and parents. There remains a lack of interventions or resources that reflect Aboriginal and Torres Strait Islander people’s perspective of health. The objective of this study is to codevelop a culturally appropriate informative resource to assist Aboriginal and Torres Strait Islander parents whose child has been hospitalised in a burn unit.MethodsIn this participatory research study, the development of a culturally safe resource will build on Aboriginal and Torres Strait Islander families’ experiences and voices, complemented by the knowledge and expertise of an Aboriginal Health Worker (AHW) and burn care experts. Data will be collected through recorded yarning sessions with families whose child has been admitted to a burn unit, the AHW and burn care experts. Audiotapes will be transcribed and data will be analysed thematically. Analysis of yarning sessions and resource development will follow a cyclical approach.Ethics and disseminationThis study has been approved by the Aboriginal Health and Medical Research Council (AH&MRC) (1690/20) and the Sydney Children’s Hospitals Network ethics committee (2020/ETH02103). Findings will be reported to all participants and will be disseminated with the broader community, the funding body and health workers at the hospital. Dissemination with the academic community will be through peer-reviewed publications and presentations in relevant conferences.

IntroductionRacialized population groups have worse health outcomes across the world compared with non-racialized populations. Evidence suggests that collecting race-based data should be done to mitigate racism as a barrier to health equity, and to amplify community voices, promote transparency, accountability, and shared governance of data. However, limited evidence exists on the best ways to collect race-based data in healthcare contexts. This systematic review aims to synthesize opinions and texts on the best practices for collecting race-based data in healthcare contexts.Methods and AnalysesWe will use the Joanna Briggs Institute (JBI) method for synthesizing text and opinions. JBI is a global leader in evidence-based healthcare and provides guidelines for systematic reviews. The search strategy will locate both published and unpublished papers in English in CINAHL, Medline, PsycINFO, Scopus and Web of Science from 1 January 2013 to 1 January 2023, as well as unpublished studies and grey literature of relevant government and research websites using Google and ProQuest Dissertations and Theses. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement methodology for systematic reviews of text and opinion will be applied, including screening and appraisal of the evidence by two independent reviewers and data extraction using JBI’s Narrative, Opinion, Text, Assessment, Review Instrument. This JBI systematic review of opinion and text will address gaps in knowledge about the best ways to collect race-based data in healthcare. Improvements in race-based data collection, may be related to structural policies that address racism in healthcare. Community participation may also be used to increase knowledge about collecting race-based data.Ethics and disseminationThe systematic review does not involve human subjects. Findings will be disseminated through a peer-reviewed publication in JBI evidence synthesis, conferences and media.PROSPERO registration numberCRD42022368270.

IntroductionPostoperative radiological surveillance following primary resection of a soft tissue sarcoma (sarcoma of the retroperitoneum, abdomen, pelvis, trunk or extremities) is standard of care in all international high-volume sarcoma centres in the world. The intensity of postoperative surveillance imaging is highly varied and knowledge of the impact of surveillance and surveillance intensity on patients’ quality of life is limited. The aim of this systematic review is to summarise the experiences of patients and their relatives/caregivers of postoperative radiological surveillance following resection of a primary soft tissue sarcoma and its impact on their quality of life.Methods and analysisWe will systematically search MEDLINE, EMBASE, PsycINFO, CINAHL Plus and Epistemonikos. Hand searching of reference lists of included studies will be conducted. Further searches will be performed via Google Scholar, to reveal further studies within unpublished ‘grey’ literature. Two reviewers will independently screen the titles and abstracts following the eligibility criteria. After retrieval of the full text of the selected studies, the methodological quality will be appraised using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research and the Center for Evidence-Based Management checklist for Critical Appraisal of a Cross-Sectional Study. Data on the study population, relevant themes and conclusions will be extracted from the selected papers, and a narrative synthesis will be conducted.Ethics and disseminationThe systematic review does not require ethics approval. The findings of the proposed work will be published in a peer-reviewed journal and disseminated widely to patients, clinicians and allied health professionals through the Sarcoma UK website, the Sarcoma Patient Advocacy Global Network and the Trans-Atlantic Australasian Retroperitoneal Sarcoma Working Group. In addition, the outcomes of this research will be presented at national and international conferences.PROSPERO registration numberCRD42022375118.

ObjectivesTo evaluate the profile of non-urgent patients triaged ‘green’, as part of a triage trial in the emergency department (ED) of a secondary care hospital in India. The secondary aim was to validate the triage trial with the South African Triage Score (SATS).DesignProspective cohort study.SettingA secondary care hospital in Mumbai, India.ParticipantsPatients aged 18 years and above with a history of trauma defined as having any of the external causes of morbidity and mortality listed in block V01–Y36, chapter XX of the International Classification of Disease version 10 codebook, triaged green between July 2016 and November 2019.Primary and secondary outcome measuresOutcome measures were mortality within 24 hours, 30 days and mistriage.ResultsWe included 4135 trauma patients triaged green. The mean age of patients was 32.8 (±13.1) years, and 77% were males. The median (IQR) length of stay of admitted patients was 3 (13) days. Half the patients had a mild Injury Severity Score (3–8), with the majority of injuries being blunt (98%). Of the patients triaged green by clinicians, three-quarters (74%) were undertriaged on validating with SATS. On telephonic follow-up, two patients were reported dead whereas one died while admitted in hospital.ConclusionsOur study highlights the need for implementation and evaluation of training in trauma triage systems that use physiological parameters, including pulse, systolic blood pressure and Glasgow Coma Scale, for the in-hospital first responders in the EDs.

IntroductionAlthough treatment of obstructive sleep apnoea (OSA) using continuous positive airway pressure (CPAP) reduces blood pressure (BP), adherence to CPAP is often suboptimal. A mandibular advancement device (MAD) is a guideline-endorsed alternative therapy for OSA. Still, there is limited evidence on the relative efficacy between MAD and CPAP on BP reduction. We evaluate whether treatment of moderate-to-severe OSA using MAD can improve BP and other health-related outcomes compared with CPAP.Methods and analysisThis is a randomised, controlled, non-inferiority trial conducted. We will recruit 220 Asians with a history of hypertension and high cardiovascular risk for an overnight polysomnography screening. Those with moderate-to-severe OSA (apnoea–hypopnoea index ≥15 events/hour) will be randomised to treatment with either MAD or CPAP in a 1:1 ratio. Stratified by age (60 vs 2) and apnoea–hypopnoea index (30 vs Ethics and disseminationThe Domain Specific Review Board-C, National Healthcare Group under approved the study protocol (NHG DSRB Ref: 2019/00359, approved on 28 August 2019). Study findings will be disseminated to various local, national, and international audiences through abstract presentations and publication in peer-reviewed journals.Trial registration numberNCT04119999.

ObjectiveCanadian Armed Forces (CAF) post-deployment screening aims to facilitate early care for members with mental health issues. The process consists of a questionnaire to screen for mental health problems, followed by an interview with a healthcare provider during which recommendations for follow-up care are provided if needed. In this study, we examined the association of self-reported mental health from the screening questionnaire with recommendation for follow-up care during the interview.DesignUsing screening data collected from CAF members who deployed from 2009 to 2012 (n=14 957), logistic regression analysis was conducted to examine the association of self-reported mental health from the screening questionnaire with clinicians’ recommendation for follow-up care.ResultsIn total, 19.7% of screened individuals were recommended for follow-up care. In the adjusted logistic regression model, some demographic characteristics, as well current and prior mental healthcare and self-reported mental health problems, had a substantial association with recommendation for follow-up. Compared with each mental health problem’s lowest severity category, recommendation for follow-up care was higher by approximately 12%–17% for those with mild to severe depression, 7% for those with panic disorder, 8%–10% for those with mild to severe anxiety, 8% for those experiencing high levels of stressors, 4%–10% for those at risk of alcohol use disorder and 7%–12% for those at risk of post-traumatic stress disorder.ConclusionsAlthough the presence of mental health problems was significantly associated with receiving a follow-up recommendation, the relationships between self-reported mental health and subsequent recommendations for care were not as high as expected. Although this may partly reflect time delays between the questionnaire and interview, further research is needed on the extent to which other factors contributed to referral decisions.

IntroductionThere is no established methodology for the perioperative management of head and neck cancer surgery and free tissue transfer reconstruction (HNS-FTR). A single dose of corticosteroid administered immediately before surgery has been shown to reduce postoperative pain and nausea/vomiting after some types of surgery. However, the efficacy of this strategy has not been demonstrated in HNS-FTR, and the increased risk of infectious complications associated with its use cannot be ruled out. This phase III, placebo-controlled, randomised, double-blind, comparative, multicentre study seeks to determine if preoperative administration of corticosteroid hormone has an adjunctive effect in terms of reducing pain and nausea/vomiting after surgery and improving the quality of postoperative recovery.Methods and analysisUsing the minimisation method, patients undergoing HNS-FTR are currently being recruited and randomly assigned to a study arm at a 1:1 allocation rate. The study treatment arm consists of 8.0 mg of dexamethasone phosphate dissolved in 100 mL of saline administered as a single dose by intravenous infusion. These treatments will be administered in a double-blind fashion. All patients will receive perioperative care according to the common multicentre enhanced recovery after surgery programme. The primary endpoint is the quality of postoperative recovery, as determined by the area under the curve (AUC) for total score on the Japanese version of the Quality of Recovery Score (QOR-40J) on postoperative days 2 and 4. The point estimate and CI for the difference in the AUC between the groups on postoperative days 2 and 4 will be calculated.Ethics and disseminationThe study will be performed in accordance with the Declaration of Helsinki and Japan’s Clinical Trials Act. The study protocol was approved by the Certified Review Board of National Cancer Center Hospital East (Reference K2021004).Trial registration numberThe study was registered in the Japan Registry of Clinical Trials (jRCTs031210593; V.3.0, November 2021, available athttps://jrct.niph.go.jp/en-latest-detail/jRCTs031210593).

IntroductionPhysical activity interventions have been used for various health conditions, including cardiovascular disease. However, the literature is still limited regarding the effect of physical activity on coronary heart disease among firefighters.Methods and analysisThe review will be conducted according to recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) and PRISMA Protocol guidelines. This scoping review will provide a synthesis of current evidence on the effects of physical activity on coronary heart disease among firefighters. Search strategies will be performed in the following databases: Cochrane database, PubMed, Medline, (EbscoHost), Web of Science, Academic Search Complete, CINAHL (EBSCO), SAGE journals, ScienceDirect and Scopus. We will include literature in the English language that are full-text peer-reviewed articles from inception to November 2021. Screening of (titles, abstracts and full text of potential articles) will be done by two independent authors using EndNote V.9 software tool. A standardised data extraction form will be designed for the extraction. Two authors will independently extract the data from the selected articles and all differences will be discussed by an invited third reviewer if a consensus cannot be reached. The primary outcomes will be the impact of physical fitness on firefighters experiencing coronary artery disease. This information can assist policy-makers in decision-making related to the use of physical activity in firefighters experiencing coronary heart disease.Ethics and disseminationEthical clearance has been obtained from the University ethics committee and the City of Cape Town. The findings will be disseminated through publications and the physical activity guidelines will be submitted to the Fire Departments within the City of Cape Town. Data analysis will start on 1 April 2023.

IntroductionIn recent decades, there has been a significant increase in childlessness. This paper analysed childlessness in China, specifically examining its socio and regional disparities.MethodsWith data from China’s 2020 population census, supplemented with data from China’s 2010 population census and 2015 inter-censual 1% population sample survey, we used a basic indicator of age-specific childlessness proportion, a decomposition method, and probability distribution models to analyse, fit and project childlessness.ResultsWe presented age-specific childlessness proportions for women as a whole and by socioeconomic features, decomposition and projection results. The childlessness proportion increased markedly from 2010 to 2020, reaching 5.16% for women aged 49. The proportion is highest for city women, followed by township women, and is lowest among village women, at 6.29%, 5.50% and 3.72 % for women aged 49, respectively. The proportion for women aged 49 with high college education or above was 7.98%, and only 4.42% for women with junior high school education. The proportion also exhibits marked provincial discrepancies, and the total fertility rate is negatively correlated with childlessness at the province level. The decomposition results distinguished the different contribution of change in educational structure and change in childlessness proportion for subgroups to the total childlessness proportion change. It is projected that city women, women with high education will have higher childlessness proportion, and the proportion will further increase with the rapid increase in education level and urbanisation.ConclusionsChildlessness has risen to a relatively high level, and varies among women with different characteristics. This should be taken into consideration in China’s countermeasures to reduce childlessness and curtail further fertility decline accordingly.

IntroductionWith technological advancement and the COVID-19 pandemic, paper-based media are giving way to screen-based media to promote healthy ageing. However, there is no review available covering paper and screen media use by older people, so the objective of this review is to map the current use of paper-based and/or screen-based media for health education aimed at older people.Methods and analysisThe literature will be searched in Scopus, Web of Science, Medline, Embase, Cinahl, The ACM Guide to Computing Literature and Psyinfo databases. Studies in English, Portuguese, Italian or Spanish published from 2012 to the date of the search will be examined. In addition, an additional strategy will be carried out, which will be a Google Scholar search, in which the first 300 studies according to Google’s relevance algorithm will be verified. The terms used in the search strategy will be focused on older adults, health education, paper-based and screen-based media, preferences, intervention and other related terms. This review will include studies where the average age of the participants was 60 years or older and were users of health education strategies through paper-based or screen-based media. Two reviewers will carry out the selection of studies in five steps: identification of studies and removal of duplicates, pilot test, selection by reading titles and abstracts, full-text inclusion and search for additional sources. A third reviewer will resolve disagreements. To record information from the included studies, a data extraction form will be used. The quantitative data will be presented in a descriptive way and the qualitative data through Bardin’s content analysis.Ethics and disseminationEthical approval is not applicable to the scoping review. The results will be disseminated through presentations at significant scientific events and published in journals in the area.Protocol registration numberOpen science framework (DOI: DOI 10.17605/OSF.IO/GKEAH).

ObjectiveWith the COVID-19 pandemic, telemedicine has been increasingly deployed in lieu of face-to-face consultations for management of diabetes in primary care. There was a need to evaluate clinical effectiveness of telephone consultations for diabetes management and this study aimed to show whether one-off telephone consultation was inferior or not to face-to-face consultation in terms of glycaemic control among patients with suboptimally controlled type 2 diabetes.DesignRetrospective cohort study. Data of all patients with type 2 diabetes who had a chronic disease consultation during the period 9 April 2020–18 September 2020, and met the study’s inclusion and exclusion criteria was obtained from the electronic medical records.SettingA primary care clinic in the north-eastern region of Singapore. The clinic’s patient population was representative of Singapore’s population in terms of gender and age.Participants644 patients with type 2 diabetes and glycated haemoglobin (HbA1c) 7.0% and above, aged 21–80 years old.InterventionsParticipants either underwent telephone or face-to-face consultation for diabetes management.Outcome measureMean HbA1c change (∆HbA1c) between preintervention and postintervention.ResultsOver 4 months, the mean ∆HbA1c was −0.16 percentage points (p.p.) (95% CI −0.26 to –0.07) and −0.11 p.p. (95% CI −0.20 to –0.02) for face-to-face and telephone consultation groups, respectively. The difference in mean ∆HbA1c between the two groups was +0.05 p.p. (95% CI −∞ to 0.16), with the upper limit of the one-sided 95% CI less than the prespecified non-inferiority margin of 0.5 p.p. (pConclusionFor patients with suboptimally controlled type 2 diabetes, one-time telephone consultation was non-inferior to face-to-face consultation in terms of glycaemic control in the short term. However, more studies are required to investigate the long-term effects of telephone consultations and for those with HbA1c≥9%.

ObjectiveTo describe the experiences of nephrologists on caring for patients undergoing in-centre haemodialysis during the COVID-19 pandemic in Latin America.DesignTwenty-five semistructured interviews were conducted by Zoom videoconference in English and Spanish languages during 2020 until data saturation. Using thematic analysis, we conducted line-by-line coding to inductively identify themes.Setting25 centres across nine countries in Latin America.ParticipantsNephrologists (17 male and 8 female) were purposively sampled to include diverse demographic characteristics and clinical experience.ResultsWe identified five themes: shock and immediate mobilisation for preparedness (overwhelmed and distressed, expanding responsibilities to manage COVID-19 infection and united for workforce resilience); personal vulnerability (being infected with COVID-19 and fear of transmitting COVID-19 to family); infrastructural susceptibility of dialysis units (lacking resources and facilities for quarantine, struggling to prevent cross-contamination, and depletion of personal protective equipment and cleaning supplies); helplessness and moral distress (being forced to ration life-sustaining equipment and care, being concerned about delayed and shortened dialysis sessions, patient hesitancy to attend to dialysis sessions, being grieved by socioeconomic disparities, deterioration of patients with COVID-19, harms of isolation and inability to provide kidney replacement therapy); and fostering innovative delivery of care (expanding use of telehealth, increasing uptake of PD and shifting focus on preventing syndemics).ConclusionNephrologists felt personally and professionally vulnerable and reported feeling helpless and morally distressed because they doubted their capacity to provide safe care for patients undergoing dialysis. Better availability and mobilisation of resources and capacities to adapt models of care, including telehealth and home-based dialysis, are urgently needed.

ObjectivesLate presentation or diagnosis of cancer results in a poor clinical prognosis, negatively affects treatment and subsequently lowers one’s chances of survival. This study aimed to identify the factors associated with late lung and colorectal cancer presentation and diagnosis in Jordan.DesignThis correlational cross-sectional study was based on face-to-face interviews and medical chart reviews from a cancer registry database. A structured questionnaire based on a review of the literature was used.Setting and participantsThe study participants were a representative sample of adult patients with colorectal or lung cancer who visited the outpatient clinics at King Hussein Cancer Center in Amman, Jordan, between January 2019 and December 2020, to get their first medical consultation.Results382 study participants were surveyed, with a response rate of 82.3%. Of these, 162 (42.2%) reported a late presentation and 92 (24.1%) reported a late diagnosis of cancer. The results of backward multivariate logistic regression analyses showed that female gender and not seeking a medical advice when feeling ill combined was associated with an almost three times increased likelihood of reporting a late presentation with cancer (adjusted OR 2.97, 95% CI 1.19 to 7.43). Not having health insurance and not seeking medical advice combined was also associated with late presentation (2.5, 95% CI 1.02 to 6.12). For lung cancer, Jordanians living in rural areas were 9.29 (95% CI 2.46 to 35.1) times more likely to report late diagnosis. Jordanians who did not screen for cancer in the past were 7.02 (95% CI 1.69 to 29.18) times more likely to report late diagnosis. For colorectal cancer, those having no previous knowledge about cancers or screening programmes had increased odds of reporting late diagnosis (2.30, 95% CI 1.06 to 4.97).ConclusionsThis study highlights important factors associated with the late presentation and diagnosis of colorectal and lung cancers in Jordan. Investing in national screening and early detection programmes as well as public outreach and awareness campaigns will have a significant impact on early detection to improve treatment outcomes.

ObjectivesThis paper explores the Bangladeshi tobacco advertising, promotion and sponsorship (TAPS) legislative environment, to highlight any potential policy loopholes and to facilitate the identification of additional provisions for inclusion. The study also aimed to identify valuable lessons applicable to other low-income and middle-income countries (LMICs).MethodsWe conducted a qualitative health policy analysis using the health policy triangle model to frame the collection and extraction of publicly available information from academic literature search engines, news media databases and websites of national and international organisations, published up until December 2020. We coded and analysed textual data using the thematic framework approach to identify themes, relationships and connections.ResultsFour themes underpin the Bangladesh legislative environment on TAPS: (1) engaging international actor interest in TAPS policies, (2) the incremental approach to TAPS policy-making, (3) time-sensitive TAPS monitoring data and (4) innovative TAPS monitoring and policy enforcement system. The findings highlight the role of international actors (such as multinational organisations and donors), tobacco control advocates and the tobacco industry in the policy-making process and the competing agendas they bring. We also outline the chronology of TAPS policy-making in Bangladesh and the existing loopholes and policy changes over time. Lastly, we describe the innovative approaches to TAPS monitoring and policy enforcement in Bangladesh to combat the tobacco industry marketing strategies.ConclusionThis study highlights the role of tobacco control advocates as crucial in TAPS policy-making, monitoring and enforcement in LMICs, and identifies good practices for the sustainability of tobacco control programmes. However, it also points out that tobacco industry interference, coupled with increasing pressure on advocates and legislators, may block progress in tobacco endgame approaches.

ObjectivesMost kidney stones contain calcium, which is closely associated with human bone health. Therefore, we aimed to determine the relationship between the history of kidney stones and human bone health. This study examined the associations between lumbar bone mineral density (BMD), serum 25-hydroxyvitamin D (25-OHD) and a history of kidney stones in individuals aged between 30 years and 69 years.Design and data analysisA multivariate logistic regression model was used to estimate the relationship between lumbar BMD, serum 25-OHD levels and kidney stones in this cross-sectional study. All models incorporated survey sample weights and were adjusted for covariates.SettingNational Health and Nutrition Examination Survey (NHANES) 2011–2018. The exposure and outcomes of this study included the lumbar BMD and presence of kidney stones.ParticipantsAll the 7500 participants for this cross-sectional survey were selected from the NHANES between 2011 and 2018.Main outcome measuresThe main outcome of this study was the presence of kidney stones. The interviewers asked the questions on kidney stones while the respondents were at home, using a computer-assisted personal interview system.ResultsLumbar BMD was negatively correlated with a history of kidney stones in all three multivariate linear regression models; the negative association existed in all genders after adjusting for all confounding factors. In the multiple regression analysis, there was an interaction between serum 25-OHD and lumbar BMD (pConclusionThe study results suggest that maintaining a high lumbar BMD may reduce the incidence of kidney stone formation. Simultaneously, maintaining a high serum 25-OHD level may be more beneficial in preventing the occurrence or recurrence of stones while ensuring a high lumbar BMD.

ObjectiveThis study aimed to characterise the burden of malnutrition and assess how underlying determinants at the structural and intermediary levels contributed to malnutrition among late adolescent and young women in rural Pakistan.DesignCross-sectional enrolment data assessment.Setting and participantsThis study was conducted using data from adolescent and young women (n=25 447) enrolled in the Matiari emPowerment and Preconception Supplementation Trial, collected from June 2017 to July 2018 in Matiari District, Pakistan. The WHO-based cut-offs were applied to anthropometric measures to estimate body mass index (BMI) categories (underweight, overweight, obese) and stunting. Hierarchical models were generated to evaluate the association between the determinants with BMI categories and stunting among late adolescent girls and young women, respectively.Primary and secondary outcome measuresThe main outcomes of interest were BMI categories and stunting. Explanatory variables included measures of socioeconomic status, education, occupation, health, well-being, food security, empowerment and food practices.ResultsRegardless of age group, the prevalence of underweight was high (36.9%; 95% CI 36.3% to 37.5%). More late adolescent girls were underweight, while more young women were overweight/obese (pConclusionsThis study informs the data gap and need for comprehensive research on adolescent nutritional status. Findings suggest factors related to poverty played an important, underlying role in undernutrition among participants. Commitment to improving the nutritional status of all adolescent and young women in Pakistan will be critical given the observed burden of malnutrition.Trial registration numberNCT03287882.

IntroductionFalls from height are a leading cause of serious injury and fatality globally. In South Africa, work at heights is regulated by occupational health and safety legislation, which places responsibility on employers to ensure their workers are fit for high-risk work. There is however no formal procedure or consensus on how fitness to work at heights should be assessed. This paper presents an a priori protocol for a scoping review that seeks to identify and map the current evidence base around the assessment of fitness to work at heights. It forms the initial phase of a PhD study aimed at developing an interdisciplinary consensus statement for assessing fitness to work at heights in the South African construction industry.Methods and analysisThis scoping review will follow the Joanna Briggs Institute (JBI) scoping review framework and will be guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping reviews (PRISMA-ScR) checklist. An iterative search will be conducted in a selection of multidisciplinary databases including, Proquest Central, PubMed, Scopus, Science Direct, Web of Science, PsychINFO and Google Scholar. Thereafter, searches for grey literature will be performed in Google.com and websites of various national and international agencies, governing bodies and professional organisations with an interest in occupational health and work at heights. Where appropriate, targeted requests for clarification for further information will be undertaken with information sources. A descriptive qualitative content analysis of the results will be conducted and a level of evidence rating will be assigned to each study using the JBI approach. This will allow us to provide some commentary on the rigour of the existing evidence base.Ethics and disseminationEthics approval for the PhD study was granted by the Research Ethics Committee, Faculty of Health Sciences, University of Pretoria, ethics reference number, 486/2021. Results of the scoping review will be submitted to a scientific journal for publication.Trial registration numberThis protocol is registered on the Open Science Framework at osf.io/yd5gw.

IntroductionAtrial fibrillation (AF) is the most common postoperative complication after surgical aortic valve replacement (SAVR) and occurs in up to 50% of the patients. Development of postoperative AF (POAF) is associated with a 2–3 fold increased risk of adverse events, including stroke, myocardial infarction and death.Several studies have implied that prophylactic Atorvastatin therapy could prevent POAF in patients undergoing coronary artery bypass graft. These studies suggest that Atorvastatin has rapid and significant pleiotropic actions that reduce the risk of POAF. However, prophylactic treatment with statins has yet to be understood in SAVR. The aim of this study is to investigate whether prophylactic administration of torvastatin reduces POAF in patients undergoing SAVR.Methods and analysisIn this investigator-initiated, prospective, parallel-group, randomised, double-blind, placebo-controlled single-centre trial, 266 patients undergoing elective solitary SAVR with bioprosthetic valve, with no prior history of AF, and statin-naïve will be randomised (1:1) to treatment with Atorvastatin (80 mg once daily) or matching placebo for 1–2 weeks prior to and 30 days after surgery. The primary endpoint is POAF defined as an episode of irregular RR-intervals without a traceable p-wave of at least 30 s duration. After discharge and until day 30 after surgery, POAF will be documented by either rhythm strip or 12-lead ECG.Ethics and disseminationProtocol approval has been obtained from the Regional Scientific Ethical Committee for Southern Denmark (S-20210159), The Danish Medicines Agency (2021103821) and the Data Protection Agency (21/65621).The trial is conducted in accordance with the Declaration of Helsinki, the ICH-GCP (International Conference on Harmonisation Good Clinical Practice) guidelines and the legal regulations of Denmark. Study findings will be shared via peer-reviewed journal publication and conference presentations.Trial registration numberNCT05076019.

IntroductionDespite cultural, religious and legal constraints, alcohol and drug abuse is rising in the United Arab Emirates (UAE). Therefore, we aim to produce a scoping review to summarise available scientific literature on alcohol and substance dependence (ASD) in all ethnic and religious groups in the UAE to inform future scientific inquiries.Methods and analysisSocial work faculty from the UAE University will conduct the scoping review between March 2023 and February 2024. Drawing on the participants, concept, context (PCC) framework, the following review question was developed: What can be learnt from a review of scientific literature on alcohol and substance abuse in all ethnic and religious groups in the UAE? The scientific literature on ASD in the UAE published between 1971 and January 2023, in either English or Arabic, will be considered, including all ethnic, religious and age groups. Grey literature, such as postgraduate dissertations and conference proceedings, will also be considered. Eight English and two Arabic databases and print copies of literature sources in university libraries will be included. EndNote and Covidence software will be used for deduplication, screening and data extraction. Screening and reviewing search results will involve two English-speaking and two Arabic-speaking team members who will work independently. A third reviewer will resolve conflicts. The inter-rater reliability data from the title and abstract screening stage will be exported, and Cohen’s kappa coefficient will be calculated. Data charting informed by the Covidence data extraction tool 2.0 will occur after pilot testing, followed by qualitative content analysis. Reporting of the findings will align with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews tool.Ethics and disseminationEthical approval is not required for this study because this is a scoping review of published studies and grey literature. Findings will be disseminated via peer-reviewed journal publications, scientific conferences and a policy brief.

ObjectivesAreas with high sexually transmitted infection (STI) testing rates may not require additional strategies to improve testing. However, it may be necessary to intervene in areas with elevated STI risk, but with low STI testing rates. We aimed to compare STI-related risk profiles and STI testing rates by geographical area to determine areas for improvement of sexual healthcare access.DesignCross-sectional population-based study.SettingGreater Rotterdam area, the Netherlands (2015–2019).ParticipantsAll residents aged 15–45 years. Individual population-based register data were matched with laboratory-based STI testing data of general practitioners (GPs) and the only sexual health centre (SHC).Outcome measuresPostal code (PC) area-specific STI risk scores (based on age, migratory background, education level and urbanisation), STI testing rates and STI positivity.ResultsThe study area consists of approximately 500 000 residents aged 15–45 years. Strong spatial variation in STI testing, STI positivity and STI risk was observed. PC area testing rate ranged from 5.2 to 114.9 tests per 1000 residents. Three PC clusters were identified based on STI risk and testing rate: (1) high–high; (2) high–low; (3) low, independently of testing rate. Clusters 1 and 2 had comparable STI-related risk and STI positivity, but the testing rate differed greatly (75.8 vs 33.2 per 1000 residents). Multivariable logistic regression analysis with generalised estimating equation was used to compare residents in cluster 1 and cluster 2. Compared with cluster 1, residents in cluster 2 more often did not have a migratory background, lived in less urbanised areas with higher median household income, and more distant from both GP and SHC.ConclusionThe determinants associated with individuals living in areas with high STI-related risk scores and low testing rates provide leads for improvement of sexual healthcare access. Opportunities for further exploration include GP education, community-based testing and service (re)allocation.

ObjectivesExcessive alcohol use can bring about adverse health and work-related consequences in civilian and military populations. Screening for excessive drinking can help identify individuals at risk for alcohol-related problems who may require clinical interventions. The brief validated measures of alcohol use such as the Alcohol Use Disorders Identification Test (AUDIT), or abbreviated AUDIT-Consumption (AUDIT-C), are often included in military deployment screening and epidemiologic surveys, but appropriate cut-points must be used to effectively identify individuals at risk. Although the conventional AUDIT-C cut-points ≥4 for men and ≥3 for women are commonly used, recent validation studies of veterans and civilians recommend higher cut-points to minimise misclassification and overestimation of alcohol-related problems. This study aims to ascertain optimal AUDIT-C cut-points for detecting alcohol-related problems among serving Canadian, UK and US soldiers.DesignCross-sectional pre/post-deployment survey data were used.SettingsComprised Army locations in Canada and UK, and selected US Army units.ParticipantsIncluded soldiers in each of the above-mentioned settings.Outcome measuresSoldiers’ AUDIT scores for hazardous and harmful alcohol use or high levels of alcohol problems served as a benchmark against which optimal sex-specific AUDIT-C cut-points were assessed.ResultsAcross the three-nation samples, AUDIT-C cut-points of ≥6/7 for men and ≥5/6 for women performed well in detecting hazardous and harmful alcohol use and provided comparable prevalence estimates to AUDIT scores ≥8 for men and ≥7 for women. The AUDIT-C cut-point ≥8/9 for both men and women performed fair-to-good when benchmarked against AUDIT ≥16, although inflated AUDIT-C-derived prevalence estimates and low positive predictive values were observed.ConclusionThis multi-national study provides valuable information regarding appropriate AUDIT-C cut-points for detecting hazardous and harmful alcohol use, and high levels of alcohol problems among soldiers. Such information can be useful for population surveillance, pre-deployment/post-deployment screening of military personnel, and clinical practice.

ObjectiveTo index levels of hearing loss with respect to area-level indices of deprivation in a Welsh population.DesignA cross-sectional observational study of all adults (aged >18) that attended Abertawe Bro Morgannwg University (ABMU) Health Board audiology services between 2016 and 2018. Service access, first hearing aid fitting appointment rates and hearing loss at time of first hearing aid provision were used to index population hearing loss versus area-level indices of deprivation based on patient postcode.SettingPrimary and secondary care.Participants59 493 patient entries met the inclusion criteria. Patient entries were grouped by age (18–30, 31–40, 41–50, 51–60, 61–70, 71–80, >80 years) and deprivation decile.ResultsThe interaction between age group and deprivation decile predicted access rate to ABMU audiology services (b=−0.24, t(6858) = −2.86, p80 years. First hearing aid fitting rates were highest among the most deprived in the four youngest age groups (pConclusionsHearing health inequalities are prevalent among adults accessing ABMU audiology services. Our findings suggest that deprivation increases the likelihood of developing hearing loss, brings earlier onset of hearing loss and is linked to delays in getting help for hearing problems. However, it is not possible to know the true scale of these disparities without knowing the hearing health of the Welsh adult population including those who do not seek help for hearing problems.