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Background: Healthcare-associated infections (HCAIs) and variation in antibiotic prescribing pose a significant public health challenge in hospitals of low-resource countries.Aim: To critically appraise and synthesize the evidence on HCAI and the prescribing of antibiotics in Caribbean Community (CARICOM) states.Methods: All primary qualitative and quantitative studies that addressed HCAI, and the prescribing of antibiotics in hospitalized patients of CARICOM states were included. Ovid Medline, Embase, Global Health, and regional databases were searched. Risk of bias was assessed using the Mixed Methods Appraisal Tool. Findings were presented in narrative and table formats.Findings: Twenty-one studies met the inclusion criteria for this mixed-methods systematic review (MMSR). Studies were from four different CARICOM states: Trinidad and Tobago, Jamaica, Haiti, and Antigua and Barbuda. Intensive care units (ICUs) had the highest rate of infections (67% over four years). Surgical site infections were discussed by seven studies and ranged from 1.5% to 7.3%. For inpatients with contaminated or infected wounds, rates ranged from 29% to 83%. Empiric and prophylactic therapies were common and inappropriately prescribed. Resources and training for healthcare workers in infection control and antimicrobial stewardship were insufficient. Few qualitative studies existed, so it was not possible to integrate evidence from qualitative and quantitative paradigms.Conclusion: Evidence from CARICOM states shows high rates of HCAI and inappropriately prescribed antibiotics, primarily in ICUs. Disease surveillance, infection control, and antimicrobial stewardship programmes require urgent evidence-based improvements. [ABSTRACT FROM AUTHOR]

We present a technique called corrected integral shape averaging (CISA) for quantifying shape and shape differences in a set of signals. CISA can be used to account for signal differences which are purely due to affine time warping (jitter and dilation/compression), and hence provide access to intrinsic shape fluctuations. CISA can also be used to define a distance between shapes which has useful mathematical properties; a mean shape signal for a set of signals can be defined, which minimizes the sum of squared shape distances of the set from the mean. The CISA procedure also allows joint estimation of the affine time parameters. Numerical simulations are presented to support the algorithm for obtaining the CISA mean and parameters. Since CISA provides a well-defined shape distance, it can be used in shape clustering applications based on distance measures such as -means. We present an application in which CISA shape clustering is applied to P-waves extracted from the electrocardiogram of subjects suffering from sleep apnea. The resulting shape clustering distinguishes ECG segments recorded during apnea from those recorded during normal breathing with a sensitivity of and specificity of .

BACKGROUND Studies have shown that self-monitoring of blood pressure (BP) is effective when combined with co-interventions, but its efficacy varies in the presence of some co-morbidities. This study examined whether self-monitoring can reduce clinic BP in patients with hypertension-related co-morbidity. METHODS A systematic review was conducted of articles published in Medline, Embase, and the Cochrane Library up to January 2018. Randomized controlled trials of self-monitoring of BP were selected and individual patient data (IPD) were requested. Contributing studies were prospectively categorized by whether they examined a low/high-intensity co-intervention. Change in BP and likelihood of uncontrolled BP at 12 months were examined according to number and type of hypertension-related co-morbidity in a one-stage IPD meta-analysis. RESULTS A total of 22 trials were eligible, 16 of which were able to provide IPD for the primary outcome, including 6,522 (89%) participants with follow-up data. Self-monitoring was associated with reduced clinic systolic BP compared to usual care at 12-month follow-up, regardless of the number of hypertension-related co-morbidities (−3.12 mm Hg, [95% confidence intervals −4.78, −1.46 mm Hg]; P value for interaction with number of morbidities = 0.260). Intense interventions were more effective than low-intensity interventions in patients with obesity (P < 0.001 for all outcomes), and possibly stroke (P < 0.004 for BP control outcome only), but this effect was not observed in patients with coronary heart disease, diabetes, or chronic kidney disease. CONCLUSIONS Self-monitoring lowers BP regardless of the number of hypertension-related co-morbidities, but may only be effective in conditions such obesity or stroke when combined with high-intensity co-interventions. [ABSTRACT FROM AUTHOR]

Objectives: To (1) establish the extent of opportunities for members of the public to check their own blood pressure (BP) outside of healthcare consultations (BP self-screening), (2) investigate the reasons for and against hosting such a service and (3) ascertain how BP self-screening data are used in primary care. Design: A mixed methods, cross-sectional study. Setting: Primary care and community locations in Oxfordshire, UK. Participants: 325 sites were surveyed to identify where and in what form BP self-screening services were available. 23 semistructured interviews were then completed with current and potential hosts of BP selfscreening services. Results: 18/82 (22%) general practices offered BP self-screening and 68/110 (62%) pharmacies offered professional-led BP screening. There was no evidence of permanent BP self-screening activities in other community settings. Healthcare professionals, managers, community workers and leaders were interviewed. Those in primary care generally felt that practice-based BP selfscreening was a beneficial activity that increased the attainment of performance targets although there was variation in its perceived usefulness for patient care. The pharmacists interviewed provided BP checking as a service to the community but were unable to develop self-screening services without a clear business plan. Among potential hosts, barriers to providing a BP self-screening service included a perceived lack of healthcare commissioner and public demand, and a weak--if any--link to their core objectives as an organisation. Conclusions: BP self-screening currently occurs in a minority of general practices. Any future development of community BP self-screening programmes will require (1) public promotion and (2) careful consideration of how best to support--and reward--the community hosts who currently perceive little if any benefit. [ABSTRACT FROM AUTHOR]

Background: Care home residents have venous thromboembolism (VTE) risk profiles similar to medical inpatients; however, the epidemiology of VTE in care homes is unclear.Aim: To determine the incidence of VTE in care homes.Design and Setting: Observational cohort study of 45 care homes in Birmingham and Oxford, UK.Method: A consecutive sample of care home residents was enrolled and followed up for 12 months. Data were collected via case note reviews of care home and GP records; mortality information was supplemented with Health and Social Care Information Centre (now called NHS Digital) cause of death data. All potential VTE events were adjudicated by an independent committee according to three measures of diagnostic certainty: definite VTE (radiological evidence), probable VTE (high clinical indication but no radiological evidence), or possible VTE (VTE cannot be ruled out). (Study registration number: ISTCTN80889792.) RESULTS: There were 1011 participants enrolled, and the mean follow-up period was 312 days (standard deviation 98 days). The incidence rate was 0.71 per 100 person years of observation (95% confidence interval [CI] = 0.26 to 1.54) for definite VTE, 0.83 per 100 person years (95% CI = 0.33 to 1.70) for definite and probable VTE, and 2.48 per 100 person years (95% CI = 1.53 to 3.79) for definite, probable, and possible VTE.Conclusion: The incidence of VTE in care homes in this study (0.71-2.48 per 100 person years) is substantial compared with that in the community (0.117 per 100 person years) and in people aged ≥70 years (0.44 per 100 person years). Further research regarding risk stratification and VTE prophylaxis in this population is needed. [ABSTRACT FROM AUTHOR]

Introduction: Emergency medicine (EM) has a high case turnover and acuity making it a demanding clinical reasoning domain especially for junior doctors who lack experience. We aimed to better understand their clinical reasoning using dual cognition as a guiding theory.Methods: EM junior doctors were recruited from six hospitals in the south of England to participate in semi-structured interviews (n=20) and focus groups (n=17) based on recall of two recent cases. Transcripts were analysed using a grounded theory approach to identify themes and to develop a model of junior doctors' clinical reasoning in EM.Results: Within cases, clinical reasoning occurred in three phases. In phase 1 (case framing), initial case cues and first impressions were predominantly intuitive, but checked by analytical thought and determined the urgency of clinical assessment. In phase 2 (evolving reasoning), non-analytical single cue and pattern recognitions were common which were subsequently validated by specific analytical strategies such as use of red flags. In phase 3 (ongoing uncertainty) analytical self-monitoring and reassurance strategies were used to precipitate a decision regarding discharge.Conclusion: We found a constant dialectic between intuitive and analytical cognition throughout the reasoning process. Our model of clinical reasoning by EM junior doctors illustrates the specific contextual manifestations of the dual cognition theory. Distinct diagnostic strategies are identified and together these give EM learners and educators a framework and vocabulary for discussion and learning about clinical reasoning. [ABSTRACT FROM AUTHOR]

The recently completed EU-funded BACCHUS Integrated Project (grant number: 312090) has focused on identification of cause-and-effect relationships between consumption of bioactive peptides and polyphenols and physiological effects on cardiovascular health. An important BACCHUS output is a toolkit to support the needs of small- and medium-sized enterprises (SMEs) in the food sector considering making health claims on their products. The toolkit draws together best practice guides, a bioactives database, an intake assessment tool and an e-learning platform. This paper focuses on the Best Practice Guide for Human Dietary Intervention Studies. The toolkit has been developed with SMEs in mind but this guidance is likely to have value far beyond the needs of businesses, in particular being a useful resource for students, early-career scientists and others new to the design and implementation of dietary intervention studies. The aim of this article is to share the principles of the guide with a broader audience. [ABSTRACT FROM AUTHOR]

Objectives: Fertility services in the UK are offered by over 200 Human Fertilisation and Embryology Authority (HFEA)-registered NHS and private clinics. While in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) form part of the National Institute for Health and Care Excellence (NICE) guidance, many further interventions are offered. We aimed to record claims of benefit for interventions offered by fertility centres via information on the centres' websites and record what evidence was cited for these claims. Methods: We obtained from HFEA a list of all UK centres providing fertility treatments and examined their websites. We listed fertility interventions offered in addition to standard IVF and ICSI and recorded statements about interventions that claimed or implied improvements in fertility in healthy women. We recorded which claims were quantified, and the evidence cited in support of the claims. Two reviewers extracted data from websites. We accessed websites from 21 December 2015 to 31 March 2016. Results: We found 233 websites for HFEA-registered fertility treatment centres, of which 152 (65%) were excluded as duplicates or satellite centres, 2 were andrology clinics and 5 were unavailable or under construction websites. In total, 74 fertility centre websites, incorporating 1401 web pages, were examined for claims. We found 276 claims of benefit relating to 41 different fertility interventions made by 60 of the 74 centres (median 3 per website; range 0 to 10). Quantification was given for 79 (29%) of the claims. 16 published references were cited 21 times on 13 of the 74 websites. Conclusions: Many fertility centres in the UK offer a range of treatments in addition to standard IVF procedures, and for many of these interventions claims of benefit are made. In most cases, the claims are not quantified and evidence is not cited to support the claims. There is a need for more information on interventions to be made available by fertility centres, to support well-informed treatment decisions. [ABSTRACT FROM AUTHOR]

Objectives: To audit the proportion of clinical trials that had been publically registered and, of the completed trials, the proportion published. Setting: 2 major research institutions supported by the National Institute of Health Research (NIHR). Primary and secondary outcome measures: The proportion of trials reporting results within 12 months, 24 months and 'ever'. Factors associated with nonpublication were analysed using logistic regression. Inclusion criteria: Phases 2-4 clinical trials identified from internal documents and publication lists. Results: In total, 286 trials were identified. We could not find registration for 4 (1.4%) of these, all of which were completed and published. Of the trials with a registered completion date pre-January 2015, just over half (56%) were published, and half of these were published within 12 months (36/147, 25%). For some trials, information on the public registers was found to be out-of-date and/or inaccurate. No clinical trial characteristics were found to be significantly associated with non-publication. We have produced resources to facilitate similar audits elsewhere. Conclusions: It was feasible to conduct an internal audit of registration and publication in 2 major research institutions. Performance was similar to, or better than, comparable cohorts of trials sampled from registries. The major resource input required was manually seeking information: if all registry entries were maintained, then almost the entire process of audit could be automated--and routinely updated--for all research centres and funders. [ABSTRACT FROM AUTHOR]

Background Depending on interest, knowledge, and skills, oncologists are adapting clinical behaviour to include integrative approaches, supporting patients to make informed complementary care decisions. The present study sought to improve the knowledge base in three ways: • Test the acceptability of a self-reported online survey for oncologists. • Provide preliminary data collection concerning knowledge, attitudes, beliefs, and current referral practices among oncologists with respect to yoga in adult cancer. • List the perceived benefits of and barriers to yoga intervention from a clinical perspective. Methods A 38-item self-report questionnaire was administered online to medical, radiation, and surgical oncologists in British Columbia. Results Some of the 29 oncologists who completed the survey (n = 10) reported having recommended yoga to patients to improve physical activity, fatigue, stress, insomnia, and muscle or joint stiffness. Other responding oncologists were hesitant or unlikely to suggest yoga for their patients because they had no knowledge of yoga as a therapy (n = 15) or believed that scientific evidence to support its use is lacking (n = 11). All 29 respondents would recommend that their patients participate in a clinical trial to test the efficacy of yoga. In qualitative findings, oncologists compared yoga with exercise and suggested that it might have similar psychological and physical health benefits that would improve patient capacity to endure treatment. Barriers to and limitations of yoga in adult cancer are also discussed. Conclusions An online self-report survey is feasible, but has response rate limitations. A small number of oncologists are currently recommending yoga to improve health-related outcomes in adult cancer. Respondents would support clinical yoga interventions to improve the evidence base in cancer patients, including men and women in all tumour groups. [ABSTRACT FROM AUTHOR]