Search

What Is Known About the Subject: Individuals with severe and enduring mental health challenges continued to consume mental health services for an average of 13 years as they needed multiple acute psychiatric admissions due to the challenges they experienced in their everyday activities. As caregivers of individuals with severe and enduring mental health challenges, they often bear the brunt of caregiving through their assistance with activities of daily living (ADL), providing emotional support and ensuring medication compliance for their loved ones. When caring for their loved ones, caregivers often reported psychological stress, social isolation and emotional exhaustion due to stressors such as uncertainty of the future, the lack of support from professional services and the isolation from their own social network and support mechanism., What the Paper Adds to Existing Knowledge: Insights from this study revealed that caregivers for individuals with severe and enduring mental health challenges went through a lonely and exhausting journey fraught with psychological, physical, social and financial challenges, echoing the caregiving needs and the prevalence of the caregiver burden., What Are the Implications for Practice: Insights shared by the caregivers demonstrated the need for a centralised point of contact to navigate Singapore's fragmented mental healthcare sector. Peer-support groups should be further promoted because they offer the benefits of information exchange, mutual support and a sense of empowerment and hopefulness, which may help ease the caregiver burden. Life skills training, such as teaching how to communicate empathetically with family members, resolve conflicts using open communication, maintain a structured daily routine and solve pragmatic problems in daily life, is more critical for individuals with severe and enduring mental health challenges. This will help them learn how to manage their well-being, live independently, and stabilise their conditions. Lastly, public awareness campaigns should honour caregivers by highlighting their strength, resilience, and dedication. The state can provide financial assistance in the form of tax relief for their income per annum or caregiver allowance to alleviate the financial stress that caregivers are facing., Abstract: Introduction The progressive deinstitutionalisation of mental healthcare has increasingly shifted care responsibilities from healthcare professionals to family caregivers for individuals with severe mental illness. Caregivers must balance many obligations, which often compromise their overall health and well-being, while helping their loved ones integrate into the community. Aim To identify and understand caregivers' needs and challenges as they help individuals with severe and enduring mental health challenges integrate into the community. Methods This study used a descriptive qualitative approach to explore the experiences and challenges of caregivers for individuals with severe and enduring mental health challenges when integrating back into the community. A semi-structured guide was used during the video-conferencing interviews conducted between December 2021 and November 2022. This study was reported according to the 32-item Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Findings Fourteen caregivers were individually interviewed by the primary author. Most caregivers were female, with an average of 15 years of experience caring for their loved ones. Using Braun and Clark's six-phase thematic framework, we inductively generate the themes and subthemes from the data. The two themes were (i) challenges (whose subthemes included personal challenges in caregiving, the lack of awareness, and stigma and employment) and (ii) support (whose subthemes included the importance of socialisation for individuals with mental health conditions, existing avenues of support and potential areas for support). Discussion Our findings informed the contemporary needs of caregivers caring for individuals with severe and enduring mental health challenges integrating into the community. Like the global challenges for people with mental health issues, psychosocial support and other supplementary support are still common themes in mental health settings. The findings further specifically highlighted the importance of accessible points of contact as resources and employment-enabling and sustaining initiatives to help manage caregivers' emotional and system challenges, which addresses the gaps identified in the findings. Caregivers' peer-support groups, life skills training and public mental health awareness are also necessitated by the caregivers' voices. Implications for Practice Priority areas include having a centralised point of contact within the community for caregivers. Government or not-for-profit organisations can take the lead by initiating employment-enabling initiatives for individuals with severe and enduring mental health challenges and their caregivers., (© 2024 John Wiley & Sons Ltd.)

Study Objectives: In coronary artery bypass grafting (CABG), abnormal cardiac repolarization is associated with adverse cardiovascular events that can be measured via the QTc interval. We investigated the impact of obstructive sleep apnea on the change in repolarization after CABG and the association of change in repolarization with the occurrence of major adverse cardiac and cerebrovascular events., Methods: A total of 1,007 patients from 4 hospitals underwent an overnight sleep study prior to a nonemergent CABG. Electrocardiograms of 954 patients (median age: 62 years; male: 86%; mean follow-up: 2.1 years) were acquired prospectively within 48 hours before CABG (T1) and within 24 hours after CABG (T2). QTc intervals were measured using the BRAVO algorithm by Analyzing Medical Parameters for Solutions LLC. The change in T2 from T1 for QTc (ΔQTc) was derived, and Cox regression was performed., Results: Compared with those without, patients who developed major adverse cardiac and cerebrovascular events (n = 115) were older and had (1) a higher prevalence of smoking, hypertension, diabetes mellitus, and chronic kidney disease; (2) a higher apnea-hypopnea index and oxygen desaturation index; and (3) a smaller ΔQTc. Cox regression analysis demonstrated a smaller ΔQTc to be an independent risk factor for major adverse cardiac and cerebrovascular events (hazard ratio: 0.997; P = .032). In the multivariable regression model, a higher oxygen desaturation index was independently associated with a smaller ΔQTc (correlation coefficient: -0.58; P < .001)., Conclusions: A higher preoperative oxygen desaturation index was an independent predictor of a smaller ΔQTc. ΔQTc within 24 hours after CABG could be a novel predictor of occurrence of major adverse cardiac and cerebrovascular events at medium-term follow-up., Clinical Trial Registration: Registry: ClinicalTrials.gov; Name: Undiagnosed Sleep Apnea and Bypass OperaTion (SABOT); URL: https://classic.clinicaltrials.gov/ct2/show/NCT02701504; Identifier: NCT02701504., Citation: Teo YH, Yong CL, Ou YH, et al. Obstructive sleep apnea and temporal changes in cardiac repolarization in patients undergoing coronary artery bypass grafting. J Clin Sleep Med . 2024;20(1):49-55., (© 2024 American Academy of Sleep Medicine.)

Globally, around half (55%) of the population live in fast-paced urban settings where many people find it challenging to manage their stress and respond to crises with a positive mindset. This resulted in prolonged distress where anxiety and fatigue caused physical and mental health concerns. Nature walks involving immersive exposure in the forest, and green spaces have been posited to offer physiological and psychological benefits. Therefore, in this systematic review, we evaluated the effects of forest bathing on psychological and physiological outcomes. We searched four English and five non-English databases (Chinese and Korean) for peer-reviewed studies published between January 2000 and March 2021. This review adhered to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analysis Statement 2020. The primary outcomes explored in this review were mainly psychological, including anxiety, depression, mood and quality of life. The secondary outcomes were physiological outcomes such as blood pressure and heart rate. We conducted a meta-analysis on each outcome using the random-effects model. Heterogeneity was assessed by the I 2 statistic. Thirty-six articles (21 in English, 3 in Chinese and 12 in Korean) with 3554 participants were included in this review. Our meta-analysis suggested that forest bathing can significantly reduce symptoms of depression and anxiety. However, we did not observe as many benefits in physiological outcomes. Against the background of the negative effects of urbanization on mental well-being, this review highlighted the potential therapeutic role of forests in the contemporary world, lending further evidence-based support for forest conservation., (© 2023 The Authors. International Journal of Mental Health Nursing published by John Wiley & Sons Australia, Ltd.)

Biomarkers are detectable molecules that can reflect specific physiological states of cells, organs, and organisms and therefore be regarded as indicators for specific diseases. And the discovery of biomarkers plays an essential role in cancer management from the initial diagnosis to the final treatment regime. Practically, reliable clinical biomarkers are still limited, restricted by the suboptimal methods in biomarker discovery. Nucleic acid aptamers nowadays could be used as a powerful tool in the discovery of protein biomarkers. Nucleic acid aptamers are single-strand oligonucleotides that can specifically bind to various targets with high affinity. As artificial ssDNA or RNA, aptamers possess unique advantages compared to conventional antibodies. They can be flexible in design, low immunogenicity, relative chemical/thermos stability, as well as modifying convenience. Several SELEX (Systematic Evolution of Ligands by Exponential Enrichment) based methods have been generated recently to construct aptamers for discovering new biomarkers in different cell locations. Secretome SELEX-based aptamers selection can facilitate the identification of secreted protein biomarkers. The aptamers developed by cell-SELEX can be used to unveil those biomarkers presented on the cell surface. The aptamers from tissue-SELEX could target intracellular biomarkers. And as a multiplexed protein biomarker detection technology, aptamer-based SOMAScan can analyze thousands of proteins in a single run. In this review, we will introduce the principle and workflow of variations of SELEX-based methods, including secretome SELEX, ADAPT, Cell-SELEX and tissue SELEX. Another powerful proteome analyzing tool, SOMAScan, will also be covered. In the second half of this review, how these methods accelerate biomarker discovery in various diseases, including cardiovascular diseases, cancer and neurodegenerative diseases, will be discussed., (© 2023. The Author(s).)

Objectives: This meta-analysis aims to evaluate the treatment outcomes of patients treated with Group cognitive behavioural therapy (GCBT) or group psychoeducation (GPE) as an adjunct to pharmacotherapy. Methods: Systematic search of PubMed, EMBASE, PsycINFO, and CENTRAL from inception till 1 March 2022 was conducted. Randomized-controlled-trials (RCTs) comparing GCBT/GPE with controls (treatment-as-usual/individualized therapy) in adults with bipolar disorder were eligible. The outcomes were relapse rates of any depressive or manic episodes and control of depressive and manic symptoms post-intervention. Overall odds-ratio was used to evaluate the relapse rates. Standard Mean Differences were pooled using a random-effects model for the control of depressive and manic symptoms. Results: 25 articles were assessed full-text independently by two members, and 11 studies were included in this meta-analysis. 601 and 590 participants were randomized into group-therapy (GCBT/GPE) and control, respectively. GPE significantly reduces relapse rates at post-intervention with Odds ratio of 0.43 (95% CI = 0.28-to-0.62, p < 0.0001) (I² = 41%) compared to control, however, no significant results were found for GPE on control of depressive or manic symptoms. No significant results were found for GCBT in all outcomes. Conclusion: This meta-analysis provides some evidence that GPE could be an efficacious treatment as an adjunct to treatment-as-usual in reducing the relapse rates of patients with bipolar disorder.

Study Objectives: Sleep apnea is prevalent in patients undergoing coronary artery bypass grafting (CABG). We investigated the relationship between sleep apnea and recurrent heart failure hospitalizations in patients undergoing nonurgent CABG., Methods: Between November 2013 and December 2018, 1,007 patients completed a sleep study prior to CABG and were followed up until April 2020. Recurrent heart failure hospitalizations were analyzed by Poisson, negative binomial, Andersen-Gill, and joint frailty models, with partial and full adjustment for covariates., Results: At an average follow-up of 3.3 years, the number of patients with 0, 1, or ≥ 2 heart failure hospitalizations were 908 (90.2%), 62 (6.2%), and 37 (3.7%), respectively. The total number of heart failure hospitalizations was 179, comprising 62 (35%) first and 117 (65%) repeat events. The numbers of heart failure hospitalizations for the sleep apnea (n = 513, 50.9%) and nonsleep apnea groups were 127 and 52, respectively. Negative binomial regression demonstrated that sleep apnea was associated with recurrent heart failure hospitalizations (fully adjusted rate ratio, 1.71; 95% confidence interval [CI], 1.12-2.62; P = .013). Similar results were found in Poisson (1.63; 95% CI, 1.15-2.31; P = .006), Andersen-Gill (1.66; 95% CI, 1.01-2.75; P = .047), and joint frailty models (1.72; 95% CI, 1.00-3.01; P = .056)., Conclusions: In patients after CABG, repeat events accounted for two-thirds of heart failure hospitalizations. Sleep apnea was independently associated with recurrent heart failure hospitalizations., Citation: Teo YH, Tam WT, Koo C-Y, et al. Sleep apnea and recurrent heart failure hospitalizations after coronary artery bypass grafting. J Clin Sleep Med . 2021;17(12):2399-2407., (© 2021 American Academy of Sleep Medicine.)

Despite the increased awareness of mental health-related issues, people experiencing mental health conditions have continued to face stigmatization worldwide. The literature on help-seeking behaviours has frequently highlighted the development of self-stigma because of public stigma and emphasized the need to address public stigmatization faced by them. Given the increasing acceptance of digital services in recent years, this systematic review aimed to examine the effects of online and face-to-face anti-stigma interventions in reducing public stigma towards people experiencing mental health conditions. A search was conducted on the Cochrane Library, CINAHL, PubMed, Embase, PsycInfo, and ProQuest from inception of the databases to October 2020. Studies were included in this review if they have explored: (i) public stigmatization towards people of all ages with different types of mental health conditions; (ii) online interventions; and (iii) face-to-face interventions. Nine studies were included in this review, of which only five were included in the meta-analysis as the remaining four had incomplete data. The meta-analysis included an aggregate of 1203 participants while the four excluded studies included 713 participants. Results revealed that online interventions performed favourably with small effect sizes in comparison to face-to-face, wait-list control, and no-intervention groups. Results from the studies excluded from the meta-analysis also found a significant reduction of public stigmatization with online interventions. Such findings provide insightful evidence for the effectiveness of online interventions in reducing public stigmatization. Hence, mental health organizations and groups can consider adopting online interventions suitable for their target audience and type of mental health conditions., (© 2021 The Authors. International Journal of Mental Health Nursing published by John Wiley & Sons Australia, Ltd.)

Background: Functional near-infrared spectroscopy (fNIRS) is an emerging neuroimaging modality that provides a direct and quantitative assessment of cortical haemodynamic response during a cognitive task. It may be used to identify neurophysiological differences between psychiatric disorders with overlapping symptoms, such as bipolar disorder (BD) and borderline personality disorder (BPD). Hence, this preliminary study aimed to compare the cerebral haemodynamic function of healthy controls (HC), patients with BD and patients with BPD., Methods: Twenty-seven participants (9 HCs, 9 patients with BD and 9 patients with BPD) matched for age, gender, ethnicity and education were recruited. Relative oxy-haemoglobin and deoxy-haemoglobin changes in the frontotemporal cortex was monitored with a 52-channel fNIRS system during a verbal fluency task (VFT). VFT performance, clinical history and symptom severity were also noted., Results: Compared to HCs, both patient groups had lower mean oxy-haemoglobin in the frontotemporal cortex during the VFT. Moreover, mean oxy-haemoglobin in the left inferior frontal region is markedly lower in patients with BPD compared to patients with BD. Task performance, clinical history and symptom severity were not associated with mean oxy-haemoglobin levels., Conclusions: Prefrontal cortex activity is disrupted in patients with BD and BPD, but it is more extensive in BPD. These results provide further neurophysiological evidence for the separation of BPD from the bipolar spectrum. fNIRS could be a potential tool for assessing the frontal lobe function of patients who present with symptoms that are common to BD and BPD.

The relative and combined effects of sleep apnea with diabetes mellitus (DM) on cardiovascular outcomes in patients undergoing coronary artery bypass grafting (CABG) remain unknown. In this secondary analysis of data from the SABOT study, 1007 patients were reclassified into four groups based on their sleep apnea and DM statuses, yielding 295, 218, 278, and 216 patients in the sleep apnea (+) DM (+), sleep apnea (+) DM (-), sleep apnea (-) DM (+), and sleep apnea (-) DM (-) groups, respectively. After a mean follow-up period of 2.1 years, the crude incidence of major adverse cardiac and cerebrovascular event was 18% in the sleep apnea (+) DM (+), 11% in the sleep apnea (+) DM (-), 13% in the sleep apnea (-) DM (+), and 5% in the sleep apnea (-) DM (-) groups. Using sleep apnea (-) DM (-) as the reference group, a Cox regression analysis indicated that sleep apnea (+) and DM (+) independently predicted MACCEs (adjusted hazard ratio, 3.2; 95% confidence interval, 1.7-6.2; p = 0.005) and hospitalization for heart failure (adjusted hazard ratio, 12.6; 95% confidence interval, 3.0-52.3; p < 0.001). Sleep apnea and DM have independent effects on the prognosis of patients undergoing CABG.Clinical trial registration: ClinicalTrials.gov identification no. NCT02701504.

Background: Neurobiological feedback in surgical training could translate to better educational outcomes such as measures of learning curve. This work examined the variation in brain activation of medical students when performing laparoscopic tasks before and after a training workshop, using functional near-infrared spectroscopy (fNIRS)., Methods and Procedures: This single blind randomised controlled trial examined the prefrontal cortex activity (PFCA) differences in two groups of novice medical students during the acquisition of four laparoscopic tasks. Both groups were shown a basic tutorial video, with the "Trained-group" receiving an additional standardised one-to-one training on the tasks. The PFCA was measured pre- and post-intervention using a portable fNIRS device and reported as mean total oxygenated hemoglobin (HbOµm). Primary outcome of the study is the difference in HbOµm between post- and pre-intervention readings for each of the four laparoscopic tasks. The pre- and post-intervention laparoscopic tasks were recorded and assessed by two blinded individual assessors for objective scores of the performance., Results: 16 Trained and 16 Untrained, right-handed medical students with an equal sex distribution and comparable age distribution were recruited. Trained group had an attenuated left PFCA in the "Precision cutting" (p = 0.007) task compared to the Untrained group. Subgroup analysis by sex revealed attenuation in left PFCA in Trained females compared to Untrained females across two laparoscopic tasks: "Peg transfer" (p = 0.005) and "Precision cutting" (p = 0.003). No significant PFCA attenuation was found in male students who underwent training compared to Untrained males., Conclusion: A standardised laparoscopic training workshop promoted greater PFCA attenuation in female medical students compared to males. This suggests that female and male students respond differently to the same instructional approach. Implications include a greater focus on one-to-one surgical training for female students and use of PFCA attenuation as a form of neurobiological feedback in surgical training.

Objectives: Although cognitive behavioural therapy for insomnia (CBT-I) has been recommended the initial therapy for insomnia, its clinical usage remains limited due to the lack of therapists. Digital CBT-I (dCBT-I) can potentially circumvent this problem. This meta-analysis aims to evaluate the short-term and long-term efficacy of dCBT-I for adults with insomnia., Methods: Systematic search of PubMed, EMBASE, PsycINFO, and CENTRAL from inception till 5 March 2020 was conducted. Randomised controlled trials (RCTs) comparing dCBT-I with controls (wait-list/treatment-as-usual/online education) in adults with insomnia were eligible. The primary outcome was insomnia severity index (ISI) at post-intervention, short-term follow-up (ranging 4 weeks to 6 months) and 1-year follow-up. Mean differences were pooled using the random-effects model., Results: 94 articles were assessed full-text independently by two team members and 33 studies were included in this meta-analysis. 4719 and 4645 participants were randomised to dCBT-I and control respectively. dCBT-I significantly reduces ISI at post-intervention with mean difference -5.00 (95% CI -5.68 to -4.33, p < 0.0001) (I 2  = 79%) compared to control. The improvements were sustained at short-term follow-up, -3.99 (95% CI -4.82 to -3.16, p < 0.0001) and 1-year follow-up, -3.48 (95% CI -4.21 to -2.76, p < 0.0001). Compared to dCBT-I, face-to-face CBT-I produced greater improvement in ISI, 3.07 (95% CI 1.18 to 4.95, p = 0.001). However, this was within the non-inferiority interval of 4 points on ISI., Conclusion: This meta-analysis provides strong support for the effectiveness of dCBT-I in treating insomnia. dCBT-I has potential to revolutionise the delivery of CBT-I, improving the accessibility and availability of CBT-I content for insomnia patients worldwide., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: Patients with advanced coronary artery disease are referred for coronary artery bypass grafting (CABG) and it remains unknown if sleep apnoea is a risk marker. We evaluated the association between sleep apnoea and major adverse cardiac and cerebrovascular events (MACCE) in patients undergoing non-emergent CABG., Methods: This was a prospective cohort study conducted between November 2013 and December 2018. Patients from four public hospitals referred to a tertiary cardiac centre for non-emergent CABG were recruited for an overnight sleep study using a wrist-worn Watch-PAT 200 device prior to CABG., Results: Among the 1007 patients who completed the study, sleep apnoea (defined as apnoea-hypopnoea index ≥15 events per hour) was diagnosed in 513 patients (50.9%). Over a mean follow-up period of 2.1 years, 124 patients experienced the four-component MACCE (2-year cumulative incidence estimate, 11.3%). There was a total of 33 cardiac deaths (2.5%), 42 non-fatal myocardial infarctions (3.7%), 50 non-fatal strokes (4.9%) and 36 unplanned revascularisations (3.2%). The crude incidence of MACCE was higher in the sleep apnoea group than the non-sleep apnoea group (2-year estimate, 14.7% vs 7.8%; p=0.002). Sleep apnoea predicted the incidence of MACCE in unadjusted Cox regression analysis (HR 1.69; 95% CI 1.18 to 2.43), and remained statistically significant (adjusted HR 1.57; 95% CI 1.09 to 2.25), after adjustment for age, sex, body mass index, left ventricular ejection fraction, diabetes mellitus, hypertension, chronic kidney disease and excessive daytime sleepiness., Conclusion: Sleep apnoea is independently associated with increased MACCE in patients undergoing CABG., Trial Registration Number: NCT02701504., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Aims: Excessive use of electronic devices has become a major global problem. However, little is known about the development and current landscape of research concerning this field. This study aimed at exploring the overall publication trend and topics of research on the overuse of electronic devices and the Internet from 1971 to 2017., Methods: We systematically searched the Web of Science (WoS) and Scopus databases for published articles on the excessive use of electronic devices and the Internet. Data regarding the publication volume, international collaborations, and geographical locations were analyzed by bibliometrics analysis. Latent Dirichlet Allocation (LDA) was undertaken to categorize publications into different research topics., Results: A total of 2,276 papers from the WOS and 600 papers from the Scopus were included. We found a dramatic increase in the number of scientific papers towards addiction to electronic devices and the Internet. The United State led in all publication parameters including the total number of papers and total citations. China, Korea and Taiwan were among the most prolific countries/regions. Smartphone addiction was the main concern, and the relationship between the overuse of electronic devices and the Internet and mental health issues have been highlighted. On the other hand, our study found a limited appearance of discussion on effective treatment and intervention., Discussion and Conclusion: The findings of this study call for more national and international cooperation in evaluating and intervening addiction to electronic devices and the Internet to gather more knowledge about this phenomenon and evaluate the effectiveness of treatment.

Reduced haemodynamic response in the frontotemporal cortices of patients with major depressive disorder (MDD) has been demonstrated using functional near-infrared spectroscopy (fNIRS). Most notably, changes in cortical oxy-haemoglobin during a Japanese phonetic fluency task can differentiate psychiatric patients from healthy controls (HC). However, this paradigm has not been validated in the English language. Therefore, the present work aimed to distinguish patients with MDD from HCs, using haemodynamic response measured during an English letter fluency task. One hundred and five HCs and 105 patients with MDD took part in this study. NIRS signals during the verbal fluency task (VFT) was acquired using a 52-channel system, and changes in oxy-haemoglobin in the frontal and temporal regions were quantified. Depression severity, psychosocial functioning, pharmacotherapy and psychiatric history were noted. Patients with MDD had smaller changes in oxy-haemoglobin in the frontal and temporal cortices than HCs. In both regions of interest, oxy-haemoglobin was not associated with any of the clinical variables studied. 75.2% and 76.5% of patients with MDD were correctly classified using frontal and temporal region oxy-haemoglobin, respectively. Haemodynamic response measured by fNIRS during an English letter fluency task is a promising biomarker for MDD.

Background: Functional near infrared spectroscopy (fNIRS) provides a direct and quantitative assessment of cortical haemodynamic function during a cognitive task. This functional neuroimaging modality may be used to elucidate the pathophysiology of psychiatric disorders, and identify neurophysiological differences between co-occurring psychiatric disorders. However, fNIRS research on borderline personality disorder (BPD) has been limited. Hence, this study aimed to compare cerebral haemodynamic function in healthy controls (HC), patients with major depressive disorder (MDD) and patients with BPD., Methods: fNIRS signals during a verbal fluency task designed for clinical assessment was recorded for all participants. Demographics, clinical history and symptom severity were also noted., Findings: Compared to HCs (n = 31), both patient groups (MDD, n = 31; BPD, n = 31) displayed diminished haemodynamic response in the frontal, temporal and parietal cortices. Moreover, haemodynamic response in the right frontal cortex is markedly lower in patients with MDD compared to patients with BPD., Interpretation: Normal cortical function in patients with BPD is disrupted, but not as extensively as in patients with MDD. These results provide further neurophysiological evidence for the distinction of patients with MDD from patients with BPD., Competing Interests: Declaration of competing interest None., (Copyright © 2019 The Author(s). Published by Elsevier B.V. All rights reserved.)

: The purpose of our study was to carry out a meta-analysis of current literature to determine whether total mastectomy and breast-conserving surgery induce different outcomes in quality of life, based on the breast-cancer-specific module of the European Organizaation for Research and Treatment of Cancer core questionnaire (EORTC QLQ-BR23) used postoperatively. A systematic literature search of PubMed and EMBASE was conducted. Observational clinical studies that compared the quality of life in different surgery groups and presented empirical findings were selected. Six studies met the inclusion criteria. Breast-conserving surgery has statistically significant better outcomes than mastectomy in three of the eight outcomes measured in the EORTC QLQ-BR23, namely body image (standard mean difference, SMD = 1.742, 95% CI 0.579-2.905, p = 0.003), future perspective (SMD = 0.606, 95% CI 0.075-1.138, p = 0.025) and systemic therapy side effects (SMD = -0.641, 95% CI 0.101-1.181, p = 0.020). Our study highlighted that breast-conserving surgery was preferred over mastectomy because breast-conserving surgery leads to better outcomes in body image, future perspectives and less systemic side effects., Competing Interests: The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the result.

Objective: The aim of this meta-analysis was to examine the efficacy of cognitive behavioral therapy (CBT) for hemodialysis patients with comorbid depression and to identify which other aspects, including anxiety and quality of life, can be improved through intervention., Methods: A systematic literature review was performed using multiple databases (PubMed, EMBase, PsycINFO, CENTRAL). The inclusion criteria included randomized controlled trials (RCTs) of CBT conducted in hemodialysis patients with depression. Study reporting quality was assessed with the Cochrane tool and Review Manager version 5.3 was used to obtain pooled results., Results: Eight RCTs, with a total sample size of 540 participants, met the inclusion criteria. Compared with control groups, the CBT groups had statistically significant improvements in depression (standardized mean differences [SMD] = -0.68, 95% confidence interval [CI] (-0.94 to -0.42), P < .001), anxiety (SMD = -0.99, 95%CI (-1.99 to 0.00), P = .05) and quality of life (SMD = 0.34, 95%CI (0.13 to 0.54), P < .001)., Conclusions: The results of this meta-analysis showed that CBT could have an effective role in reducing symptoms of depression and anxiety as well as improving quality of life in hemodialysis patients with comorbid depression., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Anxiety, although as common and arguably as debilitating as depression, has garnered less attention, and is often undetected and undertreated in the general population. Similarly, anxiety among medical students warrants greater attention due to its significant implications. We aimed to study the global prevalence of anxiety among medical students and the associated factors predisposing medical students to anxiety. In February 2019, we carried out a systematic search for cross-sectional studies that examined the prevalence of anxiety among medical students. We computed the aggregate prevalence and pooled odds ratio (OR) using the random-effects model and used meta-regression analyses to explore the sources of heterogeneity. We pooled and analyzed data from sixty-nine studies comprising 40,348 medical students. The global prevalence rate of anxiety among medical students was 33.8% (95% Confidence Interval: 29.2-38.7%). Anxiety was most prevalent among medical students from the Middle East and Asia. Subgroup analyses by gender and year of study found no statistically significant differences in the prevalence of anxiety. About one in three medical students globally have anxiety-a prevalence rate which is substantially higher than the general population. Administrators and leaders of medical schools should take the lead in destigmatizing mental illnesses and promoting help-seeking behaviors when students are stressed and anxious. Further research is needed to identify risk factors of anxiety unique to medical students., Competing Interests: The authors declare no conflict of interest.

Background: Major Depressive Disorder (MDD) is the most common psychiatric disorder with high prevalence and disease burden. Biological treatments of MDD over the last several decades include a wide range of antidepressants and neurostimulation therapies. While recent meta-analyses have explored the efficacy and tolerability of antidepressants, the changing trends of biological treatments have not been evaluated. Our study measured the indices of change, expectations, and popularity of biological treatments of MDD between 1988 and 2017., Methods: We performed a scientometric analysis to identify all relevant publications related to biological treatments of MDD from 1988 to 2017. We searched the Web of Science websites for publications from 1 January 1988 to 31 December 2017. We included publications of fluoxetine, paroxetine, citalopram, sertraline, amitriptyline, fluvoxamine, escitalopram, venlafaxine, duloxetine, milnacipran, desvenlafaxine, levomilnacipran, clomipramine, nortriptyline, bupropion, trazodone, nefazodone, mirtazapine, agomelatine, vortioxetine, vilazodone, electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), vagus nerve stimulation (VNS), deep brain stimulation (DBS), and transcranial direct current stimulation (tDCS). We excluded grey literature, conference proceedings, books/book chapters, and publications with low quality as well as publications not related to medicine or human health. The primary outcomes assessed were indices of change, expectations, and popularity., Results: Of 489,496 publications identified, we included 355,116 publications in this scientometric analysis. For the index of change, fluoxetine, sertraline and ECT demonstrated a positive index of change in 6 consecutive periods. Other neurostimulation therapies including rTMS, VNS, DBS and tDCS had shown a positive index of change since 1998. We calculated the index of change of popularity index (PI), which indicates that from 2013 to 2017, the number of publications on tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) were reduced by 85.0% and 81.3% respectively, as compared with the period 2008-2012. For the index of expectation, fluoxetine and ECT showed the highest index of expectations in six consecutive periods and remained the highest in 2013-2017. For popularity, the three antidepressants with highest PI were fluoxetine (4.01), paroxetine (2.09), and sertraline (1.66); the three antidepressants with lowest PI were desvenlafaxine (0.08), vilazodone (0.04) and levomilnacipran (0.03). Among neurostimulation therapies, ECT has the highest PI (2.55), and tDCS the lowest PI (0.14). The PI of SSRI remained the highest among all biological treatments of MDD in 2013-2017. In contrast, the PI of ECT was reduced by approximately 50% during the period 2008 to2012 than that in the period 2013 to 2017., Conclusions: This scientometric analysis represents comprehensive evidence on the popularity and change in prospects of biological treatments for MDD from 1988 to 2017. The popularity of SSRI peaked between 1998 and 2002, when their efficacy, tolerability and safety profile allowed them to replace the TCAs and MAOIs. While the newer neurostimulation therapies are gaining momentum, the popularity of ECT has sustained.

The burnout syndrome is characterized by emotional exhaustion, depersonalization, and reduced personal achievement. Uncertainty exists about the prevalence of burnout among medical and surgical residents. Associations between burnout and gender, age, specialty, and geographical location of training are unclear. In this meta-analysis, we aimed to quantitatively summarize the global prevalence rates of burnout among residents, by specialty and its contributing factors. We searched PubMed, PsycINFO, Embase, and Web of Science to identify studies that examined the prevalence of burnout among residents from various specialties and countries. The primary outcome assessed was the aggregate prevalence of burnout among all residents. The random effects model was used to calculate the aggregate prevalence, and heterogeneity was assessed by I 2 statistic and Cochran's Q statistic. We also performed meta-regression and subgroup analysis. The aggregate prevalence of burnout was 51.0% (95% CI: 45.0-57.0%, I 2 = 97%) in 22,778 residents. Meta-regression found that the mean age (β = 0.34, 95% CI: 0.28-0.40, p < 0.001) and the proportion of males (β = 0.4, 95% CI = 0.10-0.69, p = 0.009) were significant moderators. Subgroup analysis by specialty showed that radiology (77.16%, 95% CI: 5.99-99.45), neurology (71.93%, 95% CI: 65.78-77.39), and general surgery (58.39%, 95% CI: 45.72-70.04) were the top three specialties with the highest prevalence of burnout. In contrast, psychiatry (42.05%, 95% CI: 33.09-51.58), oncology (38.36%, 95% CI: 32.69-44.37), and family medicine (35.97%, 95% CI: 13.89-66.18) had the lowest prevalence of burnout. Subgroup analysis also found that the prevalence of burnout in several Asian countries was 57.18% (95% CI: 45.8-67.85); in several European countries it was 27.72% (95% CI: 17.4-41.11) and in North America it was 51.64% (46.96-56.28). Our findings suggest a high prevalence of burnout among medical and surgical residents. Older and male residents suffered more than their respective counterparts.

As the number of migrants worldwide increases, it is worthwhile to examine the extent to which depression has affected this group of often vulnerable individuals. The purpose of this systematic review and meta-analysis is to examine the aggregate prevalence of depression among international migrants and to explore the variations in prevalence with demographic and educational factors. A search was conducted on the online databases PubMed and ScienceDirect whole using the terms "depression", "depressive disorder", "immigration", "immigrant", "migration", and "migrant". A total of 25 studies met our inclusion criteria. A random-effects model meta-analysis calculated an aggregate prevalence of 15.6% among migrants. Heterogeneity was identified by meta-regression and subgroup analyses, and the level of educational attainment, employment status, and length of residency spent in country of migration were found to be significant moderators contributing to depression prevalence. In conclusion, newly arrived migrants appear to be susceptible to developing depression and it is imperative that more in the form of preventive strategies and increased assistance be incorporated to ensure their psychological wellbeing and improve their mental health outcomes. Further research should be conducted to better understand the risk of psychiatric disorders among members of this subpopulation.

Objectives : This meta-analysis aims to study the effects of atomoxetine and methylphenidate on heart rate (HR), systolic blood pressure (SBP), and a number of adverse cardiac events on patients receiving treatment for attention-deficit hyperactive disorder (ADHD) in comparison to placebo and between atomoxetine and methylphenidate. Methods : We searched the following databases: PubMed, EMBASE, and ScienceDirect. Meta-analysis was performed on studies that examined the relationships between methylphenidate or atomoxetine and HR, SBP, as well as a number of adverse cardiac events. These studies were either placebo-controlled or comparison studies between methylphenidate and atomoxetine. Meta-regression identified patient- and treatment-related factors that may contribute to heterogeneity. Results : Twenty-two studies were included and the total number of participants was 46,107. Children/adolescents and adults treated with methylphenidate had more significant increases in post- vs. pre-treatment HR (p < 0.001) and SBP (p < 0.001) than those treated by placebo. Children and adolescents treated with atomoxetine had more significant increases post- vs. pre-treatment HR (p = 0.025) and SBP (p < 0.001) than those treated with methylphenidate. Meta-regression revealed mean age of participants, mean dose, and duration of atomoxetine and methylphenidate as significant moderators that explained heterogeneity. There were no differences in the number of adverse cardiac events between participants with methylphenidate treatment and placebo or atomoxetine., Conclusions: Children/adolescents and adults treated with methylphenidate resulted in significant increases in post- vs. pre-treatment HR and SBP as compared to placebo. Similarly, children and adolescents treated with atomoxetine had significant increases in post- vs. pre-treatment HR and SBP than those treated with methylphenidate. These findings have potential implications for continuous monitoring of HR and SBP throughout the course of treatment although the risk for adverse cardiac events were insignificant., Competing Interests: The authors declare no conflict of interest.

We carried out systematic review and meta-analysis to evaluate whether peripheral levels of pro-inflammatory markers including Interleukin-1 beta (IL-1β), Interleukin-6 (IL-6), Tumor Necrosis Factor-α (TNF- α) and C-Reactive Protein (CRP) are significantly higher in elderly with depression and Alzheimer's disease. We searched Pubmed, PsycINFO and Embase, and thirty-four relevant studies (2609 with Depression, 1645 with Alzheimer's disease and 14363 Controls) were included. Compared with controls, IL-1β (pooled standardized mean difference [SMD]: 0.642; 95% confidence interval [CI]: 0.078-1.206; significant heterogeneity: I 2  = 86.28%) and IL-6 (pooled SMD: 0.377; 95% CI: 0.156-0.598; significant heterogeneity: I 2  = 88.75%) were significantly elevated in depression. There was no difference in TNF-α (p = 0.351) and CRP (p = 0.05) between those with depression and controls. Compared with controls, IL-1β (pooled SMD: 1.37, 95% CI: 0.06-2.68, significant heterogeneity: I 2  = 96.01%) was significantly elevated in Alzheimer's disease. There were no differences in IL-6 (p = 0.138), TNF-α (p = 0.451) and CRP (p = 0.07) between elderly with Alzheimer's disease and controls. After Bonferroni adjustment, only IL-6 remained significantly higher in depression. Elderly with depression have higher IL-6 than controls, while those with Alzheimer's disease did not have higher peripheral inflammatory markers.

Introduction : Major Depressive Disorder (MDD) is a common psychiatric disorder. Currently, there is no objective, cost-effective and non-invasive method to measure biological markers related to the pathogenesis of MDD. Previous studies primarily focused on urinary metabolite markers which are not proximal to the pathogenesis of MDD. Herein, we compare urinary monoamines, steroid hormones and the derived ratios amongst MDD when compared to healthy controls. Methods : Morning urine samples of medicated patients suffering from MDD ( n = 47) and healthy controls ( n = 41) were collected. Enzyme-linked immunosorbent assay (ELISA) was performed to measure five biomarkers: cortisol, dopamine, noradrenaline, serotonin and sulphate derivative of dehydroepiandrosterone (DHEAS). The mean urinary levels and derived ratios of monoamines and steroid hormones were compared between patients and controls to identify potential biomarkers. The receiver operative characteristic curve (ROC) analysis was conducted to evaluate the diagnostic performance of potential biomarkers. Results : Medicated patients with MDD showed significantly higher spot urine ratio of DHEAS/serotonin (1.56 vs. 1.19, p = 0.004) and lower ratio of serotonin/dopamine (599.71 vs. 888.60, p = 0.008) than healthy controls. A spot urine serotonin/dopamine ratio cut-off of >667.38 had a sensitivity of 73.2% and specificity of 51.1%. Conclusions : Our results suggest that spot urine serotonin/dopamine ratio can be used as an objective diagnostic method for adults with MDD.

The prevalence of depression may be affected by changes in psychiatric practices and the availability of online mental health information in the past two decades. This study aimed to evaluate the aggregate prevalence of depression in communities from different countries between 1994 and 2014 and to explore the variations in prevalence stratified by geographical, methodological and socio-economic factors. A total of 90 studies were identified and met the inclusion criteria (n = 1,112,573 adults) with 68 studies on single point prevalence, 9 studies on one-year prevalence, and 13 studies on lifetime prevalence of depression. A random-effects model meta-analysis that was performed to calculate the aggregate point, one-year and lifetime prevalence of depression calculated prevalences of 12.9%, 7.2% and 10.8% respectively. Point prevalence of depression was significantly higher in women (14.4%), countries with a medium human development index (HDI) (29.2%), studies published from 2004 to 2014 (15.4%) and when using self-reporting instruments (17.3%) to assess depression. Heterogeneity was identified by meta-regression and subgroup analysis, and response rate, percentage of women and year of publication, respectively, were determined contribute to depression prevalence. This meta-analysis allows benchmarking of the prevalence of depression during the era when online health information emerged, facilitating future comparisons.

Objective: To provide a comprehensive picture of mental health problems (MHPs) in Brazilian medical students by documenting their prevalence and association with co-factors., Methods: We systematically searched the MEDLINE/PubMed, SciELO, LILACS, and PsycINFO databases for cross-sectional studies on the prevalence of MHPs among medical students in Brazil published before September 29, 2016. We pooled prevalences using a random-effects meta-analysis, and summarized factors associated with MHP., Results: We included 59 studies in the analysis. For meta-analyses, we identified the summary prevalence of different MHPs, including depression (25 studies, prevalence 30.6%), common mental disorders (13 studies, prevalence 31.5%), burnout (three studies, prevalence 13.1%), problematic alcohol use (three studies, prevalence 32.9%), stress (six studies, prevalence 49.9%), low sleep quality (four studies, prevalence 51.5%), excessive daytime sleepiness (four studies, prevalence 46.1%), and anxiety (six studies, prevalence 32.9%). Signs of lack of motivation, emotional support, and academic overload correlated with MHPs., Conclusion: Several MHPs are highly prevalent among future physicians in Brazil. Evidence-based interventions and psychosocial support are needed to promote mental health among Brazilian medical students.

Background: Due to a rapidly ageing population in the world, it is increasingly pertinent to promote successful ageing strategies which are cost-effective, easily accessible, and more likely to be acceptable to the elderly. Past research associates exposure to natural environments and horticultural therapy (HT) with positive psychological, social and physical health benefits. This Randomized Controlled Trial (RCT) is designed to evaluate the efficacy of HT in promoting Asian elderly' mental health, cognitive functioning and physical health., Methods/design: 70 elderly participants aged 60 to 85 years old will be randomized to participate in either the active horticultural therapy group or be in the waitlist control. Sessions will be weekly for 12 weeks, and monthly for 3 months. Mental health will be assessed through self-reports of depressive and anxiety symptomatology, life satisfaction, social connectedness and psychological well-being, collaborated with immunological markers. Outcome measures of cognitive functioning and physical health include neuropsychological tests of cognitive function and basic health screening. Outcomes will be assessed at baseline, 3 months and 6 months post-intervention., Discussion: This RCT comprehensively investigates the efficacy of a non-invasive intervention, HT, in enhancing mental health, cognitive functioning and physical health. The results have tremendous potential for supporting future successful ageing programs and applicability to larger populations., Trial Registration: ClinicalTrials.gov NCT02495194 . Trial registration date: July 13, 2015. Retrospectively registered.

Comparisons of home-based versus hospital-based approach in managing patients with suspected obstructive sleep apnoea syndrome(OSAS). A prospective, controlled CPAP parallel study of new referrals with suspected OSAS randomized into group A) home-based or B) hospital-based approach. Following detection of AHI ≥ 15/hr by Embletta sleep study (group A) or polysomnography (group B), patients received CPAP for 3 months after an overnight autoCPAP titration at home or in hospital respectively. Modified intention-to-treat analysis of those with AHI ≥ 15/hr on CPAP (n = 86 vs 86) showed no difference in Epworth sleepiness score, the primary endpoint, but greater improvement in Sleep-Apnoea-Quality-of-Life-Index[difference 0.3,(95%CI 0.02, 0.6), p = 0.033] at 3 months in group A. The mean costs for the patients in group A and group B were HK$8479(989) and HK$22,248(2407) respectively. The mean difference between groups was HK$-13,769(USD 1770 equivalent) per patient with 95% CI. (-14324, -13213), p < 0.001. The waiting time of patients with AHI ≥ 15/hr who were started on CPAP treatment from the first clinic consultation to the diagnostic sleep test, autoCPAP titration, and CPAP treatment was 189.6, 148.8 and 145.0 days shorter in group A than group B respectively. Home-based approach is non-inferior to hospital-based approach in managing patients with suspected OSAS, with shorter waiting time, and substantial cost savings.

Objective: Systematic reviews (SRs) often poorly report key information, thereby diminishing their usefulness. Previous studies evaluated published SRs and determined that they failed to meet explicit criteria or characteristics. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was recommended as a reporting guideline for SR and meta-analysis (MA), but previous studies showed that adherence to the statement was not high for SRs published in different medical fields. Thus, the aims of this study are twofold: (1) to investigate the number of nursing journals that have required or recommended the use of the PRISMA statement for reporting SR, and (2) to examine the adherence of SRs and/or meta-analyses to the PRISMA statement published in nursing journals., Design: A cross-sectional study., Methods: Nursing journals listed in the ISI journal citation report were divided into 2 groups based on the recommendation of PRISMA statement in their 'Instruction for Authors'. SRs and meta-analyses published in 2014 were searched in 3 databases. 37 SRs and meta-analyses were randomly selected in each group. The adherence of each item to the PRISMA was examined and summarised using descriptive statistics. The quality of the SRs was assessed by Assessing the Methodological Quality of Systematic Reviews. The differences between the 2 groups were compared using the Mann-Whitney U test., Results: Out of 107 nursing journals, 30 (28.0%) recommended or required authors to follow the PRISMA statement when they submit SRs or meta-analyses. The median rates of adherence to the PRISMA statement for reviews published in journals with and without PRISMA endorsement were 64.9% (IQR: 17.6-92.3%) and 73.0% (IQR: 59.5-94.6%), respectively. No significant difference was observed in any of the items between the 2 groups., Conclusions: The median adherence of SRs and meta-analyses in nursing journals to PRISMA is low at 64.9% and 73.0%, respectively. Nonetheless, the adherence level of nursing journals to the PRISMA statement does not significantly vary whether they endorse or recommend such a guideline., Competing Interests: Conflicts of Interest: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Compression-only cardiopulmonary resuscitation (CPR) has been advocated as a preferable approach for bystanders in an out-of-hospital cardiac arrest (OHCA) event as it has been associated with an increased chance of survival. The elimination of mouth-to-mouth ventilation also addresses some of the barriers to performing CPR. The aim of this study is to undertake a literature review investigating the effectiveness of compression-only CPR in improving rescuers' CPR performance when compared with standard CPR., Methods: A literature search was conducted in the following databases: Cumulative Index to Nursing and Allied Health Literature, Science Direct, Scopus and PubMed from January 2003 to January 2014, to include research studies that compared compression-only CPR with standard CPR on participants above the age of 21, and reported quality of CPR performance as the primary outcome., Findings: Of the 3004 articles retrieved, 16 met the inclusion criteria. The reviewed studies revealed that compression-only CPR requires a shorter time to initiate CPR and delivers a higher number of total compressions. The depth of compressions in compression-only CPR performed may be shallower than that of standard CPR due to greater rescuer fatigue. It therefore remains inconclusive if compression-only CPR can deliver a higher number of adequate compressions over extended periods of time. It is also unclear if simplified CPR can improve skill retention level in the long run., Conclusions: More studies are needed to determine whether compression-only CPR can indeed help improve rescuers' CPR performance. Future research efforts, together with resuscitation policy and practice implications, are needed to further improve rescuers' CPR performance with the ultimate goal to enhance OHCA survival rates., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Quantum key distribution (QKD) provides an attractive means for securing communications in optical fibre networks. However, deployment of the technology has been hampered by the frequent need for dedicated dark fibres to segregate the very weak quantum signals from conventional traffic. Up until now the coexistence of QKD with data has been limited to bandwidths that are orders of magnitude below those commonly employed in fibre optic communication networks. Using an optimised wavelength divisional multiplexing scheme, we transport QKD and the prevalent 100 Gb/s data format in the forward direction over the same fibre for the first time. We show a full quantum encryption system operating with a bandwidth of 200 Gb/s over a 100 km fibre. Exploring the ultimate limits of the technology by experimental measurements of the Raman noise, we demonstrate it is feasible to combine QKD with 10 Tb/s of data over a 50 km link. These results suggest it will be possible to integrate QKD and other quantum photonic technologies into high bandwidth data communication infrastructures, thereby allowing their widespread deployment.

Background: Major international guidelines do not offer explicit recommendations on any specific angiotensin-converting enzyme inhibitor (ACEI) agent over another within the same drug group. This study compared the effectiveness of lisinopril vs. perindopril in reducing the incidence of hospital admission due to all-cause, cardiovascular disease and respiratory disease., Methods: Adult patients who received new prescriptions of lisinopril or perindopril from 2001 to 2005 in all public hospitals and clinics in Hong Kong were included, and followed up for ≥2years. The incidence of admissions due to all-cause, cardiovascular disease and respiratory disease were evaluated, respectively, by using Cox proportional hazard regression models. The regression models were constructed with propensity score matching to minimize indication biases., Results: A total of 20,252 eligible patients with an average age of 64.5years (standard deviation 15.0) were included. The admission rate at 24months within the date of index prescription due to any cause, cardiovascular disease and respiratory disease among lisinopril vs. perindopril users was 24.8% vs. 24.8%, 13.7% vs. 14.0% and 6.9% vs. 6.3%, respectively. Lisinopril users were significantly more likely to be admitted due to respiratory diseases (adjusted hazard ratios [AHR]=1.25, 95% CI 1.08 to 1.43, p=0.002 at 12months; AHR=1.17, 95% CI 1.04 to 1.31, p=0.009 at 24months) and all causes (AHR=1.12, 95% CI 1.05 to 1.19, p<0.001 at 24months) than perindopril users., Conclusions: These findings support intra-class differences in the effectiveness of ACEIs, which could be considered by clinical guidelines when the preferred first-line antihypertensive drugs are recommended., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

An open-label trial on intravenous peramivir was conducted among adult patients hospitalised for influenza-associated lower respiratory tract complications (LRTCs). Virus culture and quantitative reverse transcription PCR (qRT-PCR) were performed serially until Day 10. Peramivir treatment was associated with viral RNA decline as well as culture and RNA negativity, which occurred at rates comparable with those of oseltamivir: by Day 5, viral load decline -2.5 log10 copies/mL [βinteraction -0.071, standard error (SE) 0.121, 95% confidence interval (CI) -0.309 to 0.167]; culture-negative, 94% (vs. 95%); and RNA-negative, 44% (vs. 36%). Extended treatment of >5 days was required in 69% of cases because of slow clinical resolution and viral clearance in LRTCs. Peramivir was well tolerated. These data are useful for future trial design in this unique population., (Copyright © 2016 Elsevier B.V. and International Society of Chemotherapy. All rights reserved.)

Background: Tai Chi, a systematic callisthenic exercise first developed in ancient China, involves a series of slow and rhythmic circular motions. It emphasises use of 'mind' or concentration to control breathing and circular body motions to facilitate flow of internal energy (i.e. 'qi') within the body. Normal flow of 'qi' is believed to be essential to sustain body homeostasis, ultimately leading to longevity. The effect of Tai Chi on balance and muscle strength in the elderly population has been reported; however, the effect of Tai Chi on dyspnoea, exercise capacity, pulmonary function and psychosocial status among people with chronic obstructive pulmonary disease (COPD) remains unclear., Objectives: • To explore the effectiveness of Tai Chi in reducing dyspnoea and improving exercise capacity in people with COPD.• To determine the influence of Tai Chi on physiological and psychosocial functions among people with COPD., Search Methods: We searched the Cochrane Airways Group Specialised Register of trials (which included the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Allied and Complementary Medicine Database (AMED) and PsycINFO); handsearched respiratory journals and meeting abstracts; and searched Chinese medical databases including Wanfang Data, Chinese Medical Current Contents (CMCC), Chinese Biomedical Database (CBM), China Journal Net (CJN) and China Medical Academic Conference (CMAC), from inception to September 2015. We checked the reference lists of all primary studies and review articles for relevant additional references., Selection Criteria: We included randomised controlled trials (RCTs) comparing Tai Chi (Tai Chi alone or Tai Chi in addition to another intervention) versus control (usual care or another intervention identical to that used in the Tai Chi group) in people with COPD. Two independent review authors screened and selected studies., Data Collection and Analysis: Two independent review authors extracted data from included studies and assessed risk of bias on the basis of suggested criteria listed in the Cochrane Handbook for Systematic Reviews of Interventions. We extracted post-programme data and entered them into RevMan software (version 5.3) for data synthesis and analysis., Main Results: We included a total of 984 participants from 12 studies (23 references) in this analysis. We included only those involved in Tai Chi and the control group (i.e. 811 participants) in the final analysis. Study sample size ranged from 10 to 206, and mean age ranged from 61 to 74 years. Programmes lasted for six weeks to one year. All included studies were RCTs; three studies used allocation concealment, six reported blinded outcome assessors and three studies adopted an intention-to-treat approach to statistical analysis. No adverse events were reported. Quality of evidence of the outcomes ranged from very low to moderate.Analysis was split into three comparisons: (1) Tai Chi versus usual care; (2) Tai Chi and breathing exercise versus breathing exercise alone; and (3) Tai Chi and exercise versus exercise alone.Comparison of Tai Chi versus usual care revealed that Tai Chi demonstrated a longer six-minute walk distance (mean difference (MD) 29.64 metres, 95% confidence interval (CI) 10.52 to 48.77 metres; participants = 318; I(2) = 59%) and better pulmonary function (i.e. forced expiratory volume in one second, MD 0.11 L, 95% CI 0.02 to 0.20 L; participants = 258; I(2) = 0%) in post-programme data. However, the effects of Tai Chi in reducing dyspnoea level and improving quality of life remain inconclusive. Data are currently insufficient for evaluating the impact of Tai Chi on maximal exercise capacity, balance and muscle strength in people with COPD. Comparison of Tai Chi and other interventions (i.e. breathing exercise or exercise) versus other interventions shows no superiority and no additional effects on symptom improvement nor on physical and psychosocial outcomes with Tai Chi., Authors' Conclusions: No adverse events were reported, implying that Tai Chi is safe to practise in people with COPD. Evidence of very low to moderate quality suggests better functional capacity and pulmonary function in post-programme data for Tai Chi versus usual care. When Tai Chi in addition to other interventions was compared with other interventions alone, Tai Chi did not show superiority and showed no additional effects on symptoms nor on physical and psychosocial function improvement in people with COPD. With the diverse style and number of forms being adopted in different studies, the most beneficial protocol of Tai Chi style and number of forms could not be commented upon. Hence, future studies are warranted to address these topics.

Purpose: Public stigma is an important barrier to the recovery of patients with psychosis. This study aimed to explore public stigma associated with a newly adopted Chinese name for psychosis 'si-jue-shi-tiao' in a representative Chinese population in Hong Kong, focusing on factors contributing to public stigma. Exposure to mass media and its relationship with the stigma were explored in detail., Methods: Random telephone survey of general population in Hong Kong was conducted. Information including basic demographics, psychosis literacy, recent news recall about psychosis and stigma, measured with the revised Link's Perceived Discrimination-Devaluation Scale (LPDDS) were obtained. Univariate analysis of LPDDS score and demographic variables, news exposure, previous contacts with people with psychosis and knowledge about psychosis were conducted. Further hierarchical regression analysis was performed., Results: A total of 1,016 subjects were interviewed. The sample was comparable with the whole Hong Kong population aged 18 years and above. Those of female gender, with higher educational level and better knowledge about symptoms and treatment of psychosis had higher score of LPDDS. The model significantly explained 8.3% of variance of LPDDS score (F(7, 895) = 12.606, p < .0001, p < .0001). The negative news recall had trend significance in the model., Conclusion: The finding suggested that discrimination among the general public against people with psychosis was still common. Specific strategies will need to be established in targeting media news reporting about psychosis, knowledge disseminating and needs of specific population. Further researches should be conducted to understand the mechanisms of the stigma development in relation to these factors so that more focused and effective strategies could be developed., (© The Author(s) 2015.)

The aim of the study was to examine how well aggregate data meta-analyses (ADMAs) and individual patient data meta-analyses (IPDMAs) agree in their overall results and how frequently interactions are detected in IPDMAs and ADMAs.ADMA articles immediately published before the IPDMA and matching the research topic were identified. Agreement in the overall result was achieved if the estimate was in the same direction. The number of subgroup analyses, in particular that of significant interactions, was compared between the 2 types of meta-analyses.A total of 829 IPDMA articles were identified; 129 (15.6%) were found to have a matched ADMA article and 204 paired meta-analyses were identified. Agreement in the overall effect was observed in 187 (91.7%) of the 204 paired meta-analyses. Fifty-three (26.0%) ADMAs and 121 (59.3%) IPDMAs conducted subgroup analyses and presented 150 and 634 subgroup analyses, respectively. The IPDMAs conducted 7 times more subgroup analyses on interaction (544 in IPDMAs vs 68 in ADMAs) and identified 14 times more potential interactions (44 in IPDMAs vs 3 in ADMAs).ADMAs will almost always agree with their corresponding IPDMAs in the overall result if greater efforts are made to improve the methodology in conducting ADMAs. The IPDMA is required mostly if interactions are suspected., Competing Interests: The authors report no conflicts of interest to disclose.

Context: Medical schools are known to be stressful environments for students and hence medical students have been believed to experience greater incidences of depression than others. We evaluated the global prevalence of depression amongst medical students, as well as epidemiological, psychological, educational and social factors in order to identify high-risk groups that may require targeted interventions., Methods: A systematic search was conducted in online databases for cross-sectional studies examining prevalences of depression among medical students. Studies were included only if they had used standardised and validated questionnaires to evaluate the prevalence of depression in a group of medical students. Random-effects models were used to calculate the aggregate prevalence and pooled odds ratios (ORs). Meta-regression was carried out when heterogeneity was high., Results: Findings for a total of 62 728 medical students and 1845 non-medical students were pooled across 77 studies and examined. Our analyses demonstrated a global prevalence of depression amongst medical students of 28.0% (95% confidence interval [CI] 24.2-32.1%). Female, Year 1, postgraduate and Middle Eastern medical students were more likely to be depressed, but the differences were not statistically significant. By year of study, Year 1 students had the highest rates of depression at 33.5% (95% CI 25.2-43.1%); rates of depression then gradually decreased to reach 20.5% (95% CI 13.2-30.5%) at Year 5. This trend represented a significant decline (B = - 0.324, p = 0.005). There was no significant difference in prevalences of depression between medical and non-medical students. The overall mean frequency of suicide ideation was 5.8% (95% CI 4.0-8.3%), but the mean proportion of depressed medical students who sought treatment was only 12.9% (95% CI 8.1-19.8%)., Conclusions: Depression affects almost one-third of medical students globally but treatment rates are relatively low. The current findings suggest that medical schools and health authorities should offer early detection and prevention programmes, and interventions for depression amongst medical students before graduation., (© 2016 John Wiley & Sons Ltd.)

Bronchoscopy is considered a stressful procedure performed on patients. Hence, the use of music to ease the anxiety of patients has been examined in various studies, but the results have been inconclusive. The aim of this review is to synthesize the findings of previous studies on the effects of music therapy on the physiological outcomes of patients undergoing bronchoscopy. An electronic database search was performed to identify the literature. Random-effects model was used to combine the results, and meta-regression was used to explore the heterogeneity. Seven studies with 829 subjects were included. Results showed that the combined mean differences (95% confidence interval) for systolic and diastolic blood pressure were -11.99 (-15.82, -6.57) and -4.84 (-7.78, -1.90) mm Hg, respectively, whereas that for heart rate was -10.57 (-16.63, -4.51) beats per minute. In conclusion, listening to music reduced blood pressure and heart rate among patients undergoing bronchoscopy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Neuropsychiatric systemic lupus erythematosus (NPSLE) is one of the most devastating presentations of SLE and comprises of psychiatric, central and peripheral neurological signs and symptoms. Previous studies suggest the possible associations between various autoantibodies (Abs) and NPSLE. The magnitudes of such association varied between studies. We performed a meta-analysis to pool data on serum and cerebrospinal fluid (CSF) levels and positivity of Abs in blood and cerebrospinal fluid in patients with NPSLE and SLE. A systematic literature search was conducted to identify studies that fulfilled inclusion criteria. A random-effects model was used to calculate overall combined odd ratio (OR) and mean levels with its corresponding 95% confidence interval to evaluate the relationship between individual Abs and NPSLE patients relative to SLE patients. Forty-one studies met the inclusion criteria and were used in this analysis. There was a significantly greater proportion of NPSLE patients who demonstrated positivity for serum anti-cardiolipin (aCL) Abs (OR=1.63, p=0.016), lupus anticoagulants (LA) Abs (OR=1.91 p=0.01), anti-phospholipid (APL) Abs (OR=2.08, p=0.001), anti-ribosomal P Abs (OR=2.29, p<0.001), anti-neuronal Abs (OR=9.50, p<0.001) as compared to SLE patients. In NPSLE patients, there was a significant increased prevalence of positive titres for CSF anti-neuronal Abs (OR=36.84, p=0.001) as compared to SLE patients. Among the 19 neuropsychiatric syndromes, the positivity of these serum autoantibodies were found specifically significantly associated with the manifestations of mood disorder, psychosis, cerebrovascular disease, seizure disorders, acute confusional state, cognitive dysfunction, headache, movement disorder, demyelinating syndrome and polyneuropathy, with ORs ranging from 1.84 to 4.73. Meta-regression identified proportion of women as significant moderator for the heterogeneity of aCL (p=0.004) and anti-neuronal Abs (p=0.0007); mean age for the heterogeneity of aCL (p=0.042) and LA (p=0.020) Abs, mean duration of illness for the heterogeneity of aCL Abs (p=0.035), and mean SLEDAI scores for the heterogeneity of anti-ribosomal P Abs (p=0.014). NPSLE patients are more likely to have elevated serum levels of aCL, LA, APL, anti-ribosomal P Abs and anti-neuronal Abs compared with SLE patients. Further research is required to evaluate the accuracy of using the above antibodies as an adjunct diagnostic tool in NPSLE., (Copyright © 2015 Elsevier B.V. All rights reserved.)

We aimed to study factors influencing outcomes of adults hospitalised for seasonal and pandemic influenza.  Individual-patient data from three Asian cohorts (Hong Kong, Singapore and Beijing; N=2649) were analysed. Adults hospitalised for laboratory-confirmed influenza (prospectively diagnosed) during 2008-2011 were studied. The primary outcome measure was 30-day survival. Multivariate Cox regression models (time-fixed and time-dependent) were used. Patients had high morbidity (respiratory/nonrespiratory complications in 68.4%, respiratory failure in 48.6%, pneumonia in 40.8% and bacterial superinfections in 10.8%) and mortality (5.9% at 30 days and 6.9% at 60 days). 75.2% received neuraminidase inhibitors (NAI) (73.8% received oseltamivir and 1.4% received peramivir/zanamivir; 44.5% of patients received NAI ≤2 days and 65.5% ≤5 days after onset of illness); 23.1% received systemic corticosteroids. There were fewer deaths among NAI-treated patients (5.3% versus 7.6%; p=0.032). NAI treatment was independently associated with survival (adjusted hazard ratio (HR) 0.28, 95% CI 0.19-0.43), adjusted for treatment-propensity score and patient characteristics. Superinfections increased (adjusted HR 2.18, 95% CI 1.52-3.11) and chronic statin use decreased (adjusted HR 0.44, 95% CI 0.23-0.84) death risks. Best survival was shown when treatment started within ≤2 days (adjusted HR 0.20, 95% CI 0.12-0.32), but there was benefit with treatment within 3-5 days (adjusted HR 0.35, 95% CI 0.21-0.58). Time-dependent analysis showed consistent results of NAI treatment (adjusted HR 0.39, 95% CI 0.27-0.57). Corticosteroids increased superinfection (9.7% versus 2.7%) and deaths when controlled for indications (adjusted HR 1.73, 95% CI 1.14-2.62). Early NAI treatment was associated with shorter length of stay in a subanalysis. NAI treatment may improve survival of hospitalised influenza patients; benefit is greatest from, but not limited to, treatment started within 2 days of illness. Superinfections and corticosteroids increase mortality. Antiviral and non-antiviral management strategies should be considered., (Copyright ©ERS 2015.)

Background: Percutaneous coronary intervention (PCI) is a standard treatment for coronary heart disease (CHD). Restenosis, defined as a 50% reduction in luminal diameter at six months after PCI, indicates a need for revascularisation. Restenosis has proven to be a major drawback to PCI. Tong-xin-luo is one of the prophylactic strategies for cardiovascular events in patients after PCI that is widely used in China, but its efficacy and safety have not been systematically evaluated., Objectives: To systematically assess the efficacy and safety of Tong-xin-luo capsules in preventing cardiovascular events after PCI in patients with CHD., Search Methods: We searched the Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE (OVID), EMBASE (OVID), WanFang, Chinese Biomedical Database, Chinese Medical Current Contents, and China National Knowledge Infrastructure from their inception to June 2014. We also searched other resources, including ongoing trials and research registries. We applied no language restrictions., Selection Criteria: Randomised controlled trials of participants with CHD after PCI were included. Participants in the intervention group received Tong-xin-luo capsules for at least three months., Data Collection and Analysis: Two review authors independently extracted data and assessed the risk of bias. Any disagreements were resolved by discussion with a third review author. The primary outcomes included occurrence of angiographic restenosis and adverse events; the secondary outcomes included myocardial infarction, heart failure, angina, all cause mortality, mortality due to any cardiovascular event, use of revascularisation, patient acceptability, quality of life and cost-effectiveness. Dichotomous data were measured with risk ratios (RRs) with 95% confidence intervals (CIs)., Main Results: Sixteen studies involving 1063 participants were identified. The risk of bias for fifteen studies was high and along with imprecision and possible publication bias, this lowered our confidence in the results. There was low quality evidence that Tong-xi-luo reduced the rates of angiographic restenosis (RR 0.16, 95% CI 0.07 to 0.34), myocardial infarction (RR 0.32, 95% CI 0.16 to 0.66), heart failure (RR 0.26, 95% CI 0.11 to 0.62), and use of revascularisation (RR 0.26, 95% CI 0.15 to 0.45). There was very low quality evidence for the effect of Tong-xin-luo on all-cause mortality (RR 0.38, 95% CI 0.06 to 2.56), angina (RR 0.24, 95% CI 0.17 to 0.34) and death due to any cardiovascular event (RR 0.31, 95% CI 0.08 to 1.12). Adverse events were seldom reported, and included gastrointestinal reactions and nausea., Authors' Conclusions: The addition of Tong-xin-luo to conventional Western medicine may possibly prevent restenosis and recurrence of cardiovascular events in patients with CHD after PCI. However, the data are limited by publication bias and high risk of bias for included studies. Further high-quality trials are required to evaluate the potential effects of this intervention.

Childhood obesity is a global public health issue, including in the Chinese setting, and its prevalence has increased dramatically throughout the last decade. Since the origins of childhood obesity may lie in the pre-school period, factors relating to very young children's food consumption should be investigated. Parental influence, including feeding style, is the major determinant of childhood dietary behaviour through altering food provision and social environment. However, the applicability of previous research on parental feeding styles was limited by small sample size. To evaluate the influence of parental feeding styles on children's dietary patterns, a cross-sectional study was conducted among 4553 pre-schoolers in Hong Kong. Information was obtained about dietary intake and how regularly they had breakfast, using previous health surveillance surveys taken among primary school students. Parental feeding styles were assessed by a validated Parental Feeding Style Questionnaire and categorized into 'instrumental feeding', 'emotional feeding', 'prompting and encouragement to eat' and 'control over eating'. Multivariable analysis was performed, adjusted for demographic information. Instrumental and/or emotional feeding was found to relate to inadequate consumption of fruit, vegetables and breakfast, and positively correlated with intake of high-energy-density food. Encouragement on eating was associated with more frequent consumption of fruits, vegetables, dairy products and breakfast. Control over eating correlated with more frequent consumption of fruits, vegetables and breakfast, and less consumption of dairy products and high-energy-density food. The present study has provided evidence on the associations between parental feeding styles and dietary patterns of Hong Kong pre-school children from a reasonably large population. Parents should avoid instrumental and emotional feeding, and implement control and encouragement to promote healthy food intake. Longitudinal studies and interventions on parental feeding style are required to confirm the research findings.

Patient experience reflects quality of care from the patients' perspective; therefore, patients' experiences are important data in the evaluation of the quality of health services. The development of an abbreviated, reliable and valid instrument for measuring inpatients' experience would reflect the key aspect of inpatient care from patients' perspective as well as facilitate quality improvement by cultivating patient engagement and allow the trends in patient satisfaction and experience to be measured regularly. The study developed a short-form inpatient instrument and tested its ability to capture a core set of inpatients' experiences. The Hong Kong Inpatient Experience Questionnaire (HKIEQ) was established in 2010; it is an adaptation of the General Inpatient Questionnaire of the Care Quality Commission created by the Picker Institute in United Kingdom. This study used a consensus conference and a cross-sectional validation survey to create and validate a short-form of the Hong Kong Inpatient Experience Questionnaire (SF-HKIEQ). The short-form, the SF-HKIEQ, consisted of 18 items derived from the HKIEQ. The 18 items mainly covered relational aspects of care under four dimensions of the patient's journey: hospital staff, patient care and treatment, information on leaving the hospital, and overall impression. The SF-HKIEQ had a high degree of face validity, construct validity and internal reliability. The validated SF-HKIEQ reflects the relevant core aspects of inpatients' experience in a hospital setting. It provides a quick reference tool for quality improvement purposes and a platform that allows both healthcare staff and patients to monitor the quality of hospital care over time.

Background: Optimal adherence with antihypertensive medications is crucial to prevent hypertension-related complications. This study evaluated whether the duration of initial antihypertensive prescription is associated with better medication adherence in a large sample of Chinese hypertensive patients., Methods and Results: From a validated clinical database which consists of all patients in the public healthcare sector in Hong Kong, all patients on their first-ever antihypertensive agent from 2001 to 2005 (N=203,259) were included and followed-up for 12 months (and up to 5 years in separate analyses). The average age was 58.7 years (SD 17.3), and the overall rate of optimal adherence (as measured by having the Proportion of Days Covered≥0.80) was 32.4%. The proportion of patients whose initial prescriptions lasted for ≤6 days; 7-14 days; 15-28 days and ≥29 days was 23.7%, 24.3%, 15.1% and 37.0%, respectively. The corresponding proportion of optimal adherence was 18.1%, 20.1%, 31.0% and 50.3%. The binary logistic regression analysis showed that after controlling for age, sex, socioeconomic status, service type, drug class, and district of residence, those whose initial prescription was 7-14 days (adjusted odds ratio [AOR]=1.17, 95% C.I. 1.12-1.22); 15-28 days (AOR=1.90, 95% C.I. 1.82-1.99) and ≥29 days (AOR=4.13, 95% C.I. 3.96-4.31) were significantly more likely to be adherent than those who were prescribed for ≤6 days (all p<0.001). These findings remained significant in separate analyses where the period of follow-up was extended to 5 years., Conclusions: Shorter duration of first antihypertensive prescriptions was associated with poorer medication adherence, and this practice should be avoided if possible., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Current evidence is mixed regarding the association between antihypertensive prescriptions and cancer mortality. We evaluated this association in a large Chinese hypertensive population. We followed for five years all patients who were prescribed their first-ever antihypertensive agents between 2001 and 2005 in a public healthcare sector of Hong Kong. The association between antihypertensive drug class and cancer mortality was evaluated by Cox proportional hazard models with propensity score matching. Age, gender, socioeconomic status, service settings, district of residence, proportion of days covered reflecting medication adherence, and the number of comorbidities were adjusted. From 217,910 eligible patients, 9500 (4.4%) died from cancer within five years after their first-ever antihypertensive prescription. Most cancer deaths occurred in the digestive (38.9%) and respiratory system (30.4%); the breast (6.2%); and the lympho-hematopoietic tissues (5.3%). The proportion of patients who died from cancer was the highest in the calcium channel blocker (CCB) group (6.5%), followed by thiazide diuretics (4.4%), angiotensin converting enzyme inhibitors (4.2%) and β-blockers (2.6%). When compared with β-blockers, patients prescribed CCBs (Adjusted Hazard Ratio [AHR]=1.406, 95% C.I. 1.334-1.482, p<0.001) were more likely to die from cancer. Thiazide users were also more likely to suffer from cancer deaths (AHR=1.364, 95% C.I. 1.255-1.483, p<0.001), but became insignificant in stratified analysis. The association between cancer mortality and use of CCB, and perhaps thaizide, may alert physicians to the need for more meticulous and comprehensive care of these patients in clinical practice. We recommend prospective studies to evaluate cause-and-effect relationships of these associations., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Lisinopril and perindopril are two commonly used first-line antihypertensive agents. Few studies compared their effectiveness in reducing the incidence of renal diseases and diabetes., Methods: Adult patients who received new prescriptions of lisinopril or perindopril from 2001 to 2005 in all public hospitals and clinics in Hong Kong were included, and followed up for at least 2 years. Patients prescribed the angiotensin converting enzyme inhibitors (ACEIs) for <1 month were excluded. The incidence of admissions due to renal diseases and diabetes was evaluated. We used Cox proportional hazard regression models to assess hospital admissions as the outcome measures, adjusting for age, sex, socioeconomic status, service types, and the proportion of days covered as a measure of medication adherence. The regression models were constructed with propensity score matching to minimize indication biases., Results: 20,252 eligible patients with an average age of 64.5 years (SD 15.0) were included. The admission rates 24 months within the date of index prescription due to renal diseases were 3.1% (lisinopril) and 2.3% (perindopril); and 9.6% (lisinopril) and 7.2% (perindopril) for diabetes. Except for admissions due to diabetes at 6 months, lisinopril users were significantly more likely to be admitted due to renal diseases (adjusted hazard ratios: 1.304 to 1.378) and diabetes (1.146 to 1.231) than perindopril users at all time points., Conclusions: Patients prescribed different ACEIs might have a different incidence of hospital admissions. Future studies should be conducted to evaluate the comparative effectiveness of different ACEIs on various patient-centered outcomes by head-to-head randomized controlled trials., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: A meta-analysis may provide more conclusive results than a single trial. The major cost of meta-analysis is the time of waiting before the meta-analysis becomes available and resources spent on consequent trials that may not be necessary. The objective of this study is to address how often the result of a single trial, in particular the first trial, differs from that of its corresponding meta-analysis so as to reduce unnecessary waiting time and subsequent trials., Study Design and Settings: A meta-epidemiologic study was conducted by collecting meta-analyses from the Cochrane Database of Systematic Reviews and five major medical journals. Effect size of a single trial was compared with that of its corresponding meta-analysis. The single trial includes the first trial, last trial and any trial randomly selected from the meta-analysis., Results: 647 meta-analyses are included and the median number of trials in a meta-analysis is 5. 233 (36.0%) meta-analyses have the first trial with a statistically significant result. When the first trial is statistically significant, 84.1% (95% CI: 79.4%, 88.8%) of the corresponding meta-analyses is both in the same direction and statistically significant. When the first trial is statistically insignificant, 57.9% (95% CI: 53.2%, 62.8%) of the meta-analysis is also statistically insignificant regardless of direction. The median number of years is 6.5 years from the first to the 5th trial., Conclusion: The conclusion of the first trial that the treatment is effective or harmful is mostly likely correct. A statistically significant trial agrees more often with its corresponding meta-analysis than a large trial. These findings imply that particularly in some urgent, life-saving or other critical circumstances for which no other effective methods are available, cautious recommendation based on the significant result of the first trial seems justifiable and could start use of an effective intervention by 5-8 years earlier.

Background: Perindopril and lisinopril are two common ACE inhibitors prescribed for management of hypertension. Few studies have evaluated their comparative effectiveness to reduce mortality. This study compared the all-cause and cardiovascular related mortality among patients newly prescribed ACE inhibitors., Methods: All adult patients newly prescribed perindopril or lisinopril from 2001 to 2005 in all public clinics or hospitals in Hong Kong were retrospectively evaluated, and followed up until 2010. Patients prescribed the ACE inhibitors for less than a month were excluded. The all-cause mortality and cardiovascular-specific (i.e. coronary heart disease, heart failure and stroke) mortality were compared. Cox proportional hazard regression model was used to assess the mortality, controlling for age, sex, socioeconomic status, patient types, the presence of comorbidities, and medication adherence as measured by the proportion of days covered. An additional model using propensity scores was performed to minimize indication bias., Results: A total of 15,622 patients were included in this study, in which 6910 were perindopril users and 8712 lisinopril users. The all-cause mortality (22.2% vs. 20.0%, p<0.005) and cardiovascular mortality (6.5% vs. 5.6%, p<0.005) were higher among lisinopril users than perindopril users. From regression analyses, lisinopril users were 1.09-fold (95% C.I. 1.01-1.16) and 1.18-fold (95% C.I. 1.02-1.35) more likely to die from any-cause and cardiovascular diseases, respectively. Age-stratified analysis showed that this significant difference was observed only among patients aged >70 years. The additional models controlled for propensity scores yielded comparable results., Conclusions: The long-term all-cause and cardiovascular related mortality rates of lisinopril users was significantly different from those of perindopril users. These findings showed that intra-class variation on mortality exists among ACE inhibitors among those aged 70 years or older. Future studies should consider a longer, large-scale randomized controlled trial to compare the effectiveness between different medications in the ACEI class, especially among the elderly., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

This study evaluated whether short term exposures to NO2, O3, particulate matter <10 mm in diameter (PM10) were associated with higher risk of mortality. A total of 223,287 hypertensive patients attended public health-care services and newly prescribed at least 1 antihypertensive agent were followed-up for up to 5 years. A time-stratified, bi-directional case-crossover design was adopted. For all-cause mortality, significant positive associations were observed for NO2 and PM10 at lag 0-3 days per 10 μg/m(3) increase in concentration (excess risks 1.187%-2.501%). Significant positive associations were found for O3 at lag 1 and 2 days and the excess risks were 1.654% and 1.207%, respectively. We found similarly positive associations between these pollutants and respiratory disease mortality. These results were significant among those aged ≥65 years and in cold seasons only. Older hypertensive patients are susceptible to all-cause and respiratory disease-specific deaths from these air pollutants in cold weather., (Copyright © 2014 Elsevier Ltd. All rights reserved.)