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New England Journal of Medicine, Volume 388, Issue 9, Page 841-842, March 2023.

Since 1999, the US suicide rate has increased by more than 30%. Numerous studies have demonstrated that suicide mortality is elevated among people with cancer, especially cancers with lower 5-year survival. In this issue of JAMA Oncology, Potter et al report that patients who underwent surgery for cancers with lower 5-year survival also died of suicide much sooner than patients with less deadly cancers, implicating the importance of screening patients with cancer for psychiatric conditions and suicide risk. In addition, the data highlight the importance of ensuring access to evidence-based psychological and behavioral treatments both before and after cancer surgery. Approximately 1 in 6 patients have a preexisting psychiatric condition. Apart from an association with suicide mortality, psychiatric conditions can adversely affect a range of outcomes, including increased perioperative complications, longer hospital stays, higher rates of readmission, and increased risk of postoperative suicidal ideation. Preoperative or perioperative treatment of psychiatric conditions may therefore lead to improved outcomes.

This Medical News feature discusses a new federal strategic plan to reduce homelessness in the US.

Pochi giorni fa governo danese ha ordinato abbattimenti in massa

Introduction
The health burden due to depression is ever increasing in the world. Prevention is a key to reducing this burden. Guided internet cognitive–behavioural therapies (iCBT) appear promising but there is room for improvement because we do not yet know which of various iCBT skills are more efficacious than others, and for whom. In addition, there has been no platform for iCBT that can accommodate ongoing evolution of internet technologies.

Methods and analysis
Based on our decade-long experiences in developing smartphone CBT apps and examining them in randomised controlled trials, we have developed the Resilience Training App Version 2. This app now covers five CBT skills: cognitive restructuring, behavioural activation, problem-solving, assertion training and behaviour therapy for insomnia. The current study is designed as a master protocol including four 2×2 factorial trials using this app (1) to elucidate specific efficacies of each CBT skill, (2) to identify participants’ characteristics that enable matching between skills and individuals, and (3) to allow future inclusion of new skills. We will recruit 3520 participants with subthreshold depression and ca 1700 participants without subthreshold depression, to examine the short-term efficacies of CBT skills to reduce depressive symptoms in the former and to explore the long-term efficacies in preventing depression in the total sample. The primary outcome for the short-term efficacies is the change in depressive symptoms as measured with the Patient Health Questionnaire-9 at week 6, and that for the long-term efficacies is the incidence of major depressive episodes as assessed by the computerised Composite International Diagnostic Interview by week 50.

Ethics and dissemination
The trial has been approved by the Ethics Committee of Kyoto University Graduate School of Medicine (C1556).

Trial registration number
UMIN000047124.

Objective
To describe the implementation and impact of the Getting it Right First Time (GIRFT) national orthopaedic improvement programme at the level of individual National Health Service (NHS) Trusts.

Design
Qualitative case studies conducted at six NHS Trusts, as part of a mixed-methods evaluation of GIRFT.

Setting
NHS elective orthopaedic surgery in England.

Participants
59 NHS staff.

Intervention
Improvement bundle, including bespoke routine performance data and improvement recommendations for each organisation, delivered via ‘deep-dive’ visits to NHS Trusts by a senior orthopaedic clinician.

Results
Although all case study sites had made improvements to care, very few of these were reportedly a direct consequence of GIRFT. A range of factors, operating at three different levels, influenced their ability to implement GIRFT recommendations: at the level of the orthopaedic team (micro—eg, how individuals perceived the intervention); the wider Trust (meso—eg, competition for theatre/bed space) and the health economy more broadly (macro—eg, requirements to form local networks). Some sites used GIRFT evidence to support arguments for change which helped cement and formalise existing plans. However, where GIRFT measures were not a Trust priority because of more immediate demands—for example, financial and bed pressures—it was less likely to influence change.

Conclusion
Dynamic relationships between the different contextual factors, within and between the three levels, can impact the effectiveness of a large-scale improvement intervention and may account for variations in implementation outcomes in different settings. When designing an intervention, those leading future improvement programmes should consider how it sits in relation to these three contextual levels and the interactions that may occur between them.

Objective
To examine whether increases in physician volume in primary healthcare facilities are associated with reduced utilisation of hospital outpatient and inpatient services after China facilitated the establishment of the hierarchical medical system.

Design
We used a two-way fixed-effects regression to examine the association between the annual number of physicians in primary healthcare facilities and that of patient visits per physician, inpatient admissions and total expenses per outpatient visit in public hospitals during 2010–2014 and 2015–2019. Variables were log transformed to ensure the normal distribution of the data.

Setting
Province-level data of all 31 provinces in mainland China from 2010 to 2019 were collected from the China Health Statistics Yearbook published by the China Health Commission.

Participants
All 31 provinces in mainland China.

Primary and secondary outcome measures
The annual number of outpatient visits per physician, hospital admission and total expenses per outpatient visit in public hospitals.

Results
During 2015–2019, we found that, on average, a 1% increase in the number of primary healthcare physicians was accompanied by a 0.19% (95% CI –0.33% to –0.05%) reduction in the annual number of visits per physician in public hospitals, and a 0.31% (95% CI –0.52% to –0.10%) reduction in patient visits in city-administered hospitals. No significant associations were found between 2010 and 2014. We also did not observe any significant associations between primary healthcare physician volume and hospital admissions or outpatient expenses during neither 2010–2014 and 2015–2019.

Conclusions
In the context of the hierarchical medical system, enhancing physician volume in primary healthcare facilities helps reduce outpatient visits in public hospitals, especially city-administered hospitals. However, more efforts are required to be continuously made to improve primary healthcare capacity to avoid preventable hospital admissions and outpatient expenses.

Objectives
Increasing access to mental health support is a key factor for treating mental disorders, however, important barriers complicate help-seeking, among them, mental health related stigma being most prominent. We aimed to systematically review the current evidence for interventions focusing on reducing stigma related to mental health problems in small and medium enterprises (SMEs).

Design
Systematic review with a focus on interventions targeting mental health related stigma in the workplace in accordance with PRISMA guidelines. The methodological quality of included articles was assessed using the Quality Assessment Tool for Quantitative Studies Scale.

Data sources
PubMed, Ovid Medline, PsycINFO, Scopus, and Cochrane databases and Google Scholar were searched from January 2010 until November 2022.

Eligibility criteria for selecting studies
We included experimental or quasi-experimental studies about workplace interventions aiming to reduce stigma, where the outcomes were measured in terms of stigmatisation against depression, anxiety and/or other mental health problems.

Data extraction and synthesis
Records were screened by two independent reviewers after inspecting titles and abstracts and a full-text read of the articles to assess whether they meet inclusion criteria. The results were synthesised narratively.

Results
We identified 22 intervention studies, 3 with high quality, 13 with moderate quality and 6 with weak quality. Only 2 studies included SMEs, but no study focused on SMEs exclusively . The mode of delivery of the intervention was face to face in 15 studies, online in 4 studies and mixed in 3 studies. We found a significant reduction in stigmatising attitudes in almost all studies (20/22), using 10 different instruments/scales. Effects seemed to be independent of company size. Online interventions were found to be shorter, but seemed to be as effective as face-to-face interventions.

Conclusions
Although we did not find interventions focusing exclusively on SMEs, it is likely that antistigma interventions also will work in smaller workplaces.

Trial registration
PROSPERO: ID: CRD42020191307

Objectives
Secondary distribution of HIV self-test (HIVST) kits from pregnant women attending antenatal care (ANC) to their male partners is shown to increase HIV couples testing and disclosure, and is being scaled up in sub-Saharan Africa. Understanding couples-level barriers and facilitators influencing HIVST uptake is critical to designing strategies to optimise intervention coverage.

Design
To investigate these couples-level barriers and facilitiators, we conducted focus group discussions and in-depth interviews. Transcripts were analysed thematically and the interdependence model of communal coping and health behaviour change was adapted to explore factors impacting HIVST acceptability.

Setting
We recruited pregnant women attending two public ANC clinics in Kampala, Uganda, and male partners of pregnant women between April 2019 and February 2020.

Participants
We conducted gender-stratified focus group discussions (N=14) and in-depth interviews (N=10) with pregnant women with and without HIV attending ANC, and male partners of pregnant women (N=122 participants).

Intervention
We evaluated pregnant women’s and male partners’ perceptions of HIVST secondary distribution in Uganda, leveraging the interdependence model of communal coping and health behaviour change.

Primary and secondary outcome measures
Key areas of focus included HIVST interest and acceptability, perspectives on HIV status disclosure to partners and gender roles.

Results
Participants felt that predisposing factors, including trust, communication, fear of partner and infidelity, would influence women’s decisions to deliver HIVST kits to partners, and subsequent communal coping behaviours such as couples HIV testing and disclosure. Pregnancy was described as a critical motivator for men’s HIVST uptake, while HIV status of pregnant women was influential in couples’ communal coping and health-enhancing behaviours. Generally, participants felt HIV-negative women would be more likely to deliver HIVST, while women with HIV would be more hesitant due to concerns about discovery of serodifference and relationship dissolution. Participants stressed the importance of counsellor availability throughout the process including guidance on how women should approach their partners regarding HIVST and post-test support in case of a positive test.

Conclusions
HIV-negative women in relationships with positive predisposing factors may be most likely to deliver HIVST and leverage interdependent coping behaviours. Women with HIV or those in relationships with negative predisposing factors may benefit from targeted counselling and disclosure support before and after HIVST kit distribution. Results can help support policy guidelines for HIVST kit distribution.

Introduction
The Early Detection of Deterioration in Elderly residents (EDDIE+) programme is a theory-informed, multi-component intervention aimed at upskilling and empowering nursing and personal care staff to identify and manage early signs of deterioration in residents of aged care facilities. The intervention aims to reduce unnecessary hospital admissions from residential aged care (RAC) homes. Alongside a stepped wedge randomised controlled trial, an embedded process evaluation will be conducted to assess the fidelity, acceptability, mechanisms of action and contextual barriers and enablers of the EDDIE+ intervention.

Methods and analysis
Twelve RAC homes in Queensland, Australia are participating in the study. A comprehensive mixed-methods process evaluation, informed by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, will assess intervention fidelity, contextual barriers and enablers, mechanisms of action, and the acceptability of the programme from various stakeholder perspectives. Quantitative data will be collected prospectively from project documentation, including baseline context mapping of participating sites, activity tracking and regular check-in communication sheets. Qualitative data will be collected postintervention via semi-structured interviews with a range of stakeholder groups. The i-PARIHS constructs of innovation, recipients, context and facilitation will be applied to frame the analysis of quantitative and qualitative data.

Ethics and dissemination
Ethical approval for this study has been granted by the Bolton Clarke Human Research Ethics Committee (approval number: 170031) with administrative ethical approval granted by the Queensland University of Technology University Human Research Ethics Committee (2000000618). Full ethical approval includes a waiver of consent for access to residents’ demographic, clinical and health services de-identified data. A separate health services data linkage based on RAC home addresses will be sought through a Public Health Act application. Study findings will be disseminated through multiple channels, including journal publications, conference presentations and interactive webinars with a stakeholder network.

Trial registration number
Australia New Zealand Clinical Trial Registry (ACTRN12620000507987).

Introduction
Newborns are at risk for early-onset sepsis (EOS). In the Netherlands, EOS affects less than 0.2% of newborns, but approximately 5% are treated with empirical antibiotics. These numbers form an example of overtreatment in countries using risk-factor based guidelines for administrating antibiotics. An alternative to these guidelines is the EOS calculator, a tool that calculates an individual EOS risk and provides management recommendation. However, validation outside the North-American setting is limited, especially for safety outcomes. We aim to investigate whether EOS calculator use can safely reduce antibiotic exposure in newborns with suspected EOS compared with the Dutch guideline.

Methods and analysis
This protocol describes a cluster randomised controlled trial assessing whether EOS calculator use is non-inferior regarding safety, and superior regarding limiting overtreatment, compared with the Dutch guideline. We will include newborns born at ≥34 weeks’ gestation, with at least one risk factor consistent with EOS within 24 hours after birth. After 1:1 randomisation, the 10 participating Dutch hospitals will use either the Dutch guideline or the EOS calculator as standard of care for all newborns at risk for EOS. In total, 1830 newborns will be recruited. The coprimary non-inferiority outcome will be the presence of at least one of four predefined safety criteria. The coprimary superiority outcome will be the proportion of participants starting antibiotic therapy for suspected and, or proven EOS within 24 hours after birth. Secondary outcomes will be the total duration of antibiotic therapy, the percentage of antibiotic therapy started between 24 and 72 hours after birth, and parent-reported quality of life. Analyses will be performed both as intention to treat and per protocol.

Ethics and dissemination
This trial has been approved by the Medical Ethics Committee of the Amsterdam UMC (NL78203.018.21). Results will be presented in peer-reviewed journals and at international conferences.

Trial registration number
NCT05274776.

Circulation, Volume 147, Issue 7, Page 526-528, February 14, 2023.

Introduction
Opioid prescribing rates are disproportionately high in the North of England. In addition to patients’ complex health needs, clinician prescribing behaviour is also a key driver. Although strategies have been initiated to reduce opioid prescribing nationally, the COVID-19 pandemic has interrupted service provision and created challenges for the system and health professionals to tackle this complex issue. A pilot intervention using smartphone video messaging has been developed to remotely explain the rationale for opioid reduction and facilitate self-initiation of support. The aim of this study is to evaluate the potential benefits, risks and economic consequences of ‘at scale’ implementation.

Methods and analysis
This will be a mixed-methods study comprising a quasi-experimental non-randomised before-and-after study and qualitative interviews. The intervention arm will comprise 50 General Practitioner (GP) Practices using System 1 (a clinical computer system hosting the intervention) who will deliver the video to their patients via text message. The control arm will comprise 50 practices using EMIS (a different computer system) who will continue usual care. Monthly practice level prescribing and consultation data will be observed for 6 months postintervention. A general linear model will be used to estimate the association between the exposure and the main outcome (opioid prescribing; average daily quantity (ADQ)/1000 specific therapeutic group age-sex related prescribing unit). Semi-structured interviews will be undertaken remotely with purposively selected participants including patients who received the video, and health professionals involved in sending out the videos and providing additional support. Interviews will be audio recorded, transcribed and analysed thematically.

Ethics and dissemination
Ethics approval has been granted by the NHS Health Research Authority Research Ethics Committee (22/PR/0296). Findings will be disseminated to the participating sites, participants, and commissioners, and in peer-reviewed journals and academic conferences.

Trial registration number
NCT05276089.

Introduction
Individuals ageing with spinal cord injury (SCI) experience an accelerated trajectory of diseases and disorders, such as cardiovascular disease and diabetes, that resemble those experienced with ageing alone. Currently, an evidence-based approach toward managing this problem does not exist and therefore the purpose of this study is to determine the feasibility of conducting a high-intensity exercise intervention in individuals with acute (

Stroke, Volume 54, Issue Suppl_1, Page AWP33-AWP33, February 1, 2023. Atrial fibrillation (AF) is responsible for 15-20% of ischemic strokes. AF can be asymptomatic and remain undetected following acute stroke, initially classifying the event as cryptogenic. Implantable loop recorders (ILRs) provide long-term cardiac monitoring and are superior to traditional methods for detecting AF in patients with cryptogenic stroke. ILR placement is often performed by a cardiologist in an outpatient setting. Our institution identified that some patients were missing or cancelling appointments for device implantation. Failure to detect AF is associated with a greater risk of stroke recurrence. An interdisciplinary inpatient process was developed to place ILRs at the bedside on the stroke unit, prior to discharge. The purpose of the program was to increase patient compliance with ILRs, improve detection of asymptomatic AF, and reduce incidence of stroke recurrence through timely initiation of oral anticoagulants. To evaluate the program and provide recommendations, measures of success included rates of patient compliance with ILR implantation using inpatient vs. outpatient procedure and the percentage of patients who received a diagnosis of AF after ILR placement. Using 18 months of pre-implementation data as a benchmark, the average implant rate increased in the first 12 months following implementation. Of 97 patients who received ILR placement, nine (9%) have received a diagnosis of AF. Since three-year ILR monitoring has shown significantly higher AF detection than 30-day cardiac monitoring after cryptogenic stroke, more patients with AF may yet be identified. This presentation will demonstrate an increase in ILR implant rates and AF detection and highlight positive results using advanced practice professionals to perform the procedure. The program produced financial benefit and mitigated access to care barriers, with no poor outcomes or compromise in quality, and no negative impact on inpatient length of stay. In conclusion, bedside insertion of ILRs prior to discharge after cryptogenic stroke is a safe, efficient, cost-effective process that increases patient compliance when compared to outpatient return visits, improving detection of AF and prompt initiation of oral anticoagulants, and may reduce stroke recurrence.