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Aims: An overview of systematic reviews (SRs) and network meta-analysis (NMA) was conducted to synthesize evidence of comparative effectiveness of different peri-discharge complex interventions for reducing 30-day hospital readmissions among heart failure (HF) patients. Methods: We searched five databases for SRs from their inception to August 2019 and conducted additional search for randomized controlled trials (RCTs) published between 2003 and 2020. We used random-effect pairwise meta-analysis with pooled risk ratios (RRs) and 95% confidence intervals (CIs) to quantify the effect of complex interventions, and NMA to evaluate comparative effectiveness among complex interventions. Primary outcome was 30-day all-cause hospital readmissions, while secondary outcomes were 30-day HF-related hospital readmissions, 30-day mortality, and 30-day emergency department visits. Results: From 20 SRs and additional RCT search, 21 eligible RCTs (n = 5362) assessing eight different peri-discharge complex interventions were included. Pairwise meta-analysis showed no significant difference between peri-discharge complex interventions and controls on all outcomes, except that peri-discharge complex interventions were significantly more effective than controls in reducing 30-day mortality (pooled RR = 0.68, 95% CI: 0.49–0.95, 5 RCTs). NMA indicated that for reducing 30-day all-cause hospital readmissions, supportive–educative intervention had the highest probability to be the best intervention, followed by disease management; while for reducing 30-day HF-related hospital readmissions, disease management is likely to be the best intervention. Conclusions: Our results suggest that disease management has the best potential to reduce 30-day all-cause and HF-related hospital readmissions. Benefits of the interventions may vary across health system contexts. Evidence-based complex interventions require local adaptation prior to implementation. [ABSTRACT FROM AUTHOR]

Background: Measure Yourself Medical Outcome Profile (MYMOP) is a patient generated outcome instrument applicable in the evaluation of both allopathic and complementary medicine treatment. This study aims to adapt MYMOP into Chinese, and to assess its validity, responsiveness and minimally important change values in a sample of patients using Chinese medicine (CM) services.Methods: A Chinese version of MYMOP (CMYMOP) is developed by forward-backward-forward translation strategy, expert panel assessment and pilot testing amongst patients. 272 patients aged 18 or above with subjective symptoms in the past 2 weeks were recruited at a CM clinic, and were invited to complete a set of questionnaire containing CMYMOP and SF-36. Follow ups were performed at 2nd and 4th week after consultation, using the same set of questionnaire plus a global rating of change question. Criterion validity of CMYMOP was assessed by its correlation with SF-36 at baseline, and responsiveness was evaluated by calculating the Cohen effect size (ES) of change at two follow ups. Minimally important difference (MID) values were estimated via anchor based method, while minimally detectable difference (MDC) figures were calculated by distribution based method.Results: Criterion validity of CMYMOP was demonstrated by negative correlation between CMYMOP Profile scores and all SF-36 domain and summary scores at baseline. For responsiveness between baseline and 4th week follow up, ES of CMYMOP Symptom 1, Activity and Profile reached the moderate change threshold (ES>0.5), while Symptom 2 and Wellbeing reached the weak change threshold (ES>0.2). None of the SF-36 scores reached the moderate change threshold, implying CMYMOP's stronger responsiveness in CM setting. At 2nd week follow up, MID values for Symptom 1, Symptom 2, Wellbeing and Profile items were 0.894, 0.580, 0.263 and 0.516 respectively. For Activity item, MDC figure of 0.808 was adopted to estimate MID.Conclusions: The findings support the validity and responsiveness of CMYMOP for capturing patient centred clinical changes within 2 weeks in a CM clinical setting. Further researches are warranted (1) to estimate Activity item MID, (2) to assess the test-retest reliability of CMYMOP, and (3) to perform further MID evaluation using multiple, item specific anchor questions. [ABSTRACT FROM AUTHOR]

Background: The combined effects of some modifiable lifestyle factors on incident inflammatory bowel disease (IBD) are uncertain., Aims: To evaluate the combined association between healthy lifestyle behaviours and IBD incidence., Methods: This population-based prospective cohort study used data from the UK Biobank. We included 105,715 participants aged 40-70 who had no IBD diagnosis at baseline in the analyses. The five healthy lifestyle behaviours that we studied were never smoking, optimal sleep, high level of vigorous physical activity, high dietary quality, and moderate alcohol intake. The outcome was the overall incidence of IBD and individual incidences of Crohn's disease (CD) and ulcerative colitis (UC). We derived hazard ratios (HR) and 95% confidence intervals (CI) for associations., Results: The multivariable adjusted HRs (95% CI) associated with having 1, 2 and 3-5 healthy lifestyle behaviours for IBD incidence compared with those with none of these behaviours were 0.75 (0.59-0.97), 0.72 (0.56-0.92), and 0.50 (0.37-0.68), respectively (p for trend < 0.001). We observed similar findings for CD and UC. Only never smoking exhibited significant independent inverse associations with the overall incidence of IBD (HR 0.70, 95% CI 0.58-0.83, p < 0.001) and the incidence of UC (HR 0.58, 95% CI 0.48-0.72, p < 0.001)., Conclusions: Healthy lifestyle behaviours are significantly associated with lower IBD incidence in middle-aged and elderly individuals, suggesting the potential of lifestyle modifications as a primary prevention strategy for IBD., (© 2025 John Wiley & Sons Ltd.)

Objectives: To assess the therapeutic effects and safety of Tongxie Yaofang (TXYF) granules vs placebo as an alternative treatment for diarrhoea-predominant irritable bowel syndrome (IBS-D). We hypothesised that TXYF would improve clinical responses among patients with IBS-D., Design: A randomised, double-blind, placebo-controlled, phase II, superiority trial., Setting: Outpatients attending the Fangshan Hospital, Beijing University of Chinese Medicine, Beijing, China., Participants: 96 eligible participants included men and women ranging from late adolescence to middle adulthood (18-65 years), diagnosed with IBS-D according to the Rome IV criteria. In addition, they were required to have an irritable bowel syndrome symptom severity score (IBS-SSS) of at least 75., Interventions: TXYF granules (3.7 g) twice daily (taken orally before meals) or placebo for 8 weeks., Primary and Secondary Outcomes: The primary outcome was the response rate measured by the change in IBS-SSS compared with baseline at week 8. Secondary outcomes included stool frequency; stool consistency at weeks 4, 8 and 20; and quality of life, anxiety and depression at week 8; and safety was monitored throughout the trial., Results: The TXYF and placebo groups each comprised 48 participants. The response rate was not significantly different at week 8 between the two groups (the unadjusted treatment effect estimate (intention-to-treat analysis) was 1.12 (95% CI (0.89, 1.41)), p=0.348). Both groups had a high and similar rate of symptom reduction (79.2% (38/48) vs 70.8% (34/48)). There were no statistically significant differences between the two groups on secondary outcomes, although both groups showed substantial improvements. Adverse events in the TXYF and placebo groups were one (sinus arrhythmia) and two (elevated transaminases, weakly positive faecal occult blood), respectively. No serious adverse events occurred., Conclusions: Despite showing clinically meaningful improvements in IBS-D symptoms and a reasonable safety profile after 8 weeks, no significant differences were observed between the TXYF and placebo groups. This suggests that the severity of IBS-D symptoms in both treatment arms might have decreased over time, regardless of the treatment, and highlights the need to investigate the relationship between IBS-D and patient psychology. Future large-scale, rigorously designed trials with longer treatment and follow-up periods are essential to evaluate the therapeutic effects and safety of TXYF, and to explore the psychological factors., Trial Registration Number: ISRCTN12453166., Competing Interests: Competing interests: NR is the guest professor of Beijing University of Chinese Medicine, Centre of Evidence-Based Chinese Medicine (certification number 20210017)., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Background: Systematic reviews (SRs) could offer the best evidence supporting interventions, but methodological flaws limit their trustworthiness in decision-making. This cross-sectional study appraised the methodological quality of SRs on atopic dermatitis (AD) treatments., Methods: We searched MEDLINE, EMBASE, PsycINFO, and Cochrane Database for SRs on AD treatments published in 2019-2022. We extracted SRs' bibliographical data and appraised SRs' methodological quality with AMSTAR (A MeaSurement Tool to Assess systematic Reviews) 2. We explored associations between methodological quality and bibliographical characteristics., Results: Among the 52 appraised SRs, only one (1.9%) had high methodological quality, while 45 (86.5%) critically low. For critical domains, only five (9.6%) employed comprehensive search strategy, seven (13.5%) provided list of excluded studies, 17 (32.7%) considered risk of bias in primary studies, 21 (40.4%) contained registered protocol, and 24 (46.2%) investigated publication bias. Cochrane reviews, SR updates, SRs with European corresponding authors, and SRs funded by European institutions had better overall quality. Impact factor and author number positively associated with overall quality., Conclusions: Methodological quality of SRs on AD treatments is unsatisfactory. Future reviewers should improve the above critical methodological aspects. Resources should be devolved into upscaling evidence synthesis infrastructure and improving critical appraisal skills of evidence users.

Background: Meta-analyses (MAs) provide up-to-date, quantified evidence on treatment effects, which may be useful for clinical and policy decision-making. However, the quality of MAs varies, and methodological flaws can limit their reliability., Aims: This review evaluated the methodological quality of MAs on sleep disorder treatments., Methods: We searched MEDLINE, EMBASE, and PsycINFO for eligible MAs on randomized controlled trials of sleep disorder treatments published between 2018 and 2023. We extracted MAs' bibliographical characteristics with a predesigned form and appraised their methodological quality using AMSTAR (A Measurement Tool to Assess Systematic Reviews) 2. We explored the associations between bibliographical characteristics and methodological quality ratings using Kruskal-Wallis tests and Spearman's rank correlation coefficients., Results/outcomes: Among the 104 MAs, the majority (n = 82; 78.9%) had critically low quality, 19 (18.3%) had low quality, and only 3 (2.9%) had high quality. Regarding AMSTAR 2 critical domains, 97 (93.3%) MAs did not provide a list of excluded studies and justify the exclusions, 75 (72.1%) did not use a comprehensive literature search strategy, and 56 (53.9%) lacked a registered protocol and did not justify protocol deviations. Cochrane reviews (p = 0.018), MAs with European corresponding authors (p < 0.001), and MAs receiving European funding (p < 0.001) performed better than their counterparts., Conclusions/interpretation: The methodological quality of recent MAs on sleep disorder treatments is unsatisfactory. Future reviewers should address the identified critical methodological issues. In addition, substantial resources and funding should be allocated to support training in evidence synthesis and critical appraisal for researchers and clinicians., (© 2024 The Author(s). Brain and Behavior published by Wiley Periodicals LLC.)

Purpose: Current evidence supports the use of integrative oncology (IO) interventions in cancer supportive care. The demand for outpatient IO services in Hong Kong is expected to soar following the surge in cancer incidence due to population ageing. This study identified the factors influencing the delivery and utilisation of outpatient IO from local stakeholders' perspectives and developed corresponding implementation strategies., Methods: This study involved two sequential stages. First, with individual semi-structured interviews guided by the Theoretical Domains Framework (TDF), we explored stakeholders' views on the barriers to and facilitators for implementing IO. Second, guided by a TDF-based qualitative data analysis of interview transcripts, we performed intervention mapping to develop Behaviour Change Wheel-based implementation strategies that may overcome the barriers and strengthen the facilitators., Results: We interviewed 31 stakeholders, including traditional Chinese medicine (TCM) practitioners ( n  = 8), biomedically-trained doctors ( n  = 7), nurses ( n  = 6), administrators ( n  = 4), caregivers ( n  = 4), and pharmacists ( n  = 2). The key local factors influencing outpatient IO are (1) lacking nursing and administrative workforce supporting IO service delivery, (2) lacking awareness of IO services among healthcare professionals, administrators, patients, and caregivers, and (3) lacking knowledge among healthcare professionals of herb-drug interaction and herbal toxicities., Conclusion: We recommended a multi-faceted implementation strategies package that included arranging funding to train, recruit, and retain nursing and administrative staff, devolving resources into promoting interprofessional collaborations and evidence on IO effectiveness and safety, integrating evidence on herb-drug interactions and herbal toxicities into automated electronic health record systems monitored by pharmacists with dual qualifications in TCM and conventional pharmacy., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Ho, Kwong, Li, Nilsen, Ho, Zhong, Wong, Lin and Chung.)

Objectives: Telemedicine has been widely used during the COVID-19 pandemic. Among other health care professionals, Chinese medicine practitioners (CMPs) face practical challenges in providing telemedicine consultations. This study aims to explore CMPs' experience and perceptions of telemedicine service provision before and during the pandemic. Methods: A territory-wide cross-sectional online survey was conducted in Hong Kong between April and May 2022. A structured questionnaire with open-ended questions was used to investigate the provision of and perception on telemedicine service, as well as usability of telemedicine among CMPs. Results: A total of 195 CMPs participated the survey. Before COVID-19, 42% (81/195) had been providing telemedicine services, and the proportion doubled during COVID-19. CMPs in the private sector are the main providers. Mobile apps including WhatsApp, WeChat, and Zoom were commonly used for consultations (75%, 120/161). Barriers in providing telemedicine included inability of conducting physical examination on patients (69%, 134/195), legal and ethical concerns over medical negligence (61%, 118/195), and patients' incompetence on e-literacy (50%, 98/195). Respondents urged professional and regulatory bodies to provide an explicit clinical guideline that demonstrate best practice in traditional Chinese medicine telemedicine, and to clarify legal and ethical implications of such practice. Conclusions: CMPs demonstrated their competency in telemedicine, and most of them provided telemedicine during COVID-19. Development of appropriate guidelines on the provision of telemedicine would support CMPs to continue provision after the pandemic, whereas a user-friendly and comprehensive telemedicine e-platform would enhance quality of such service. Facilitating patients with lower e-literacy to access telemedicine is key to reduce disparities.

Background: Previously published meta-epidemiological studies focused on Western medicine have identified some trial characteristics that impact the treatment effect of randomized controlled trials (RCTs). Nevertheless, it remains unclear if similar associations exist in RCTs on Chinese herbal medicine (CHM). Further, Chinese medicine-related characteristics have not been explored yet., Objective: To investigate trial characteristics related to treatment effect estimates on CHM RCTs., Search Strategy: This meta-epidemiological study searched 5 databases for systematic reviews on CHM treatment published between January 2011 and July 2021., Inclusion Criteria: An eligible systematic review should only include RCTs of CHM and conduct at least one meta-analysis., Data Extraction and Analysis: Two reviewers independently conducted data extraction on general characteristics of systematic reviews, meta-analyses and included RCTs. They also assessed the risk of bias of RCTs using the Cochrane risk of bias tool. A two-step approach was used for data analyses. The ratio of odds ratios (ROR) and difference in standardized mean differences (dSMD) with 95% confidence interval (CI) were applied to present the difference in effect estimates for binary and continuous outcomes, respectively., Results: Ninety-one systematic reviews, comprising 1338 RCTs were identified. For binary outcomes, RCTs incorporated with syndrome differentiation (ROR: 1.23; 95 % CI: [1.07, 1.39]), adopting Chinese medicine formula (ROR: 1.19; 95% CI: [1.03, 1.34]), with low risk of bias on incomplete outcome data (ROR: 1.29; 95% CI: [1.06, 1.52]) and selective outcome reporting (ROR: 1.12; 95% CI: [1.01, 1.24]), as well as a trial size ≥ 100 (ROR: 1.23; 95% CI: [1.04, 1.42]) preferred to show larger effect estimates. As for continuous outcomes, RCTs with Chinese medicine diagnostic criteria (dSMD: 0.23; 95% CI: [0.06, 0.41]), judged as high/unclear risk of bias on allocation concealment (dSMD: -0.70; 95% CI: [-0.99, -0.42]), with low risk of bias on incomplete outcome data (dSMD: 0.30; 95% CI: [0.18, 0.43]), conducted at a single center (dSMD: -0.33; 95% CI: [-0.61, -0.05]), not using intention-to-treat analysis (dSMD: -0.75; 95% CI: [-1.43, -0.07]), and without funding support (dSMD: -0.22; 95% CI: [-0.41, -0.02]) tended to show larger effect estimates., Conclusion: This study provides empirical evidence for the development of a specific critical appraisal tool for risk of bias assessments on CHM RCTs. Please cite this article as: Wang BH, Lin YL, Gao YY, Song JL, Qin L, Li LQ, Liu WQ, Zhong CCW, Jiang MY, Mao C, Yang XB, Chung VCH, Wu IXY. Trial characteristics and treatment effect estimates in randomized controlled trials of Chinese herbal medicine: A meta-epidemiological study. J Integr Med. 2024; 22(3): 223-234., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Shanghai Yueyang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine. Published by Elsevier B.V. All rights reserved.)

Competing Interests: Conflict-of-Interest Disclosures: None to disclose.

Objective: Systematic reviews (SRs) offer updated evidence to support decision-making on sepsis treatments. However, the rigour of SRs may vary, and methodological flaws may limit their validity in guiding clinical practice. This cross-sectional study appraised the methodological quality of SRs on sepsis treatments., Methods: We searched MEDLINE, EMBASE, and Cochrane Database for eligible SRs on randomised controlled trials on sepsis treatments with at least one meta-analysis published between 2018 and 2023. We extracted SRs' bibliographical characteristics with a pre-designed form and appraised their methodological quality using AMSTAR (A MeaSurement Tool to Assess systematic Reviews) 2. We applied logistic regressions to explore associations between bibliographical characteristics and methodological quality ratings., Results: Among the 102 SRs, two (2.0%) had high overall quality, while respectively four (3.9%), seven (6.9%) and 89 (87.3%) were of moderate, low, and critically low quality. Performance in several critical methodological domains was poor, with only 32 (31.4%) considering the risk of bias in primary studies in result interpretation, 22 (21.6%) explaining excluded primary studies, and 16 (15.7%) applying comprehensive searching strategies. SRs published in higher impact factor journals (adjusted odds ratio: 1.19; 95% confidence interval: 1.05 to 1.36) was associated with higher methodological quality., Conclusions: The methodological quality of recent SRs on sepsis treatments is unsatisfactory. Future reviewers should address the above critical methodological aspects. More resources should also be allocated to support continuous training in critical appraisal among healthcare professionals and other evidence users., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: To evaluate the association between healthy lifestyle behaviours and the incidence of irritable bowel syndrome (IBS)., Design: Population-based prospective cohort study., Setting: The UK Biobank., Participants: 64 268 adults aged 37 to 73 years who had no IBS diagnosis at baseline were enrolled between 2006 and 2010 and followed up to 2022., Main Exposure: The five healthy lifestyle behaviours studied were never smoking, optimal sleep, high level of vigorous physical activity, high dietary quality and moderate alcohol intake., Main Outcome Measure: The incidence of IBS., Results: During a mean follow-up of 12.6 years, 961 (1.5%) incident IBS cases were recorded. Among the 64 268 participants (mean age 55.9 years, 35 342 (55.0%) female, 7604 (11.8%) reported none of the five healthy lifestyle behaviours, 20 662 (32.1%) reported 1 behaviour, 21 901 (34.1%) reported 2 behaviours and 14 101 (21.9%) reported 3 to 5 behaviours at baseline. The multivariable adjusted hazard ratios associated with having 1, 2 and 3 to 5 behaviours for IBS incidence were 0.79 (95% confidence intervals 0.65 to 0.96), 0.64 (0.53 to 0.78) and 0.58 (0.46 to 0.72), respectively (P for trend <0.001). Never smoking (0.86, 0.76 to 0.98, P=0.02), high level of vigorous physical activity (0.83, 0.73 to 0.95, P=0.006) and optimal sleep (0.73, 0.60 to 0.88, P=0.001) demonstrated significant independent inverse associations with IBS incidence. No significant interactions were observed between these associations and age, sex, employment status, geographic location, gastrointestinal infection, endometriosis, family history of IBS or lifestyle behaviours., Conclusions: Adhering to a higher number of healthy lifestyle behaviours is significantly associated with a lower incidence of IBS in the general population. Our findings suggest the potential of lifestyle modifications as a primary prevention strategy for IBS., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Proton pump inhibitors (PPIs) are widely prescribed for gastroesophageal reflux disease and peptic ulcer disease. However, the association between the regular PPIs use and the risk of cardiovascular disease (CVD) outcomes remains unclear. We aimed to determine whether regular proton pump inhibitors (PPIs) use is associated with an altered incidence of cardiovascular disease (CVD) in the general population., Methods: This prospective cohort study included 459,207 participants (mean [SD] age, 56.2 [8.1] years) from the UK Biobank study without prevalent CVD who enrolled between 2006 and 2010 and were followed until 2018. Hazard ratios (HRs) and 95% confidence intervals (CIs) for incident CVD and its components (coronary heart disease [CHD], stroke, heart failure, atrial fibrillation, and venous thromboembolism) were obtained using Cox proportional hazards models with adjustment for potential confounding factors, including demographic factors, lifestyle behaviors, prevalent comorbidities, and clinical indicators for PPIs use., Results: During the follow-up period, we recorded 26,346 incident CVD events (including 13,749 CHD events, 4144 stroke events, 5812 atrial fibrillation events, 1159 heart failure events, and 4206 venous thromboembolism events). The fully adjusted HRs (and 95% CIs) associated with PPIs users compared to nonusers were 1.44 (95% CI 1.39-1.50) for incident CVD, 1.65 (95% CI 1.57-1.74) for CHD, 1.21 (95% CI 1.09-1.33) for stroke, 1.17 (95% CI 1.08-1.28) for atrial fibrillation, 1.61 (95% CI 1.37-1.89) for heart failure, and 1.36 (95% CI 1.24-1.50) for venous thromboembolism., Conclusions: Regular PPIs use was associated with higher risk of CVD outcomes. Clinicians should therefore exercise caution when prescribing PPIs., Competing Interests: Declaration of competing interest We declare no competing interests., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objective: To systematically review the effectiveness of hypertonic dextrose prolotherapy (DPT) in plantar fasciopathy (PF) compared with other non-surgical treatments., Data Sources: PubMed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, Allied and Complementary Medicine Database, Global Health, Ovid Nursing Database, Dimensions, and WHO ICTRP were searched from inception to April 30th, 2022., Study Selection: Two independent reviewers selected randomized controlled trials (RCTs) that evaluated the effectiveness of DPT in PF compared with non-surgical treatments. Outcomes included pain intensity, foot and ankle function, and plantar fascia thickness., Data Extraction: Two independent reviewers conducted data extraction. Risk of bias (RoB) assessment was conducted using the Cochrane Risk of Bias 2 (RoB 2) tool, and certainty of evidence was assessed with Grading of Recommendation Assessment, Development, and Evaluation (GRADE)., Data Synthesis: Eight RCTs (n=469) met the inclusion criteria. Pooled results favored the use of DPT versus normal saline (NS) injections in reducing pain (weighted mean difference [WMD] -41.72; 95% confidence interval [CI] -62.36 to -21.08; P<.01; low certainty evidence) and improving function [WMD -39.04; 95% CI -55.24 to -22.85; P<.01; low certainty evidence] in the medium term. Pooled results also showed corticosteroid (CS) injections was superior to DPT in reducing pain in the short term [standardized mean difference 0.77; 95% CI 0.40 to 1.14; P<.01; moderate certainty evidence]. Overall RoB varied from "some concerns" to "high". The overall certainty of evidence presented ranges from very low to moderate based on the assessment with the GRADE approach., Conclusion: Low certainty evidence demonstrated that DPT was superior to NS injections in reducing pain and improving function in the medium term, but moderate certainty evidence showed that it was inferior to CS in reducing pain in the short term. Further high-quality RCTs with standard protocol, longer-term follow-up, and adequate sample size are needed to confirm its role in clinical practice., (Copyright © 2023 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: High 30-day readmission rates increase hospital costs and negatively impact patient outcomes in many healthcare systems, including Hong Kong. Evidence-based and local adaptable nurse-led interventions have not been established for reducing 30-day hospital readmissions among general medical patients in Hong Kong's public healthcare system., Aims: The aim of this study was to select and refine evidence-based nurse-led interventions for reducing 30-day hospital readmissions among general medical patients in Hong Kong's public healthcare system using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) framework., Methods: Eighteen local healthcare stakeholders were recruited to carry out a two-step process. In step 1, stakeholders were invited to prioritize nurse-led interventions which were supported by existing evidence and suggest important combinations of different interventions. For all interventions prioritized in step 1, step 2 involved stakeholders performing a two-round Delphi questionnaire aiming to generate consensus-based interventions appropriate to the local context. GRADE EtD framework was applied to guide the decision-making process, taking into account certainty of evidence, benefits and harms, resource use, equity, acceptability, and feasibility., Results: Four out of eight nurse-led interventions reached a positive consensus with percentage agreement ranging from 70.6% to 82.4%. GRADE EtD criteria ratings showed that over 70% of stakeholders agreed these four interventions were probably acceptable and feasible, though the certainty of evidence was low or moderate. Half of stakeholders believed their desirable effects compared to undesirable effects were large. However, the resources required and how these nurse-led interventions might affect health inequities when implemented were uncertain. Preliminary implementation issues included high complexity of delivering multiple nurse-led intervention components, and challenges of coordinating different involved parties in delivering the interventions. Appropriate resource allocation and training should be provided to address these potential problems, as suggested by stakeholders., Linking Evidence to Action: Using the GRADE EtD framework, four nurse-led interventions were recommended by healthcare stakeholders as possible strategies for reducing 30-day hospital readmissions among general medical patients in Hong Kong. To address preliminary implementation issues, nurses' role as care coordinators should also be strengthened to ensure smooth delivery of nurse-led intervention components, and to facilitate multidisciplinary collaboration during service delivery., (© 2023 The Authors. Worldviews on Evidence-based Nursing published by Wiley Periodicals LLC on behalf of Sigma Theta Tau International.)

Background: Integrative oncology (IO) appears to be beneficial to patients with cancer, but its implementation remains a challenge. Guided by the Theoretical Domains Framework (TDF) and the Capability-Opportunity-Motivation-Behaviour (COM-B) model, this systematic review identified the barriers to and facilitators of IO implementation in conventional cancer care settings., Methods: We searched eight electronic databases from their inception until February 2022 for qualitative, quantitative or mixed-methods empirical studies reporting the implementation outcomes for IO services. Critical appraisal approach was tailored according to study types. The identified implementation barriers and facilitators were mapped onto TDF domains and the COM-B model, and subsequently onto the behavioural change wheel (BCW) for formulating behavioural change interventions., Results: We included 28 studies (11 qualitative, 6 quantitative, 9 mixed-methods and 2 Delphi studies) of satisfied methodological quality. The main implementation barriers were the lack of IO knowledge, the absence of funding and healthcare professionals' low level of IO receptiveness. The key implementation facilitators were the dissemination of evidence on IO clinical benefits, the equipping of professionals with IO service delivery skills and the provision of a supportive organisational climate., Conclusion: Multifaceted implementation strategies are needed to address the determinants influencing IO service delivery. Based on our BCW-based analysis of the included studies, the key behavioural change techniques are: (1) educating healthcare professionals about the value and application of traditional and complementary medicine; (2) ensuring access to actionable clinical evidence on IO effectiveness and safety and (3) designing guidelines on communicating traditional and complementary medicine interventions with patients and caregivers for biomedically trained doctors and nurses., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The emergence and persistence of symptoms after acute COVID-19 is expected to become a major burden on healthcare systems. We assessed the features of the post-COVID-19 Syndrome (Long COVID) burden in a cohort of COVID-19 patients during the fifth major wave in Hong Kong., Methods: A cross-sectional study of 135 patients with confirmed COVID-19 from Feb to Apr 2022 who utilized traditional Chinese medicine telemedicine services was conducted. The COVID-19 Yorkshire Rehabilitation Scale was administered using an online survey 12 weeks after the COVID-19 infection. Prevalence of symptom severity and functional impairments were assessed to identify burdens and patterns. The correlation between symptom severity, functional impairments, patient characteristics, and overall health was evaluated., Results: The mean age was 46.8 years, with 46 (34.1%) males. Symptoms, functional impairments, and overall health worsened significantly when compared to the status prior to the infection. More than 50% reported the following sequelae 12 weeks after the acute infection: breathlessness, laryngeal or airway complications, fatigue, weakness, sleep, cognition, and anxiety. The presence of a single symptom or functional impairment significantly correlated with at least seven other problems positively, except for pain. Severity tended to be higher among vulnerable groups, including those who were chronic disease patients, older, less well educated, female, or had incomplete COVID-19 vaccinations., Conclusions: Long COVID is a significant healthcare burden among telemedicine users in Hong Kong, with complex needs for symptom and functional impairment management. Designing relevant health and rehabilitation services tailored to the needs of these patients is warranted.

Background: Carefully conducted systematic reviews (SRs) can provide reliable evidence on the effectiveness of treatment strategies for Alzheimer's disease (AD). Nevertheless, the reliability of SR results can be limited by methodological flaws. This cross-sectional study aimed to examine the methodological quality of SRs on AD treatments, along with potentially relevant factors., Methods: To identify eligible SRs on AD treatments, four databases including the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, and PsycINFO were searched. The Assessing the Methodological Quality of Systematic Reviews 2 instrument was used for quality appraisal of SRs. Multivariable regression analyses were used to examine factors related to methodological quality., Results: A total of 102 SRs were appraised. Four (3.90%) SRs were considered as high quality; 14 (13.7%), 48 (47.1%), and 36 (35.3%) were as moderate, low, and critically low quality, respectively. The following significant methodological limitations were identified: only 22.5% of SRs registered protocols a priori, 6.9% discussed the rationales of chosen study designs, 21.6% gave a list of excluded studies with reasons, and 23.5% documented funding sources of primary studies. Cochrane SRs (adjusted odds ratio (AOR): 31.9, 95% confidence interval (CI): 3.81-266.9) and SRs of pharmacological treatments (AOR: 3.96, 95%CI: 1.27-12.3) were related to the higher overall methodological quality of SRs., Conclusion: Methodological quality of SRs on AD treatments is unsatisfactory, especially among non-Cochrane SRs and SRs of non-pharmacological interventions. Improvement in the following methodological domains requires particular attention due to poor performance: registering and publishing protocols a priori, justifying study design selection, providing a list of excluded studies, and reporting funding sources of primary studies., (© 2022. The Author(s).)

Introduction: Functional dyspepsia (FD) is diagnosed based on self-reported symptoms and negative upper gastrointestinal endoscopic findings. The Rome criteria were not adopted as a diagnostic instrument in clinical guidelines due to their complexity. Different guidelines used relatively simple symptom assessment schemes with contents that vary significantly. A previously evaluated short Reference Standard may serve as a more standardised tool for guidelines. We evaluated its diagnostic accuracy against the Rome IV criteria in a cross-sectional study in Hong Kong., Methods: A total of 220 dyspeptic patients sampled consecutively from a tertiary hospital and the community completed the Rome IV diagnostic questionnaire, which was translated into Cantonese-Chinese, and the Reference Standard. Sensitivity, specificity, positive and negative likelihood ratios (LRs), and area under the receiver operating characteristics curve (AUC), with 95% confidence intervals (CIs), were calculated., Results: Among the participants, 160 (72.7%) fulfilled the Reference Standard with negative upper gastrointestinal endoscopic results. The Reference Standard identified patients with Rome IV-defined FD with 91.1% (95% CI 82.6%-96.4%) sensitivity and 37.6% (95% CI 29.6%-46.1%) specificity. The positive and negative LRs were 1.46 (95% CI 1.26-1.69) and 0.24 (95% CI 0.11-0.49), respectively. The AUC value was 0.64 (95% CI 0.59-0.69)., Conclusions: The Reference Standard can rule out patients without Rome IV-defined FD. It may be used as an initial screening tool for FD in settings where the use of the Rome IV criteria is impractical. It may also provide a uniform definition and diagnostic rule for future updates of clinical guidelines., (© 2022. The Author(s).)

Background: Traditional Chinese Medicine (TCM) treatment strategies are guided by pattern differentiation, as documented in the eleventh edition of the International Classification of Diseases (ICD). However, no standards for pattern differentiation are proposed to ensure inter-rater agreement. Without standardisation, research on associations between TCM diagnostic patterns, clinical features, and geographical characteristics is also not feasible. This diagnostic cross-sectional study aimed to (i) establish the pattern differentiation rules of functional dyspepsia (FD) using latent tree analysis (LTA); (ii) compare the prevalence of diagnostic patterns in Hong Kong and Hunan; (iii) discover the co-existence of diagnostic patterns; and (iv) reveal the associations between diagnostic patterns and FD common comorbidities., Methods: A total of 250 and 150 participants with FD consecutively sampled in Hong Kong and Hunan, respectively, completed a questionnaire on TCM clinical features. LTA was performed to reveal TCM diagnostic patterns of FD and derive relevant pattern differentiation rules. Multivariate regression analyses were performed to quantify correlations between different diagnostic patterns and between diagnostic patterns and clinical and geographical variables., Results: At least one TCM diagnostic pattern was differentiated in 70.7%, 73.6%, and 64.0% of the participants in the overall (n = 400), Hong Kong (n = 250), and Hunan (n = 150) samples, respectively, using the eight pattern differentiation rules derived. 52.7% to 59.6% of the participants were diagnosed with two or more diagnostic patterns. Cold-heat complex (59.8%) and spleen-stomach dampness-heat (77.1%) were the most prevalent diagnostic patterns in Hong Kong and Hunan, respectively. Spleen-stomach deficiency cold was highly likely to co-exist with spleen-stomach qi deficiency (adjusted odds ratio (AOR): 53.23; 95% confidence interval (CI): 21.77 to 130.16). Participants with severe anxiety tended to have liver qi invading the stomach (AOR: 1.20; 95% CI: 1.08 to 1.33)., Conclusions: Future updates of the ICD, textbooks, and guidelines should emphasise the importance of clinical and geographical variations in TCM diagnosis. Location-specific pattern differentiation rules should be derived from local data using LTA. In future, patients' pattern differentiation results, local prevalence of TCM diagnostic patterns, and corresponding TCM treatment choices should be accessible to practitioners on online clinical decision support systems to streamline service delivery., (© 2022. The Author(s).)

Objective: Social distancing is one of the main non-pharmaceutical interventions used in the control of the COVID-19 pandemic. This scoping review aims to synthesise research findings on the effectiveness of different types and levels of social distancing measures in the earlier stage of COVID-19 pandemic without the confounding effect of mass vaccination., Design: Scoping review., Data Sources: MEDLINE, Embase, Global Health and four other databases were searched for eligible studies on social distancing for COVID-19 published from inception of the databases to 30 September 2020., Study Selection and Data Extraction: Effectiveness studies on social distancing between individuals, school closures, workplace/business closures, public transport restrictions and partial/full lockdown were included. Non-English articles, studies in healthcare settings or not based on empirical data were excluded., Results: After screening 1638 abstracts and 8 additional articles from other sources, 41 studies were included for synthesis of findings. The review found that the outcomes of social distancing measures were mainly indicated by changes in R t , incidence and mortality, along with indirect indicators such as daily contact frequency and travel distance. There was adequate empirical evidence for the effect of social distancing at the individual level, and for partial or full lockdown at the community level. However, at the level of social settings, the evidence was moderate for school closure, and was limited for workplace/business closures as single targeted interventions. There was no evidence for a separate effect of public transport restriction., Conclusions: In the community setting, there was stronger evidence for the combined effect of different social distancing interventions than for a single intervention. As fatigue of preventive behaviours is an issue in public health agenda, future studies should analyse the risks in specific settings such as eateries and entertainment to implement and evaluate measures which are proportionate to the risk., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Non-specific effect of acupuncture constitutes part of the overall effect generated via clinical encounter beyond needle insertion and stimulation. It is unclear how responders and non-responders of acupuncture experience non-specific effects differently. We aimed to compare their experiences in a nested qualitative study embedded in an acupuncture randomized trial on functional dyspepsia., Methods: Purposive sampling was used to capture experience of responders (n=15) and non-responders (n=15) to acupuncture via individual in-depth interviews. Design and analysis followed a framework analysis approach, with reference to an existing model on acupuncture non-specific effects. Themes emerging outside of this model were purposefully explored., Results: Responders had a more trusting relationship with acupuncturist in response to their expression of empathy. In turn they were more actively engaged in lifestyle modifications and dietary advice offered by acupuncturists. Non-responders were not satisfied with the level of reassurance regarding acupuncture safety. They were also expecting more peer support from fellow participants, regarded that as an empowerment process for initiating and sustaining lifestyle changes., Conclusions: Our results highlighted key differences in acupuncture non-specific effect components experienced by responders and non-responders. Positive non-specific effects contributing to overall benefits could be enhanced by emphasizing on empathy expression from acupuncturists, trust-building, offering appropriate explanations on safety, and organizing patient support groups. Further research on the relative importance of each component is warranted., (© 2021 Korea Institute of Oriental Medicine. Published by Elsevier B.V.)

Background: Systematic reviews (SRs) synthesise the best evidence of effectiveness and safety on Chinese herbal medicine (CHM). Decision-making should be supported by the high-quality evidence of prudently conducted SRs, but the trustworthiness of conclusions may be limited by poor methodological rigour., Methods: This survey aimed to examine the methodological quality of a representative sample of SRs on CHM published during January 2018 to March 2020. We conducted literature search in Cochrane Database of Systematic Reviews, MEDLINE via Ovid, and EMBASE via Ovid. Eligible SRs must be in Chinese or English with at least one meta-analysis on the treatment effect of any CHM documented in the 2015 Chinese Pharmacopoeia. Two reviewers extracted the bibliographical characteristics of SRs and appraised their methodological quality using AMSTAR 2 (Assessing the Methodological Quality of Systematic Reviews 2). The associations between bibliographical characteristics and methodological quality were investigated using Kruskal-Wallis tests and Spearman's rank correlation coefficients., Results: We sampled and appraised one hundred forty-eight SRs. Overall, one (0.7%) was of high methodological quality; zero (0%), four (2.7%), and one-hundred forty-three (96.6%) SRs were of moderate, low, and critically-low quality. Only thirteen SRs (8.8%) provided a pre-defined protocol; none (0%) provided justifications for including particular primary study designs; six (4.1%) conducted a comprehensive literature search; two (1.4%) provided a list of excluded studies; nine (6.1%) undertook meta-analysis with appropriate methods; and seven (4.7%) reported funding sources of included primary studies. Cochrane reviews had higher overall quality than non-Cochrane reviews (P < 0.001). SRs with European funding support were less likely to have critically-low quality when compared with their counterparts (P = 0.020). SRs conducted by more authors (r s  = 0.23; P = 0.006) and published in higher impact factor journals (r s  = 0.20; P = 0.044) were associated with higher methodological quality., Conclusions: Our results indicated that the methodological quality of SRs on CHM is low. Future authors should enhance the methodological quality through registering a priori protocols, justifying selection of study designs, conducting comprehensive literature search, providing a list of excluded studies with rationales, using appropriate method for meta-analyses, and reporting funding sources among primary studies., (© 2022. The Author(s).)

Background: An overview of systematic reviews(SRs) and network meta-analysis(NMA) were conducted to evaluate the comparative effectiveness of peri-discharge complex interventions for reducing 30-day readmissions among chronic obstructive pulmonary disease(COPD) patients., Methods: Five databases were searched for SRs of randomized controlled trials(RCTs). An additional search was conducted for updated RCTs from database inception until Jun 2020. Pooled effect of peri-discharge complex interventions was assessed using random-effect pairwise meta-analyses. Comparative effectiveness across different peri-discharge complex interventions was evaluated using NMA., Results: Nine SRs and 11 eligible RCTs(n = 1,422) assessing eight different peri-discharge complex interventions were included. For reducing 30-day all-cause readmissions, pairwise meta-analysis showed no significant difference between peri-discharge complex interventions and usual care, while NMA indicated no significant differences among different peri-discharge complex interventions as well as usual care. For reducing 30-day COPD-related readmissions, peri-discharge complex interventions were significantly more effective than usual care (pooled RR = 0.45, 95% CI:0.24-0.84)., Conclusions: Peri-discharge complex interventions may not differ from usual care in reducing 30-day all-cause readmissions among COPD patients but some are more effective for lowering 30-day COPD-related readmission. Thus, complex intervention comprising core components of patient education, self-management, patient-centred discharge instructions, and telephone follow up may be considered for implementation, but further evaluation is warranted., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2022 The Author(s).)

Background: Prokinetic is the first-line conventional treatment for functional dyspepsia (FD) in Asia despite potential adverse events. Chinese herbal medicine (CHM) may be an effective and safe substitution. This network meta-analysis (NMA) aimed to evaluate the comparative effectiveness of different CHM formulae for FD against prokinetics., Methods: Seven international and Chinese databases were searched from their inception to July 2020 for randomised controlled trials (RCTs) on CHM versus prokinetics. Data from each RCT were first pooled using random-effect pairwise meta-analyses and illustrated as risk difference (RD) or standardised mean difference (SMD) with 95% confidence interval (CI). Random-effect NMAs were then performed to evaluate the comparative effectiveness of CHM formulae and displayed as RD with 95% CI or SMD with 95% credible interval (CrI). The GRADE partially contextualised framework was applied for NMA result interpretation., Results: Twenty-six unique CHM formulae were identified from twenty-eight RCTs of mediocre quality. Pairwise meta-analyses indicated that CHM was superior to prokinetics in alleviating global symptoms at 4-week follow-up (pooled RD: 0.14; 95% CI: 0.10-0.19), even after trim and fill adjustment for publication bias. NMAs demonstrated that Modified Zhi Zhu Decoction may have a moderate beneficial effect on alleviating global symptoms at 4-week follow-up (RD: 0.28; 95% CI: - 0.03 to 0.75). Xiao Pi Kuan Wei Decoction may have a large beneficial effect on alleviating postprandial fullness (SMD: - 2.14; 95% CI: - 2.76 to 0.70), early satiety (SMD: - 3.90; 95% CI: - 0.68 to - 0.42), and epigastric pain (SMD: - 1.23; 95% CI: - 1.66 to - 0.29). No serious adverse events were reported., Conclusion: Modified Zhi Zhu Decoction and Xiao Pi Kuan Wei Decoction may be considered as an alternative for patients unresponsive to prokinetics. Confirmatory head-to-head trials should be conducted to investigate their comparative effectiveness against prokinetics., (© 2021. The Author(s).)

Background: Hypertension is a leading contributor to the global burden of disease and to mortality. The combined effects of sleep factors on the risk of hypertension are unclear. We aimed to evaluate the effect of combined sleep factors on the risk of hypertension and to explore whether this association is independent of genetic risk. Methods: This population-based prospective cohort study included 170,378 participants from the UK Biobank study. We conducted a healthy sleep score based on a combination of major five sleep factors and a genetic risk score based on 118 risk variants. Cox proportional hazard regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Results: A total of 170,378 participants were included. Compared to participants with a healthy sleep score of 0-1, those with healthy sleep scores of 2 (HR, 0.90; 95% CI, 0.83-0.98), 3 (HR, 0.81; 95% CI, 0.75-0.88), 4 (HR, 0.74; 95% CI, 0.68-0.81), or 5 (HR, 0.67; 95% CI, 0.59-0.77) had increasingly lower risks of hypertension ( P for trend <0.001). Participants with high genetic risk and an unfavorable sleep pattern had a 1.80-fold greater risk of hypertension than participants with low genetic risk and a favorable sleep pattern. The association between sleep patterns and hypertension persisted in subgroup analysis, stratified by the genetic risk. Nearly 18.2% of hypertension events in this cohort could be attributed to unfavorable sleep pattern. Conclusions: Favorable sleep pattern was associated with a low risk of hypertension, regardless of genetic risk. These findings highlight the potential of sleep interventions to reduce risk of hypertension across entire populations., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Li, Huang, Gao, Chung, Zhang, Shen, Zhang, Zhong, Liu, Chen, Chen, Cai, Cheng, Yang, Song, Wu, Kraus and Mao.)

Background: While well-conducted systematic reviews (SRs) can provide the best evidence on the potential effectiveness of acupuncture, limitations on the methodological rigour of SRs may impact the trustworthiness of their conclusions. This cross-sectional study aimed to evaluate the methodological quality of a representative sample of SRs on acupuncture effectiveness., Methods: Cochrane Database of Systematic Reviews, MEDLINE, and EMBASE were searched for SRs focusing on the treatment effect of manual acupuncture or electro-acupuncture published during January 2018 and March 2020. Eligible SRs must contain at least one meta-analysis and be published in English language. Two independent reviewers extracted the bibliographical characteristics of the included SRs with a pre-designed questionnaire and appraised the methodological quality of the studies with the validated AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2). The associations between bibliographical characteristics and methodological quality ratings were explored using Kruskal-Wallis rank tests and Spearman's rank correlation coefficients., Results: A total of 106 SRs were appraised. Only one (0.9%) SR was of high overall methodological quality, zero (0%) was of moderate-quality, six (5.7%) and 99 (93.4%) were of low-quality and critically low-quality respectively. Among appraised SRs, only ten (9.4%) provided an a priori protocol, four (3.8%) conducted a comprehensive literature search, five (4.7%) provided a list of excluded studies, and six (5.7%) performed meta-analysis appropriately. Cochrane SRs, updated SRs, and SRs that did not search non-English databases had relatively higher overall quality., Conclusions: Methodological quality of SRs on acupuncture is unsatisfactory. Future reviewers should improve critical methodological aspects of publishing protocols, performing comprehensive search, providing a list of excluded studies with justifications for exclusion, and conducting appropriate meta-analyses. These recommendations can be implemented via enhancing the technical competency of reviewers in SR methodology through established education approaches as well as quality gatekeeping by journal editors and reviewers. Finally, for evidence users, skills in SR critical appraisal remain to be essential as relevant evidence may not be available in pre-appraised formats., (© 2021. The Author(s).)

Objective: To examine the association of incident type 2 diabetes (T2D) risk with sleep factors, genetic risk, and their combination effects., Design: Large prospective population-based cohort study., Methods: This population-based prospective cohort study included 360 403 (mean (s.d.) age: 56.6 (8.0) years) participants without T2D at baseline from the UK Biobank. Genetic risk was categorised as high (highest quintile), intermediate (quintiles: 2-4), and low (lowest quintile) based on a polygenic risk score for T2D. Sleep scores, including long or short sleep duration, insomnia, snoring, late chronotype, and excessive daytime sleepiness, were categorized as an unfavourable, intermediate, or favourable sleep and circadian pattern., Results: During a median follow-up of 9.0 years, 13 120 incident T2D cases were recorded. Among the participants with an unfavourable sleep and circadian pattern, 6.96% (95% CI: 6.68-7.24%) developed T2D vs 2.37% (95% CI: 2.28-2.46%) of participants with a favourable sleep and circadian pattern (adjusted hazard ratio (HR): 1.53, 95% CI: 1.45-1.62). Of participants with a high genetic risk, 5.53% (95% CI: 5.36-5.69%) developed T2D vs 2.01% (95% CI: 1.91-2.11%) of participants with a low genetic risk (adjusted HR: 2.89, 95% CI: 2.72-3.07). The association with sleep and circadian patterns was independent of genetic risk strata. Participants in the lowest quintile with an unfavourable sleep and circadian pattern were 3.97-fold more likely to develop T2D than those in the lowest quintile with a favourable sleep and circadian pattern., Conclusions: Sleep and circadian patterns and genetic risk were independently associated with incident T2D. These results indicate the benefits of adhering to a healthy sleep and circadian pattern in entire populations, independent of genetic risk.

Background: Chinese medicine (CM) modalities, including acupuncture and Chinese herbal medicine (CHM), are popular palliative interventions among patients with cancer, but further clinical research is required to assess their effectiveness and safety., Objective: To prioritize top ten important CM clinical research questions from patients with cancer, cancer survivors and caregivers' perspectives via a face-to-face prioritization workshop in Hong Kong., Methods: A list of 25 CM clinical research questions for cancer palliative care, which were identified from existing systematic reviews (SRs) and overview of SRs, was presented to 17 participants (patients with cancer [n = 5], cancer survivors [n = 6] and caregivers [n = 6]). The participants were then invited to establish consensus on prioritizing top ten research questions., Results: Among the top ten priorities, five (50%) focused on acupuncture and related therapies, while five (50%) were on CHM. The three most important research priorities were (i) manual acupuncture plus opioids for relieving pain; (ii) CHM for improving quality of life among patients receiving chemotherapy; and (iii) concurrent use of CHM plus loperamide for reducing stomatitis., Conclusion: The top ten participant-endorsed CM clinical research priorities for cancer palliative care can guide local researchers on future direction. They can also inform local research funders on patient-centred allocation of limited funding. Under limited research funding, the most important co-prioritized research question from professional and patient perspectives may be addressed first., Patient or Public Contribution: Patients with cancer, cancer survivors and caregivers participated in conduct of the study to prioritize CM clinical research questions., (© 2021 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Background: In response to the World Health Organization's recommendation, policy makers have been adopting evidence-based healthcare approach to promote the development of traditional, complementary and integrative medicine (TCIM) into Hong Kong's health system. Disseminating synopses of clinical evidence from systematic reviews or randomized trials is regarded as a potentially effective strategy to promote evidence uptake. The study aimed to identify barriers and facilitators to implementing this strategy among Hong Kong Chinese medicine practitioners (CMPs)., Methods: Twenty-five CMPs aged under 45 years and trained in Hong Kong after reunification with China in 1997 were interviewed individually. Four clinical evidence synopses of randomized trials and systematic reviews on Chinese medicine interventions were presented, and CMPs were asked to comment on their applicability in routine practice. The Consolidated Framework for Implementation Research (CFIR) was applied to guide interview and analysis., Results: The barriers included: i) CMPs' perceived difficulties in applying complex evidence in decision-making and ii) inadequate training and limited consultation time. The facilitators were i) availability of publicly accessible and user-friendly synopses, ii) formation of community of evidence-based practice among CMPs with input from key opinion leaders, iii) opportunity for interprofessional collaborations with conventional healthcare providers, and iv) patients' demand for evidence-based clinical advice. Besides, i) CMPs' knowledge and beliefs in evidence-based healthcare approach, ii) presentations of evidence-based information in the synopses, and iii) clinical decision making as influenced by quality of evidence reported acted as both barriers and facilitators., Conclusions: This CFIR-based qualitative study investigated how the World Health Organization recommendation of promoting evidence use in routine practice was perceived by CMPs trained in Hong Kong after reunification with China in 1997. Key barriers and facilitators to applying evidence were identified. Such results will inform tailoring of implementation strategies for promoting evidence uptake, in the context of a well-developed health system dominated by conventional medicine., (© 2021. The Author(s).)

Background: The World Health Organization advocates integration of traditional and complementary medicine (T&CM) into the conventional health services delivery system. Integrating quality services in a patient-centred manner faces substantial challenges when T&CM is delivered within a health system dominated by conventional medicine. This review has synthesized international experiences of integration strategies across different contexts., Sources of Data: Publications describing international experiences of delivering T&CM service in conventional healthcare settings were searched. Backward and forward citation chasing was also conducted., Areas of Agreement: Capable leaders are crucial in seeking endorsement from stakeholders within the conventional medicine hierarchy and regulatory bodies. However, patient demands for integrative care can be successful as demonstrated by cases included in this review, as can the promotion of the use of T&CM for filling effectiveness gaps in conventional medicine. Safeguarding quality and safety of the services is a priority., Areas of Controversy: Different referral mechanisms between conventional and T&CM practitioners suit different contexts, but at a minimum, general guideline on responsibilities across the two professionals is required. Evidence-based condition-specific referral protocols with detailed integrative treatment planning are gaining in popularity., Growing Points: Interprofessional education is critical to establishing mutual trust and understanding between conventional clinicians and T&CM practitioners. Interprofessional communication is key to a successful collaboration, which can be strengthened by patient chart sharing, instant information exchange, and dedicated time for face-to-face interactions., Areas Timely for Developing Research: Research is needed on the optimal methods for financing integrated care to ensure equitable access, as well as in remuneration of T&CM practitioners working in integrative healthcare., (© The Author(s) 2021. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: With increasing burden of chronic non-communicable diseases (NCD), ageing becomes a global public health concern, and the World Health Organization Western Pacific Region has no exception. To address the NCD challenge, priority should be given to promote healthy ageing across the life-course. As traditional and complementary medicine (T&CM) is popular within the Region, it is of policy interest to explore possibilities of applying T&CM for promoting healthy ageing., Methods: We first summarized sources of clinical evidence supporting the use of T&CM. We then searched publications through MEDLINE from its inception to April 2020 to identify studies focusing on the perception of T&CM among older people. Finally, taking current evidence base and patient choice into account, we generated policy recommendations for of integrating T&CM into health systems., Result: Experiences from countries with different income levels suggested that promoting evidence-based T&CM as self-care modalities would be the most efficient way of maximizing impact among the older population, especially via a train the trainer approach. Meanwhile, popularity of natural products in the Region mandates policy makers to implement appropriate regulation and quality assurance, and to establish pharmacovigilance to detect potential harm. The role of pharmacists in advising patients on self-medication using natural products needs to be strengthened., Conclusion: Policy-makers will benefit from continued global dialogue and sharing of experience in T&CM policy development and implementation. Harmonizing regulatory frameworks for natural products at regional and global levels, including mutual recognition of regulatory approval, to improve standards and protect patients could be a priority., (© 2020 Korea Institute of Oriental Medicine. Publishing services by Elsevier B.V.)

Purpose: Systematic reviews (SRs) provide the best evidence on the effectiveness of treatment strategies for osteoporosis. Carefully conducted SRs provide high-quality evidence for supporting decision-making, but the trustworthiness of conclusions can be hampered by limitation in rigor. We aimed to appraise the methodological quality of a representative sample of SRs on osteoporosis treatments in a cross-sectional study., Methods: Cochrane Database of Systematic Reviews, EMBASE, MEDLINE, and PsycINFO were searched for SRs on osteoporotic treatments. AMSTAR (A MeaSurement Tool to Assess systematic Reviews) 2 was used to evaluate methodological quality of SRs. Associations between bibliographical characteristics and methodological quality ratings were explored using multivariate regression analyses., Results: A total of 101 SRs were appraised. Overall, one (1.0%) was rated "high quality", three (3.0%) were rated "moderate quality", eleven (10.9%) were rated "low quality", and eighty-six (85.1%) were rated "critically low quality". Ninety-nine (98.0%) did not explain study design selection, eighty-five (84.2%) did not provide a list of excluded studies (84.2%), and eighty-five (84.2%) did not report funding sources of included studies. SRs published in 2018 or after were associated with higher overall quality [adjusted odds ratio (AOR): 5.48; 95% confidence interval (CI): 1.12-26.89], while SRs focused on pharmacological interventions were associated with lower overall quality [AOR: 0.24; 95% CI: 0.06-0.96]., Conclusion: The methodological quality of the included SRs is far from satisfactory. Future reviewers must strengthen rigor by improving literature search comprehensiveness, registering and publishing a priori protocols, and optimising study selection and data extraction. Better transparency in reporting conflicts of interest among reviewers, as well as sources of funding among included primary studies, are also needed., Competing Interests: Declaration of competing interest The authors declare no conflict of interest. Declarations, (Copyright © 2020 Elsevier Inc. All rights reserved.)

Rationale: Systematic reviews (SRs) provide the best evidence of the effectiveness of treatment strategies for asthma. Carefully conducted SRs provide high-quality evidence for supporting decision-making, but the trustworthiness of conclusions can be hampered by limitation in rigor. Objectives: To appraise the methodological quality of a representative sample of SRs on asthma treatments in a cross-sectional study. Methods: A cross-sectional study was conducted to identify SRs on asthma treatment published between 2013 and 2019 by searching the Cochrane Database of Systematic Reviews, Embase, MEDLINE, and PsycINFO. SRs including at least one meta-analysis on asthma treatments were included. Methodological quality of included SRs was assessed with the Assessing the Methodological Quality of Systematic Reviews 2 instrument. Factors associated with methodological quality were explored using multivariate regression analysis. Results: One hundred thirty-six SRs were included and appraised, with a majority being non-Cochrane reviews (71.3%). Only 12 (8.8%) were of high overall quality; 9 (6.6%), 32 (23.5%), and 83 (61.0%) were of moderate, low, and critically low overall quality, respectively. More specifically, no SRs (0.0%) conducted a comprehensive literature search; only 3 (2.2%) justified why a particular primary study design was selected; 37 (27.2%) reported sources of funding among included studies; and 54 (39.7%) provided lists of excluded studies with justification. Cochrane reviews (adjusted odds ratio, 36.56; 95% confidence interval, 10.49-127.42) and SRs published after 2017 (adjusted odds ratio, 4.52; 95% confidence interval, 1.73-11.83) were positively associated with higher methodological quality. Conclusions: Methodological quality of SRs on asthma treatments are suboptimal. Future SRs should be improved by conducting comprehensive literature searches, justifying study design selection, providing a list of excluded studies, and reporting funding sources of included studies.

Introduction: The World Health Organization declared the coronavirus disease (COVID-19) as a pandemic on 11 March 2020, after the number of confirmed cases outside China increased 13-fold. As the epicentre of the initial outbreak, China has been updating the National COVID-19 Diagnostic and Treatment Guideline with up-to-date information about the disease. To facilitate the implementation of integrative Chinese-Western Medicine in COVID-19 management, Traditional Chinese medicine (TCM) has been recommended in recent editions of the national guideline., Methods: The national guideline summarised the opinions and frontline experience of medical experts across the country to provide by far the best management for COVID-19. We extracted the case definition and clinical classifications of COVID-19 in China along with relevant TCM treatments cited in the seventh edition of the guideline, with an intent to disseminate practical information to TCM clinicians and researchers around the world., Results: We present the most recent case definition, clinical classifications, and relevant TCM treatments of COVID-19 in accordance with the recommendations in the Chinese guideline. TCM treatments are stratified into two groups based on patients' disease status. Four types of Chinese patent medicines are recommended for suspected COVID-19 cases. Several herbal formulae are recommended for confirmed COVID-19 cases according to their clinical classification and TCM pattern diagnoses. Two herbal formulae are also recommended for rehabilitation of recovering cases., Conclusion: To control the waves of COVID-19 outbreak, countries must ensure the adherence of their citizens to local public health measures. Medical professionals should diagnose and treat patients according to up-to-date guidelines. Future evaluation of the outcomes of implementing TCM recommendations will strengthen the evidence base for COVID-19 management for the sake of public health and the internationalisation of TCM., Competing Interests: Dr Vincent CH Chung is a member of the editorial board for the European Journal of Integrative Medicine. The remaining authors declare that there are no conflicts of interest regarding the publication of this paper., (© 2020 Elsevier GmbH. All rights reserved.)

Purpose: To test the efficacy of intra-articular hypertonic dextrose prolotherapy (DPT) vs normal saline (NS) injection for knee osteoarthritis (KOA)., Methods: A single-center, parallel-group, blinded, randomized controlled trial was conducted at a university primary care clinic in Hong Kong. Patients with KOA (n = 76) were randomly allocated (1:1) to DPT or NS groups for injections at weeks 0, 4, 8, and 16. The primary outcome was the Western Ontario McMaster University Osteoarthritis Index (WOMAC; 0-100 points) pain score. The secondary outcomes were the WOMAC composite, function and stiffness scores; objectively assessed physical function test results; visual analogue scale (VAS) for knee pain; and EuroQol-5D score. All outcomes were evaluated at baseline and at 16, 26, and 52 weeks using linear mixed model., Results: Randomization produced similar groups. The WOMAC pain score at 52 weeks showed a difference-in-difference estimate of -10.34 (95% CI, -19.20 to -1.49, P = 0.022) points. A similar favorable effect was shown on the difference-in-difference estimate on WOMAC function score of -9.55 (95% CI, -17.72 to -1.39, P = 0.022), WOMAC composite score of -9.65 (95% CI, -17.77 to -1.53, P = 0.020), VAS pain intensity score of -10.98 (95% CI, -21.36 to -0.61, P = 0.038), and EuroQol-5D VAS score of 8.64 (95% CI, 1.36 to 5.92, P = 0.020). No adverse events were reported., Conclusion: Intra-articular dextrose prolotherapy injections reduced pain, improved function and quality of life in patients with KOA compared with blinded saline injections. The procedure is straightforward and safe; the adherence and satisfaction were high., (© 2020 Annals of Family Medicine, Inc.)

Background: Splinting is recommended by various organisations as a non-surgical first-line treatment for carpal tunnel syndrome (CTS), despite the limited evidence supporting its effectiveness. Previous studies on the effectiveness of low-level laser therapy (LLLT) have reported mixed results, and this systematic review aimed to resolve this controversy., Objective: To perform a network meta-analysis (NMA) for evaluating the effectiveness of LLLT compared with other conservative treatments for CTS., Methods: Eighteen electronic databases were searched for potential randomised controlled trials (RCTs). RCTs evaluating LLLT or other non-surgical treatments as an add-on to splinting were included. Included RCTs measured at least one of the following three outcomes with validated instruments: pain, symptom severity and functional status., Results: Six RCTs (418 patients) were included. NMA suggested that LLLT plus splinting has the highest probability (75%) of pain reduction, compared with sham laser plus splinting (61%), ultrasound plus splinting (57%) and splinting alone (8%). However, while LLLT plus splinting is significantly more effective than sham laser plus splinting for pain reduction, the magnitude is not clinically significant (Visual Analogue Scale mean difference -0.53cm, 95% confidence interval -1.01 to -0.05cm; P=0.03, I 2 =25%). The effect of LLLT plus splinting on symptom severity and functional status was not superior to splinting alone., Conclusion: The use of LLLT in addition to splinting for the management of CTS is not recommended, as LLLT offers limited additional benefits over splining alone in terms of pain reduction, reduction of symptom severity or improved functional status. PROSPERO for systematic reviews and meta-analyses registration number CRD42017082650., (Copyright © 2019 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)

Context: Chinese medicine modalities, including acupuncture and Chinese herbal medicine (CHM), have been used as palliative interventions among cancer patients. More research should be conducted to confirm their effectiveness., Objectives: The objective of this study was to prioritize Chinese medicine clinical research questions for cancer palliative care., Methods: Twelve international experts, including physicians, Chinese medicine practitioners, nurses, and clinical research methodologists (n = 3 from each category), from Asia, North America, Australia, and Europe participated in a two-round Delphi survey for prioritizing 29 research questions identified from existing systematic reviews. The experts were asked to 1) rate clinical importance of answering the questions on a nine-point Likert scale; 2) provide qualitative comments on their ratings; and 3) suggest outcome measurement approaches., Results: Eight research priorities reached positive consensus after the two-round Delphi survey. Six of the priorities focused on acupuncture and related therapies, of which median ratings on importance ranged from 7.0 to 8.0 (interquartile range: 1.00 to 2.50), and the percentage agreement ranged from 75.0% to 91.7%. The remaining two priorities related to CHM, with median ratings ranged from 7.0 to 8.0 (interquartile range: 1.00 to 1.50) and percentage agreement ranged from 75.0% to 83.3%. Neither positive nor negative consensus was established among the remaining 21 questions., Conclusion: The findings will inform rational allocation of scarce research funding for evaluating the effectiveness of Chinese medicine for cancer palliative care, especially on acupuncture and related therapies. Further research on herb safety and herb-drug interaction should be performed before conducting international trials on CHM., (Copyright © 2019 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background and Aim: Comorbid generalized anxiety disorder and irritable bowel syndrome are common and therapeutically challenging. We aimed to assess the effectiveness of electroacupuncture in relieving anxiety and bowel symptoms in Chinese adults with this form of comorbidity., Methods: In a single-blind randomized sham-controlled trial, subjects with comorbid generalized anxiety disorder and irritable bowel syndrome were randomly assigned to receive 10 weekly sessions of electroacupuncture or sham electroacupuncture. Patients were assessed at baseline, immediately after intervention and at 6-week follow-up. Primary outcome was anxiety (7-item Patient Health Questionnaire section for anxiety). Secondary outcomes included bowel symptoms (bowel symptoms questionnaire), depressive symptoms (9-item Patient Health Questionnaire), somatic symptoms (15-item Patient Health Questionnaire), and health-related quality of life (EuroQol-5 Dimensions)., Results: Eighty subjects, 40 in each arm, were randomized. All but two in the sham group completed 10 weekly sessions. There was no significant difference in the proportion of patients experiencing significant (≥ 50%) reduction of anxiety symptoms between the two groups immediately after intervention (32.4% vs 21.6%, P = 0.06) and at 6-week follow-up (25.7% in electroacupuncture vs 27% in sham, P = 0.65). Anxiety, depressive symptom, and bowel symptom severity did not differ significantly between electroacupuncture and sham groups., Conclusions: Findings failed to support the effectiveness of electroacupuncture for comorbid generalized anxiety disorder and irritable bowel syndrome. Further studies are needed to identify effective acupuncture treatment protocols for such comorbidity., (© 2019 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

WHO Traditional Medicine Strategy 2014-23 recommended evidence-based healthcare (EBHC) education for traditional and complementary medicine (T&CM) professionals, including Chinese medicine practitioners (CMPs). We evaluated the impact of a customized educational workshop on Hong Kong CMPs' knowledge, attitude and practice of EBHC. Two validated instruments, Evidence-based Practice Questionnaire (EPQ) and Evidence-based Practice Inventory (EPI), were used to assess the impact of EBHC education. Paired t-tests were used to compare scores before and after the workshop. Multiple linear regression was performed to explore the associations between changes in EPQ/EPI scores and CMPs' characteristics. CMPs who completed the workshop (n = 59) demonstrated significant improvements in the attitude (p = 0.013) and knowledge domains of the EPQ (p = 0.005). Significant improvements were also observed in the attitude, perceived behavioural control, decision making, and intention and behaviour domains of the EPI. CMPs who had never received prior EBHC training showed a larger magnitude of improvement in the EPI attitude (p = 0.032), decision making (p = 0.015), and intention and behaviour (p = 0.015) domains post-workshop. Our findings suggest that tailored workshop is effective in strengthening knowledge and in improving attitudes towards EBHC. Future RCTs should be conducted to affirm our findings. Future initiatives may consider incorporating this education approach into CMP curricula, as well as facilitating implementation of EBHC in routine Chinese medicine practice., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: An overview of systematic reviews (SRs) and a network meta-analysis (NMA) were conducted to evaluate the comparative effectiveness of acupuncture and related therapies used either alone, or as an add-on to other irritable bowel syndrome (IBS) treatments., Methods: A total of eight international and Chinese databases were searched for SRs of randomized controlled trials (RCTs). The methodological quality of SRs was appraised using the AMSTAR instrument. From the included SRs, data from RCTs were extracted for the random-effect pairwise meta-analyses. An NMA was used to evaluate the comparative effectiveness of different treatment options. The risk of bias among included RCTs was assessed using the Cochrane risk of bias tool., Results: From 15 SRs of mediocre quality, 27 eligible RCTs ( n = 2141) were included but none performed proper blinding. Results from pairwise meta-analysis showed that both needle acupuncture and electroacupuncture were superior in improving global IBS symptoms when compared with pinaverium bromide. NMA results showed needle acupuncture plus Geshanxiaoyao formula had the highest probability of being the best option for improving global IBS symptoms among 14 included treatment options, but a slight inconsistency exists., Conclusion: The risk of bias and NMA inconsistency among included trials limited the trustworthiness of the conclusion. Patients who did not respond well to first-line conventional therapies or antidepressants may consider acupuncture as an alternative. Future trials should investigate the potential of (1) acupuncture as an add-on to antidepressants and (2) the combined effect of Chinese herbs and acupuncture, which is the norm of routine Chinese medicine practice., Competing Interests: Conflict of interest statement: The authors declare that there is no conflict of interest.

Aims: Depression is one of the most common mental disorders and identifying effective treatment strategies is crucial for the control of depression. Well-conducted systematic reviews (SRs) and meta-analyses can provide the best evidence for supporting treatment decision-making. Nevertheless, the trustworthiness of conclusions can be limited by lack of methodological rigour. This study aims to assess the methodological quality of a representative sample of SRs on depression treatments., Methods: A cross-sectional study on the bibliographical and methodological characteristics of SRs published on depression treatments trials was conducted. Two electronic databases (the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects) were searched for potential SRs. SRs with at least one meta-analysis on the effects of depression treatments were considered eligible. The methodological quality of included SRs was assessed using the validated AMSTAR (Assessing the Methodological Quality of Systematic Reviews) tool. The associations between bibliographical characteristics and scoring on AMSTAR items were analysed using logistic regression analysis., Results: A total of 358 SRs were included and appraised. Over half of included SRs (n = 195) focused on non-pharmacological treatments and harms were reported in 45.5% (n = 163) of all studies. Studies varied in methods and reporting practices: only 112 (31.3%) took the risk of bias among primary studies into account when formulating conclusions; 245 (68.4%) did not fully declare conflict of interests; 93 (26.0%) reported an 'a priori' design and 104 (29.1%) provided lists of both included and excluded studies. Results from regression analyses showed: more recent publications were more likely to report 'a priori' designs [adjusted odds ratio (AOR) 1.31, 95% confidence interval (CI) 1.09-1.57], to describe study characteristics fully (AOR 1.16, 95% CI 1.06-1.28), and to assess presence of publication bias (AOR 1.13, 95% CI 1.06-1.19), but were less likely to list both included and excluded studies (AOR 0.86, 95% CI 0.81-0.92). SRs published in journals with higher impact factor (AOR 1.14, 95% CI 1.04-1.25), completed by more review authors (AOR 1.12, 95% CI 1.01-1.24) and SRs on non-pharmacological treatments (AOR 1.62, 95% CI 1.01-2.59) were associated with better performance in publication bias assessment., Conclusion: The methodological quality of included SRs is disappointing. Future SRs should strive to improve rigour by considering of risk of bias when formulating conclusions, reporting conflict of interests and authors should explicitly describe harms. SR authors should also use appropriate methods to combine the results, prevent language and publication biases, and ensure timely updates.

Purpose: We performed a phase 2 randomized clinical trial to evaluate the preliminary effectiveness of a clinic-based patellar mobilization therapy (PMT) in patients with knee osteoarthritis., Methods: We recruited 208 patients with knee osteoarthritis at primary care clinics in Hong Kong. Patients were randomly assigned (1:1) to the intervention group or the control group. The intervention group received 3 PMT treatment sessions from primary care physicians at 2-month intervals, with concomitant prescription of a home-based vastus medialis oblique muscle exercise. The control group received PMT after the study period. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score. Secondary outcomes included the WOMAC composite, function, and stiffness scores; the visual analog scale score for pain; objective physical function tests (30-s chair stand, 40-m walk test, timed up and go test, and EuroQol-5D). All outcomes were evaluated at baseline and at 24 weeks through intention-to-treat analysis., Results: We observed no baseline between-group differences. The WOMAC pain score showed greater improvement in the intervention group than in the control group at 24 weeks (between-group difference - 15.6, 95% CI, - 20.5 to - 10.7, P <.001). All secondary outcomes also demonstrated significant between-group differences., Conclusions: Patellar mobilization therapy has the potential to reduce pain and improve function and quality of life for patients with knee osteoarthritis. Future clinical trials with comparison to other active comparator controls will help determine the overall efficacy and facilitate the deployment of PMT in real-world practice., (© 2018 Annals of Family Medicine, Inc.)