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Background‘Tri-morbidity’ describes the complex comorbidity of chronic physical illness, mental illness, and alcohol and/or drug misuse within the homeless population. Poor health outcomes of homeless people are reflected by the higher rate of unplanned hospital admissions compared with the non-homeless population.AimTo identify whether tri-morbidity is a risk factor for unplanned hospital admissions in the homeless population.Design and settingA case–control study of patients who were registered with a specialist homeless GP surgery in Brighton (72 cases and 72 controls).MethodCases were defined as those who had ≥1 overnight hospital admission within a 12-month period. Controls were matched for demographics but with no hospital admission. The primary care record was analysed, and tri-morbidity entered into binomial logistic regression with admission as the dichotomous dependent variable.ResultsThe logistic regression analysis demonstrated that other enduring mental health disorders and/or personality disorder (odds ratio [OR] 3.84, 95% confidence interval [CI] = 1.56 to 9.44), alcohol use (OR 2.92, 95% CI = 1.42 to 5.98), and gastrointestinal disorder (OR 2.90, 95% CI = 1.06 to 7.98) were independent risk factors for admission. Tri-morbidity increased odds of admission by more than four-fold (OR 4.19, 95% CI = 1.90 to 9.27).ConclusionThis study shows that tri-morbidity is an important risk factor for unplanned hospital admissions among the homeless population, and provides an interesting starting point for the development of a risk stratification tool to identify those at risk of unplanned admission in this population.

The COVID-19 pandemic raised acute awareness regarding inequities and inequalities and poor clinical outcomes amongst ethnic minority groups. Studies carried out in North America, the UK and Australia have shown a relatively high burden of asthma and allergies amongst ethnic minority groups. The precise reasons underpinning the high disease burden are not well understood, but it is likely that this involves complex gene-environment interaction, behavioural and cultural elements. Poor clinical outcomes have been related to multiple factors including access to health care, engagement with healthcare professionals and concordance with advice which are affected by deprivation, literacy, cultural norms and health beliefs. It is unclear at present if allergic conditions are intrinsically more severe amongst patients from ethnic minority groups. Most evidence shaping our understanding of disease pathogenesis and clinical management is biased towards data generated from white population resident in high-income countries. In conjunction with standards of care, it is prudent that a multi-pronged approach towards provision of composite, culturally tailored, supportive interventions targeting demographic variables at the individual level is needed, but this requires further research and validation. In this narrative review, we provide an overview of epidemiology, sensitization patterns, poor clinical outcomes and possible factors underpinning these observations and highlight priority areas for research.

ObjectiveThis study aimed to explore the mental well-being of Syrian refugees and identify their coping mechanisms and pathways towards integration into new communities.DesignQualitative study using in-depth semi-structured interviews.Setting and participantsAdult Syrian refugees (>18 years old) currently residing in South East of England.Results12 participants (3 women and 9 men) took part in the study, all were born in Syria and the majority (n=9) were over 45 years of age. Our findings show that Syrian refugees face constant challenges as they try to integrate into a new society. Loss of and separation from loved ones as well as the nostalgia for the homeland were often cited as a source of psychological distress that created an overwhelming sense of sadness. Participants reported that they struggled for connectedness due to cultural difference and the problematic nature of rapidly formed migrant communities in their new setting. They believed in ‘being their own doctor’ and turning to faith, ritual and nature for healing and comfort. Taboo and stigma around mental health and language barriers were cited as barriers to accessing mental healthcare services.ConclusionPast experiences and present challenges frame Syrian refugees’ sense of well-being, impact use of healthcare and risk future mental health problems. It is hoped that this study will act as a catalyst for further research on this vulnerable group to promote integration, community support and culturally sensitive mental health services.

Background: Smokeless tobacco and waterpipes are used by hundreds of millions of people worldwide and consumption rates exceed that of cigarette smoking in much of South East Asia and parts of the Middle East. However, the cancer risks of these methods of tobacco consumption are less well-characterized than those of cigarette smoking. The objective of this study was to systematically review the epidemiological evidence on the association between smokeless tobacco use and waterpipe smoking and lung cancer risk.\ud \ud Methods: The MEDLINE, EMBASE, Web of Science and OpenSIGLE databases were searched to identify eligible case-control and cohort studies (published before 1st December 2020 in any language) that adjusted for cigarette smoking or included non-cigarette smokers only. Summary odds ratio/relative risk estimates and confidence intervals were extracted, and pooled risk ratios (RRs) for lung cancer were calculated using random effects meta-analysis.\ud \ud Results: The literature search identified 2,465 publications: of these, 26 studies including 6,903 lung cancer patients were included in the synthesis (20 studies of smokeless tobacco use, five of waterpipe smoking, one of both). Our results suggest that smokeless tobacco use is associated with an increased risk of lung cancer among non-cigarette smokers, and that betel quid tobacco may be particularly hazardous. The random effects meta-analysis showed that exclusive use of any type of smokeless tobacco (pooled RR= 1∙53, 95%CI 1∙09 – 2∙14), betel quid chewing (pooled RR= 1∙77, 95%CI 1∙06 – 2∙95), and waterpipe smoking (pooled RR = 3∙25, 95%CI 2.01 – 5∙25) were significantly associated with an increased risk of lung cancer.\ud \ud Conclusions: This meta-analysis of case-control/cohort studies supports the hypothesis that use of smokeless tobacco and waterpipe smoking is associated with increased risk of developing lung cancer. Considering the widespread and increasing use of smokeless tobacco in developing countries, and increasing prevalence of waterpipe smoking in almost all societies, these findings inform formulation of public health policy, legislation and tobacco control measures at national and international level to increase awareness and decrease the prevalence of smokeless tobacco use and waterpipe smoking.

Background To examine the process and mechanisms of delivering obesity interventions to physically disabled children/adolescents. Methods PubMed, Medline, CINAHL Plus, Embase, Cochrane Library, Google Scholar, ClinicalTrials.gov, Science Direct were systematically and manually searched for studies conducted in physically disabled children/adolescents (0–18 years). Included interventions were physical activity, diet and obesity prevention education. Included outcomes were body mass index (BMI)/weight and obesity prevention knowledge. The Mixed Methods Appraisal Tool aided methodological quality assessments. Data were extracted and delivery models were synthesized and narratively summarized using the social ecological model. Results Seven studies of low (n = 4) and moderate (n = 3) scoring on methodological quality were eligible for inclusion. Study duration was 5 months or less (n = 5), 8 months (n = 1) and 2 years (n = 1). Interventions were delivered at home, school, hospital and rehabilitation centre through the internet, face-to-face and parents. No intervention was delivered at three or more levels of individual, interpersonal, institutional or community levels. No study reported significant outcomes on reduction in BMI/weight, or increase in obesity prevention knowledge. Conclusions Evidence reviewed in this study shows that obesity interventions for physically disabled children/adolescents lack both in delivery and design. Gaps revealed should be considered when developing interventions for this special population.

Background Homelessness has increased dramatically in the last decade, with an estimated 165% increase in rough sleeping alone in England since 2010. People experiencing homelessness can often have what is referred to as the tri-morbidity; mental health, substance and or alcohol misuse and physical health problems. Hospital admission presents a potential point of intervention to address the health problems people have been experiencing, to link them in with services and as a bridge to housing. This service evaluation explored the role of a Hospital In-reach Service team for safer hospital discharge. Methods A qualitative in-depth interview study was conducted with six participants related to a Hospital In-reach Service team in South England. The interviews were transcribed, and analysed following Burnard's fourteen stage method. The ethical approval was obtained from Brighton and Sussex Medical School Research Governance and Ethics Committee (ER/BSMS4284/2). Results Three key themes were identified; the role of the Hospital In-reach Service team, barriers to, and facilitators for advocating patients' needs. The results indicate that the service team works incredibly well, building strong and trusting relationships with patients, community and hospital teams, taking a holistic approach to patient care. However, the structural discrimination against this patient group is reiterated in this study. Despite progress, there are still problems with non-specialist staff understanding this patient group's needs. Conclusions There is a need for clarification within Adult Social Care regarding the distribution of responsibility between hospital and community social work teams. There also appears to be a need for expansion of training for non-specialist service staff, including ward staff, discharge teams and social workers. In-reach housing services and expansion of the service team would be invaluable Key messages Hospital In-reach Service team in South England works incredibly well taking a holistic approach to patient care. Clarification in role of hospital and community social work teams is required for better management of this issue.

Background The Syrian conflict has resulted in an estimated 5.3 million registered Syrian refugees in various parts of the world. Evidence suggests that these individuals are at considerable risk of developing common mental disorders. This study aimed to explore the mental wellbeing of Syrian refugees, identify their coping mechanisms and pathways towards integration into new communities, and formulate recommendations for better access to mental healthcare services. Methods We conducted a qualitative study using in-depth semi-structured interviews with adult refugees (>18 years old) who are currently residing in Southeast of England. Interviews were conducted in Arabic, recorded, transcribed and translated verbatim. Translated transcripts were analysed using thematic analysis. Ethical Approval was obtained from the Brighton and Sussex Medical School Research Governance Ethics Committee (ER/BSMS9DAP/1). Results Twelve participants (3 females and 9 males) took part in the study; all were born in Syria and the majority (n = 9) were over 45 years of age. Participants described symptoms of reduced psychological wellbeing. Preliminary findings shows that almost all participants talked about psychological distress resulting from previous trauma, loss of and separation from family members and challenges adjusting to their host country. Barriers to accessing the healthcare system in the UK included fear of stigma, being misunderstood by healthcare staff and language issues. Communicating with loved ones, connecting with nature, practising faith and pursuing hobbies were reported as coping strategies. Conclusions For Syrian refugees in the UK, mental wellbeing embraces living with past traumatic experiences, achieving social integration and facing challenges accessing healthcare. Understanding differences between refugee and host communities is key to appropriately cater to the specific needs of each community and achieve equity in healthcare access. Key messages Syrian refugees in UK described symptoms of reduced psychological wellbeing. Understanding the needs of refugee communities is necessary to achieve equity in healthcare access.

Background Cancer and dementia are important diseases of ageing. Cancer affects 1 in 3 people in their lifetime, and dementia will affect 1 in 3 people who reach 90 years of age. Evidence suggests that people who have survived cancer may have a lower risk of subsequently developing Alzheimer's Disease (AD); however, there is no evidence on the association between cancer and incident Vascular Dementia (VD), which is the second most common form of dementia. We evaluated the prevalence of cancer history in cases and dementia-free controls using electronic health records for primary care in the United Kingdom. Methods The association between dementia (AD or VD) and history of cancer was investigated using a retrospective case-control study. N = 45,000 cases of dementia over the age of 65 were matched (age, sex, practice) 1:1 to dementia-free cases within the Clinical Research Practice Datalink. Odds Ratios (OR) for history of cancer among dementia cases and controls were computed using logistic regression models adjusting for potential confounding variables (socio-demographic and lifestyle factors, diabetes, depression, hypertension). Results Preliminary results indicate that history of cancer was less prevalent among dementia cases than among controls. Cases reporting a history of cancer had significantly lower odds of AD than controls; this association remained significant after adjustment. No significant association was found between cancer history and VD. Conclusions This study supports prior research suggesting that cancer survivors may be less likely to experience AD in their lifetime; however, this inverse association requires further research that accounts for potential survivorship bias. Moreover, the absence of an association between cancer and VD suggests a link between neurodegeneration and oncogenesis. Key messages History of cancer may have differential associations with different types of dementia, which may inform research on the aetiology of Alzheimer’s disease. Given the limitations of case-control studies, cohort studies are needed to further assess the relationship between cancer and different forms of dementia.

BackgroundHealth education materials (HEMs) are widely used in general practice. However, there is little information on the variety of HEMs currently available to patients in the UK, or their preferences for accessing educational materials.AimTo assess patients’ perceptions of HEMs, and the variety and accessibility of these materials.Design and settingCross-sectional study conducted in general practices in Brighton and Hove.MethodAn anonymous questionnaire was distributed to patients in the waiting room (WR). Additionally, an audit was conducted to measure the variety of the HEMs. Results were analysed using binary multiple logistic regression.ResultsIn all, 556 participants (response rate 83.1%) from 19 practices took part. The mean age of participants was 49.3 years (SD ±18.9) and 63% were female. Perceived usefulness of HEMs was associated with reading in the WR using written HEMs, and not having a university degree; noticeability was associated with reading in the WR, and being female; attractiveness was associated with not having a university degree and shorter waiting time. On average, WRs contained 72 posters covering 23 topics, and 53 leaflets covering 24 topics, with many outdated and poorly presented materials of limited accessibility.ConclusionThis study found substantial variation in the amount, topicality, and quality of material available in WRs. As most patients notice HEMs and find them useful, available technology could be better utilised to widen access to HEMs. The introduction of wireless free internet (Wi-Fi) to waiting rooms should provide an opportunity to update this area.

Objective: To conduct a comprehensive review and meta-analysis of the effectiveness of meditation on a variety of asthma outcomes.\ud Methods: We searched MEDLINE, EMBASE, CINAHL, PsycINFO and AMED in June 2016 to identify randomised controlled trials (RCTs) investigating the effectiveness of meditation in adults with asthma. No restriction was put on language or year of publication. Study quality was assessed using The Cochrane Risk of Bias Assessment Tool. Meta-analysis was carried out using RevMan 5.3.\ud Results: Four RCTS involving 201 patients met the inclusion criteria. Quality of studies was inconsistent with only one study reporting adequate allocation concealment. Disease-specific quality of life was assessed in two trials; a pooled result involving 62 intervention and 65 control participants indicated a significant improvement in quality of life in the meditation group compared to the control group (SMD 0.40, 95% CI 0.05 to 0.76). A pooled result from all four studies indicated the uncertain effect of meditation in forced expiratory volume in one second (FEV1) (SMD −0.67, 95% CI −2.17 to 0.82). Results from the individual trials suggest that meditation may be helpful in reducing perceived stress and the use of short-term rescue medication.\ud Conclusion: Our review suggests that there is some evidence that meditation is beneficial in improving quality of life in asthma patients. As two out of four studies in our review were of poor quality, further trials with better methodological quality are needed to support or refute this finding.

Little is known about which quality of life measure best captures the lived experience of people with a chronic skin condition. The purpose of this study was to explore patients’ views on the Dermatology Life Quality Index (DLQI) and Skindex-29. Participants were adults (n = 28) with a diagnosis of eczema or psoriasis who completed the DLQI and the Skindex-29 before being interviewed about the content and format of these questionnaires. Interviews were analysed using content analysis. Participants were generally satisfied with length and layout of both questionnaires. However, the majority preferred the Skindex-29 for its ease of understanding, use of a longer recall period and incorporation of items on a variety of emotions. Participants reported both questionnaires failing to incorporate important aspects of their lives, for instance impact on professional relationships. Participants voiced limitations in both measures but overall felt Skindex- 29 better captured their lived experience.

Background Several studies have examined associations between neurodegenerative disorders (ND) including dementia, and cancer. However, the associations and directions of these relationships vary by types of ND and cancer. In the current context of ageing populations and increased incidence of ND, dementia and cancer, and existing comorbidity between these disease groups, a better understanding of these relationships could, in future, inform prevention and therapeutics. This systematic review summarises the epidemiological evidence on these associations. Methods PubMed, MEDLINE, Embase, Scopus and Web of Science were searched to identify relevant studies published by 31/12/2018. The search strategy included a combination of search and MESH terms related to ND (e.g. Alzheimer’s, dementia), cancer and study design (case-control, cohort). The quality of included studies was assessed using the Newcastle-Ottawa scale (NOS). Results 77 studies were eligible for inclusion. The majority of studies scored 6+ on the NOS scale and some reported significant associations between ND and cancer. The association with specific types of cancer was not as evident as with all cancers. An inverse relationship was found between NDs and particularly Alzheimer’s, Parkinson’s, and Dementia and Cancer. Only one study found no association between Vascular Dementia and Cancer. Conclusions The findings report an overall inverse association between NDs and all cancers but associations are less evident with specific cancer types. Results from this review can be helpful in recommending reporting standards for future research to reduce heterogeneity between studies. Key messages Exploring the intersection of neurodegenerative disorders/dementia and cancer might help redirect research to novel therapeutic approaches. A standardised approach in design and outcome measurement is necessary to reduce heterogeneity across the studies.

Background Tuberculosis (TB) cases in England often originate from high burden TB countries due to ’reactivation’ of the latent TB infection (LTBI), an asymptomatic and non-infectious phase lasting years. 5,137 TB cases were notified in England in 2017, and 71% of these patients were born outside the UK. This mixed-method study evaluated the implementation of the four LTBI testing and treatment programme for new migrants in South East (SE) England. Methods A retrospective database (May 2016-Feb 2018) review was undertaken to identify LTBI cases using multiple data sources; LTBI testing laboratories, LTBI programmes, and the national TB team at Public Health England. In addition, a survey questionnaire was emailed to 51 stakeholders (45% response rate) and five in-depth interviews were conducted with LTBI programme leads/TB nurses to explore the challenges of the programme. Quantitative data were analysed using descriptive summary statistics and qualitative interviews were analysed using thematic content analysis. Results Of the 5931 eligible patients, 40 % (n = 2391) accepted the LTBI test and 13.4% (n = 321) tested positive. 93.1% (n = 299) of the positive patients were referred for treatment and 63.8% (n = 191) of these accepted the treatment. The programme also picked up 18 active TB cases, an unexpected incidental finding. Results from the survey and the interviews identified laboratory arrangements, workforce, and data collection/management as the greatest challenges for the LTBI programme. Patient focused care, cultural understanding, success in testing/treating migrants, and raising awareness amongst professionals/communities were highlighted as achievements of the programme. Conclusions This study found that LTBI programmes in SE England are in line with national expectations and other LTBI programmes in England. The study recognises the achievements and good practice of the LTBI teams in SE England and identifies key barriers to improve the service for the future. Key messages Data collection and management is the biggest challenges of the LTBI programmes in SE England. The LTBI programmes in SE England are in line with national expectations.

Background The popularity of e-cigarette is increasing recently, both as an alternative nicotine delivery tool or smoking cessation aid. Austria is a country with a high smoking prevalence; 28% of the population are current smoker and 21% have tried e-cigarettes at least once. In this current context, it is important to understand the opinion regarding e-cigarettes. Methods This cross-sectional survey examined the use, knowledge, attitudes and beliefs towards e-cigarettes among undergraduate students from Carinthia University of Applied Sciences in Austria. The anonymous questionnaire was handed out in 29 classrooms during compulsory lecturers, and completed questionnaire was returned to a provided box in the front of the classroom. Descriptive summary statistics was used to summarize the results using SPSS 24. Statistical significance was considered at p < 0.05. Results A total of 528 students were approached and all returned the questionnaire giving a 100% completion rate. 83.7% were female and half (50.2%) were in the age group 20 and 24. 96.6% of students reported being aware of e-cigarettes and 32.4% mentioned trying e-cigarettes at least once. 71.2% reported of ever smoking tobacco. 53.8% disagreed that e-cigarettes are an effective way for smoking cessation and only 10.3% agreed recommending it to a friend or family for smoking cessation. 78.1% believed that e-cigarettes are harmful to the health of those who use them and 58.2% disagreed that the use of e-cigarettes should be prohibited on University Campus premises. Conclusions To our knowledge, this study is the first of its kind performed in Austria. Our study shows that self-reported ever use of e-cigarettes is 1.5 times higher among this population than among the general population in Austria. Majority of participants disagreed that e-cigarettes are an effective way for smoking cessation. There seems a gap in knowledge regarding the e-cigarette which needs to be addressed among the university students. Key messages In Austria, e-cigarettes use is 1.5 times higher among university students compared to the general population. Knowledge gap regarding e-cigarettes needs to be addressed among the university students.

Background Over 300 million people worldwide use smokeless tobacco (ST) with rates of use exceeding that of cigarette smoking in much of South-East Asia and amongst certain groups in the Middle East. This study investigated the association between consumption of ST use and waterpipe smoking and lung cancer risk. Methods A systematic review and meta-analysis was carried out to summarise the findings from the epidemiologic studies of the risk of lung cancer associated with ST use and waterpipe smoking. Search was carried out in MEDLINE, Embase, Web of Science and OpenSIGLE to identify studies published before 18th October 2018. A combination of MESH terms and keywords were used including lung cancer, smokeless tobacco, snuff, snus, betel quid, gutka, naswar, zarda, shisha. Only studies adjusted for cigarette smoking or conducted in non-smokers only were included in the analysis. Random effects meta-analysis was carried out to pool the risk estimates and subgroup analyses was carried out by tobacco type and in studies of non-smokers. Results The search yielded 1796 articles, of which 24 studies (19 studies of ST, four of waterpipes and one of both) including 6777 lung cancer patients were included in the meta-analysis. Lung cancer was found to be positively associated with waterpipe smoking (pooled OR 3·06 (95%CI 1·68 – 5·60) and betel quid tobacco chewing (pooled OR 1·77 (95%CI 1·06 – 2·95)). Among non-smokers, any type of ST use was associated with lung cancer (pooled OR 1·46 (95%CI 1·04 – 2·07). Conclusions Our study suggest positive associations between ST use and waterpipe smoking and lung cancer risk. Given the high prevalence of ST use in much of the developing world, public health policies and international tobacco control efforts should focus on aiming to reduce ST use in addition to cigarette smoking. Key messages The risk of lung cancer is approximately three times higher in waterpipe smokers than in non-smokers. International tobacco control efforts should focus on aiming to reduce smokeless tobacco use in addition to cigarette smoking.

Background: Exposure to moderate-to-high doses of ionising radiation is the only established environmental risk factor for thyroid cancer and brain and CNS tumours. Considering the high life-time prevalence and frequency of exposure to dental x-rays, the most common source of diagnostic radiation exposure in the general population, even a small associated increase in cancer risk would be of considerable public health importance. With the objective to inform clinical practice and guidelines, we synthesised the current epidemiological evidence on the association between dental x-rays and the risk of thyroid cancer, meningioma and other cancers of the head and neck region.\ud \ud Methods: The Medline, Embase and Web of Science databases were searched to identify eligible studies. Summary odds ratio/relative risk estimates and confidence intervals were extracted, and pooled risk ratios (RR) for each cancer were calculated using random effects meta-analysis. \ud \ud Results: The literature search identified 5537 publications; of these, 26 studies including 10,868 cancer patients were included in the synthesis. The random effects meta-analyses, based on seven studies of thyroid cancer (six case-control, one cohort) and eight studies of meningioma (all case-control), showed that multiple (or repeated) exposures to dental x-rays were significantly associated with an increased risk of thyroid cancer (pooled RR = 1.87, 95% CI 1.11–3.15) and meningioma (pooled RR = 1.53, 95% CI 1.26–1.85). There was no association with glioma, and there were too few studies of other cancers of the head and neck region to conduct a meaningful meta-analysis. \ud \ud Conclusions: Based on a meta-analysis of retrospective case-control studies, these findings provide some support to the hypothesis that multiple (or repeated) exposures to dental x-rays may be associated with an increased risk of thyroid cancer and meningioma. These studies did not include individual organ doses and ages at exposure, and are subject to recall bias and other limitations. Furthermore, the thyroid exposure has decreased dramatically over time from the use of thyroid shields and improved technology/equipment. Prospective studies, based on dental x-rays records and patient follow-up, are needed to test the hypothesis further and clarify the possible cancer risk associated with dental radiography, as although the risk at the individual level, particularly with improved technology/equipment, is likely to be very low, the proportion of the population exposed is high. Considering that about one-third of the general population in developed countries is routinely exposed to one or more dental x-rays per year, these findings manifest the need to reduce diagnostic radiation exposure as much as possible.

Objective: To carry out a prospective evaluation of tranexamic acid (TXA) use in trauma patients. Patients and methods: TXA was introduced to all emergency ambulances and emergency departments in the South West, UK, on 1 December 2011. We carried out a prospective evaluation of TXA use in trauma patients in the South West Peninsula between December 2011 and December 2012. We collected prehospital and hospital data on TXA administration using the Trauma Audit Research Network database. Data on prehospital administration of TXA were cross-checked with the South Western Ambulance Service Trust. Data were analysed using SPSS (version 20). Results: Altogether, 82 patients were administered TXA during the study period. The median age of the patients was 49 years (IQR 30, 66), and 72% were men. One-third of the patients arrived at hospital by air ambulance. During the first 3 months, administration of TXA was limited to one patient each month receiving the drug. However, an upward trend was observed after June until October 2012, with the increment being more than 10 fold in July, September and October 2012. Conclusion: This is the first study to evaluate the use of TXA in civilian practice in the UK. Our study shows that ambulance service personnel and emergency departments can effectively administer TXA.

Aim: This study aimed to assess the quality of the information available on the Web on gum disease.\ud \ud Methods: The term ‘gum disease’ was searched in Google and in MedlinePlus. The first 200 websites were analysed by the Journal of the American Medical Association (JAMA) criteria and the Health On the Net Foundation (HONCode) certification, instruments for assessing quality of health information. Data was analysed through the Mann-Whitney test or KruskalWallis test, followed by the Dunn’s test, using the GraphPad Prism Software version 6.\ud \ud Results: MedlinePlus presented a significantly higher JAMA score than Google. Google’s first ten results had a higher JAMA score than the remaining websites. Journalism and health portals are the most reliable affiliations, while commercial and dental practices had low JAMA scores. JAMA score was significantly higher in websites with the HONCode certification compared to the ones without it.\ud \ud Conclusion: There are current concerns regarding patients’ use of the Internet for accessing health information. However, the conclusion we can make is that Google seems to favour websites with high quality information, at least in terms of JAMA score or HONCode accreditation. The JAMA score of dental practices’ websites could be improved by providing basic information such as authorship and date.

BackgroundMore than half of patients in the UK wait between 5 and 15 minutes before seeing the GP, and this time in the waiting room (WR) provides an ideal opportunity for patient education.AimTo assess patients’ perceptions of the usefulness, noticeability and attractiveness of health education materials (HEMs); and the variety, number, topics, design and accessibility of these HEMs.MethodAn anonymous questionnaire was distributed to patients in the WR to assess their use of health information and perceptions of HEMs. A survey measured the availability of HEMs in the WR and evaluated their quality against 16 accessibility and design criteria.ResultsA total of 556 questionnaires were completed (response rate 97.9%). On average, WRs contained 72 posters covering 23 topics, and 53 leaflets covering 24 topics. Multivariate analysis showed that patients’ perception of usefulness was significantly associated with reading in the WR, using written HEMs, and not having a university degree; whilst noticeability was associated with reading in the WR, and being female. Attractiveness was associated with not having a university degree and shorter waiting time.ConclusionThis study suggests that a wide variety of HEMs are available, and that many patients find them useful and noticeable, however, fewer find them well-designed and attractive. Future research should focus on the effectiveness of generally available HEMs at changing knowledge, attitudes, intentions, and behaviours; and utilising technology to deliver innovative means of providing patient health information.

Rationale, aims and objectives: The management of rheumatoid arthritis (RA) usually entails regular hospital reviews with a specialist often when the patient is well rather than during a period of exacerbation. An alternative approach where patients initiate appointments when they need them can improve patient satisfaction and resource use whilst being safe. This service evaluation reports a system-wide implementation of a patient-initiated review appointment system called Direct Access (DA) for people with RA. The aim was to establish the impact on patient satisfaction of the new system versus usual care as well as evaluate the implementation processes. Methods: As all patients could not start on the new system at once, in order to manage the implementation, patients were randomly allocated to DA or to usual care. Instead of regular follow-up appointments, DA comprised an education session and access to a nurse-led telephone advice line where appointments could be accessed within two weeks. Usual care comprised routine follow-ups with the specialist. Data were collected on patient satisfaction, service use and outcomes of any contact to the advice line. Results: Three hundred and eleven patients with RA were assessed as being suitable for DA. In terms of patient satisfaction, between-group differences were found in favour of DA for accessibility and convenience, ease of contacting the nurse and overall satisfaction with the service. Self-reported visits to the general practitioner were also significantly lower. DA resulted in a greater number of telephone contacts (incidence rate ratio = 1.69; 95% confidence interval 1.07 to 2.68). Hospital costs of the two different service models were similar. Mean waiting time for an appointment was 10.8 days. Conclusion: This service evaluation found that DA could be implemented and it demonstrated patient benefit in a real-world setting. Further research establishing the broader cost–consequences across the whole patient pathway would add to our findings.

Objectives: Inhalation of a cotton-based particulates has previously been associated with respiratory symptoms and impaired lung function. This study investigates the respiratory health of Nepalese textile workers in relation to dust and endotoxin exposure. Methods: A total of 938 individuals from four sectors (garment, carpet, weaving and recycling) of the textile industry in Kathmandu, Nepal completed a health questionnaire and performed spirometry. A subset (n=384) performed cross-shift spirometry. Personal exposure to inhalable dust and airborne endotoxin was measured during a full shift for 114 workers. Results: The overall prevalence of persistent cough, persistent phlegm, wheeze ever, breathlessness ever and chest tightness ever was 8.5%, 12.5%, 3.2%, 6.5% and 12.3%, respectively. Symptoms were most common among recyclers and least common among garment workers. Exposure to inhalable dust significantly predicted persistent cough and chest tightness. Exposure to endotoxin did not have any independent predictive effect. Significant cross-shift reduction in forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were found (p

Background Low back pain (LBP) is one of the most prevalent occupational health problems in industrialized countries. Little is known about the epidemiology of LBP in developing countries. Aims To determine the prevalence of LBP among Nepalese textile workers and to investigate the influence of exposure to mechanical and other factors on LBP reporting. Methods Interviewers completed questionnaires with study subjects, and work-related mechanical exposures were measured by self-completed questionnaires. Associations of LBP with mechanical factors and somatic symptoms were determined by logistic regression and reported as odds ratios (ORs) with 95% confidence intervals (CI). Results Nine hundred and thirty-eight workers took part, a participation rate of 92%. The 1 month period prevalence of LBP was 35% (n = 324), being higher in females than males (45% versus 28%; P < 0.001). Several work-related mechanical factors were associated with increased odds of reporting LBP: lifting heavy weights with one hand (OR 1.7; 95% CI 1.1–2.8), pushing weights (OR 1.6; 95% CI 1.2–2.3 and pulling weights (OR 1.6; 95% CI 1.1–2.1). No association was found with working posture. Strong associations were found for reporting one (OR 2.4; 95% CI 1.7–3.4) or two somatic symptoms (OR 2.7; 95% CI 1.4–5.1). On multivariable analysis, reporting of somatic symptoms (OR 2.8; 95% CI 1.5–5.4), female gender (OR 2.2; 95% CI 1.5–3.1) and increasing age were significantly associated with increased risk of reporting LBP (OR 1.7; 95% CI 1.2–2.5), but no associations were found with mechanical factors. Conclusions This study suggests that mechanical load may not be the leading cause of LBP and adds to evidence that psychological factors play an important role in LBP in non-industrialized countries.

Background: Exposure to inhalable cotton dust particulates and endotoxin have been previously associated with respiratory symptoms and acute changes in lung function. Objectives: This study investigates the cross-shift decline in lung function of female non-smoking textile workers in relation to dust and endotoxin exposure. Methods: We present the subgroup analysis of a previously published study in Nepalese textile workers. 295 workers in four textile sectors (garment, carpet, weaving and recycling) completed a respiratory health questionnaire. A subset of 127 workers performed cross-shift spirometry. Personal exposure to inhalable dust and endotoxin was measured for 32 workers; remaining workers were assigned the geometric mean values of all workers within the same textile sector. Multiple regression analysis were carried out to identify independent predictors of cross-shift decline in lung function. Results: The overall prevalence of persistent cough, persistent phlegm, chest tightness-, wheeze- and breathlessness-ever was 9.2%, 6.1%, 3.1%, 8.5% and 13.9% respectively. A significant cross-shift reduction (p

Background Parent-reported wheeze is often used as a proxy for childhood asthma. However, discordance in labelling of wheeze among parents and health-care workers (HCWs) affects true estimates of population wheeze. This systematic review aimed to summarise the evidence of parents' and HCWs' understanding of wheeze in children, and the relevant factors affecting this knowledge. Methods A systematic literature search was performed to identify studies published in English from Jan 1, 1990, to Nov 16, 2017, in the following databases: Medline, Embase, CINAHL, BNI, Cochrane Library, and PsycINFO. Studies were eligible if they assessed parents' or HCWs' understanding (or both) of wheeze or definition of wheeze in children, or the association between parentally reported (unconfirmed) wheeze and HCW-confirmed wheeze. Non-English language studies were excluded. The methodological quality of the included articles was evaluated with Joanna Briggs Institute critical appraisal checklists. This analysis is registered with PROSPERO, number CRD42017076635. Findings The initial search yielded 15 492 unique references, of which 21 met the inclusion criteria. The focus in nine studies was on parents, three focused on HCWs, and nine included both. Across studies, the mean percentage of parents correctly defining wheeze was 44·7% (SD 24·3; 95% CI 29·6–59·7), and the mean percentage correctly identifying it on video was 52·7% (12·8; 41·5–64·0). In one study, 97% of HCWs correctly defined wheeze, and, in another study, agreement between nurses and physicians in assessing wheeze severity was 52%. The mean percentage agreement between parent-reported wheeze and clinician-confirmed wheeze was 64·6% (15·4; 55·5–73·7). Parents' understanding of wheeze was affected by respiratory history in the parent or child, English as a first language, ethnicity, parental education, and method of ascertainment of symptoms. In HCWs, understanding was affected by their profession, age, and location. Interpretation Parents' and HCWs' understanding of wheeze is inconsistent and is affected by parent-related, child-related, research-related, and HCW-related factors, with only moderate agreement between parent-reported and clinician-confirmed wheeze. These findings could have an important impact in epidemiological studies to estimate asthma prevalence, and in assessing respiratory symptoms in clinical practice. Funding None.

Background The association between alcohol dependence and sugar intake is poorly understood with evidence suggesting that some adults undergoing alcohol recovery, primarily in the early stages, have sugar cravings. This may result in swapping of alcohol dependence for sugar cravings, and therefore have an adverse impact on the recovery process and overall health. This study aimed to explore experiences and views of alcohol recovery service users and staff members of a service provider on sugar cravings during recovery and possible ways to reduce cravings during this crucial time. Methods Participants for this qualitative study were recruited from an alcohol recovery services hub in West Sussex, UK. Adult service users (age >25 years) attending the 10 week Growth Workshop Programme, and service provider staff within the hub, were eligible to participate. The researcher attended the programme in week four and outlined the study and circulated the participant information sheet and consent form. The focus group took place in week five; written informed consent was obtained from all participants. Two focus group sessions were conducted with service users, and one session with staff. The focus group audiotapes were transcribed and data analysed using a framework approach for thematic analysis. Ethics approval was obtained from Brighton and Sussex Medical School (ERA/BSMS3653/3/2). Findings Seven service users (two female) and ten staff (seven female) took part in the study. Key themes emerging from the study were lack of awareness of the impact of sugar on health, addiction swap (substitution of sugar for alcohol addiction), impact of the built environment (accessibility to sugary food and drink), barriers to healthy eating (eg, cost), drinking-related action and behaviour (eg, holding a can), and interventions. Suggested interventions included social marketing materials (posters, leaflets), fresh fruit in service hubs, and group learning sessions and staff training on nutrition. Interpretation Our findings are consistent with existing evidence about sugar cravings during alcohol recovery and could be helpful to inform future interventions focusing on a holistic approach to alcohol recovery. Our study's strengths include capturing the views of both a vulnerable population group and service providers, but the small number of sessions and participants is a limitation. Funding West Sussex County Council, Public Health Directorate (for AT).

The management of rheumatoid arthritis (RA) usually entails regular hospital reviews with a specialist often when the patient is well rather than during a period of exacerbation. An alternative approach where patients initiate appointments when they need them can improve patient satisfaction and resource use whilst being safe. This service evaluation reports a system-wide implementation of a patient-initiated review appointment system called Direct Access (DA) for people with RA. The aim was to establish the impact on patient satisfaction of the new system versus usual care as well as evaluate the implementation processes.As all patients could not start on the new system at once, in order to manage the implementation, patients were randomly allocated to DA or to usual care. Instead of regular follow-up appointments, DA comprised an education session and access to a nurse-led telephone advice line where appointments could be accessed within two weeks. Usual care comprised routine follow-ups with the specialist. Data were collected on patient satisfaction, service use and outcomes of any contact to the advice line.Three hundred and eleven patients with RA were assessed as being suitable for DA. In terms of patient satisfaction, between-group differences were found in favour of DA for accessibility and convenience, ease of contacting the nurse and overall satisfaction with the service. Self-reported visits to the general practitioner were also significantly lower. DA resulted in a greater number of telephone contacts (incidence rate ratio = 1.69; 95% confidence interval 1.07 to 2.68). Hospital costs of the two different service models were similar. Mean waiting time for an appointment was 10.8 daysThis service evaluation found that DA could be implemented and it demonstrated patient benefit in a real-world setting. Further research establishing the broader cost-consequences across the whole patient pathway would add to our findings.

Objective:Patient information leaflets (PILs) are widely used to reinforce or illustrate health information and to complement verbal consultation. The objectives of the study were to assess the readability and presentation of PILs published by Allergy UK, and to conduct a longitudinal assessment to evaluate the impact of leaflet amendment and revision on readability. Methods:Readability of Allergy UK leaflets available in 2013 was assessed using Simple Measure of Gobbledegook (SMOG) and Flesch-Kincaid Reading Grade Formula. Leaflet presentation was evaluated using the Clear Print Guidelines of the Royal National Institute of Blind People (RNIB) and the Patient Information Appraisal System developed by the British Medical Association (BMA). Changes in the leaflets’ readability scores over five years were investigated. Results:108 leaflets, covering a wide range of allergic conditions and treatment options, were assessed. The leaflets had average SMOG and Flesch-Kincaid scores of 13.9 (range 11-18, SD 1.2) and 10.9 (range 5-17, SD 2.1) respectively. All leaflets met the RNIB Clear Print guidelines, with the exception of font size which was universally inadequate. The leaflets scored on average 10 (median 10, range 7-15) out of a maximum of 27 on the BMA checklist. The overall average SMOG score of 31 leaflets available in both 2008 and 2013 had not changed significantly. The process of leaflet revision resulted in 1% change in readability scores overall, with a predominantly upward trend with six leaflets increasing their readability score by >10% and only three decreasing by >10%. Conclusion:Allergy-related patient information leaflets are well presented but have readability levels that are higher than those recommended for health information. Involving service users in the process of leaflet design, together with systematic pre-publication screening of readability would enhance the accessibility and comprehensibility of written information for people with allergy and their careers.

Background Occupational skin disease is common and bakery workers are at increased risk of hand dermatitis. Aims To explore the frequency of, and to identify risk factors for, skin symptoms in a small bakery. Methods A cross-sectional survey of workers in a small bakery in Scotland, using a self-completed questionnaire regarding skin symptoms over the last 12 months. Additionally, data on self-reported atopy status, glove use and daily hand washing frequencies were obtained. Workers were classed as being at low, medium or high risk of occupational skin disease based on their job titles. Results The overall response rate was 85% (52 women, 41 men) with a mean age of 41 (range 17–72). Eleven per cent of bakers, confectioners and packers and 31% of cleaners, cooks and food production workers reported at least one skin symptom. Thirty-three per cent of symptomatic low-risk workers, 50% of symptomatic medium-risk workers and 75% of symptomatic high-risk workers stated their symptoms usually improved away from work. While washing hands more frequently than 20 times a day had an increased risk of skin symptoms, this was not significant [OR 3.5 (95% CI 0.9–13.2)]. Conclusions There was a high prevalence of skin symptoms among these bakery workers which was more than double that previously reported in UK bakeries. Frequent washing of hands as a risk factor for skin symptoms may warrant further investigation in bakery workers.

Background Psychological stress has been widely implicated in asthma exacerbation. Evidence suggests that written emotional disclosure, an intervention that involves writing about traumatic or stressful experiences, helps to reduce stress and promote physical and psychological well-being. Written emotional disclosure may have a role in the management of asthma. Objectives This review aims to determine the effectiveness of written emotional disclosure for people with asthma, specifically, to assess: 1. overall efficacy of emotional disclosure compared with emotionally neutral writing on self reported quality of life in people with asthma; 2. overall efficacy of emotional disclosure compared with emotionally neutral writing on objective measures of health outcome in people with asthma; and 3. comparative efficacy of different types of emotional disclosure for people with asthma. Search methods Trials were identified from the Cochrane Airways Group Specialised Register of trials, CENTRAL, MEDLINE, EMBASE, CINAHL, AMED and PsycINFO. The latest search was conducted in January 2014. Selection criteria Randomised controlled trials published in any language comparing written emotional disclosure intervention versus a control writing (emotionally neutral) intervention in participants with asthma were included in the review. Data collection and analysis Two review authors independently assessed studies against predetermined inclusion criteria and extracted the data. Corresponding authors were contacted when necessary to provide additional information. Main results Four studies, involving a total of 414 participants, met the inclusion criteria. Three studies were conducted in adult participants and one in adolescents. The average age of participants ranged from 14 to 43 years. The trials lasted between two months and 12 months. The interventions were based on Pennebaker's method. The risk of bias across most domains of the studies was generally considered to be low, however three of four studies were considered at high risk of bias due to lack of assessor blinding and one study was at high risk of bias for selective reporting. The interpretation of these studies was limited by diverse outcome measurements, measurement tools, control group techniques, and number and/or times of follow-up. A pooled result from the four studies, including a total of 146 intervention and 135 control participants, indicated uncertain effect in forced expiratory volume in one second (FEV1) % predicted between the disclosure group and the control group (mean difference (MD) 3.43%, 95% confidence interval (CI) -0.61% to 7.47%; very low-quality evidence) at ≤ three months' follow-up. Similarly, evidence from two studies indicated that written emotional disclosure found uncertain effect on forced vital capacity (FVC) (standardised mean difference (SMD) -0.02, 95% CI -0.30 to 0.26; low-quality evidence) and asthma symptoms (SMD -0.22, 95% CI -0.52 to 0.09; low-quality evidence) but may result in improved asthma control at ≤ three months' follow-up (SMD 0.29, 95% CI 0.01 to 0.58; low-quality evidence). We were unable to pool the data for other outcomes. Results from individual trials did not reveal a significant benefit of written emotional disclosure for quality of life, medication use, healthcare utilisation or psychological well-being. Evidence from one trial suggests a significant reduction in beta agonist use (MD -1.62, 95% CI -2.62 to -0.62; low-quality evidence) at ≤ three months' follow-up in the disclosure group compared with controls. The review did not address any adverse effects of emotional writing. Authors' conclusions Evidence was insufficient to show whether written emotional disclosure compared with writing about non-emotional topics had an effect on the outcomes included in this review. Evidence is insufficient to allow any conclusions as to the role of disclosure in quality of life, psychological well-being, medication use and healthcare utilisation. The evidence presented in this review is generally of low quality. Better designed studies with standardised reporting of outcome measurement instruments are required to determine the effectiveness of written emotional disclosure in the management of asthma.

This systematic review summarised the literature on patient acceptability of screening for oral cancer outside dental care settings. A comprehensive search of relevant literature was performed in EMBASE, MEDLINE, Cochrane Database of Systematic Reviews, CINAHAL, psycINFO, CANCERLIT and BNI to identify relevant articles published between 1975 and Dec 2013. Studies reporting acceptability of oral cancer screening to undiagnosed individuals attending non-dental settings were eligible for inclusion. A total of 2935 references were initially identified from the computerised search but 2217 were excluded after screening the titles. From the abstracts of the remaining 178 articles, 47 full text articles were retrieved for further scrutiny, and 12 studies were found to be eligible for inclusion. In these studies, knowledge about oral cancer, anxiety related to the screening process, preference for care provision, and financial cost were influencing factors for the acceptance of screening. Written information provided to patients in primary care was reported to boost immediate knowledge levels of oral cancer, lessen anxiety, and increase intentions for screening. The majority of screening methods were entirely acceptable to patients; lack of acceptability from the patients’ viewpoint was not a significant barrier to carrying out opportunistic screening of high-risk populations. In conclusion, the available evidence suggests that acceptance of, and satisfaction with oral cancer screening is high, particularly where patients have previously been educated about oral cancer. Further research focusing on patient’s preferences would enable streamlining of the approach to oral cancer screening taken by any national programme.

OBJECTIVE: To summarize evidence regarding the effectiveness of MTX in the treatment of childhood autoimmune chronic uveitis (ACU). METHODS: A systematic search of articles between January 1990 and June 2011 was conducted using EMBASE, Ovid MEDLINE, Evidence-Based Medicine Reviews-ACP Journal Club, the Cochrane Library and EBM Reviews. Studies investigating the efficacy of MTX as a single immunosuppressant medication in the treatment of ACU refractory to therapy with topical treatment and/or systemic treatment in children (≤16 years) were eligible for inclusion. The primary outcome measure was the improvement of intraocular inflammation, expressed as Tyndall, as defined by the Standardization of Uveitis Nomenclature working group criteria. The effect measure for each study was the proportion of people classified as responders. We determined a combined estimate of the proportion of children in the eligible studies responding to MTX. RESULTS: The initial search identified 246 articles of which 52 were potentially eligible. Nine eligible articles, all retrospective chart reviews, remained in the analysis. The number of children in studies ranged from 3 to 25, and the dose of MTX varied from 7.5 to 30 mg/m2. Altogether, 95 of 135 children responded to MTX. The pooled analysis suggested that MTX has a favourable effect in the improvement of intraocular inflammation: the proportion of responding subjects was 0.73 (95% CI 0.66, 0.81). CONCLUSION: Although randomized controlled trials are needed, the available evidence supports the use of MTX in the treatment of childhood ACU: approximately three-quarters of patients on MTX can expect improvement in intraocular inflammation.

To critically review the evidence on the effectiveness of complementary therapies for patients with RA.Randomized controlled trials, published in English up to May 2011, were identified using systematic searches of bibliographic databases and searching of reference lists. Information was extracted on outcomes and statistical significance in comparison with alternative treatments and reported side effects. The methodological quality of the identified studies was determined using the Jadad scoring system. All outcomes were considered but with a focus on patient global assessment and pain reporting.Eleven eligible trials were identified covering seven therapies. Three trials that compared acupuncture with sham acupuncture reported no significant difference in pain reduction between the groups but one out of two reported an improvement in patient global assessment. Except for reduction in physician's global assessment of treatment and disease activity reported in one trial, no other comparative benefit of acupuncture was seen. There were two studies on meditation and one each on autogenic training, healing therapy, progressive muscle relaxation, static magnets and tai chi. None of these trials reported positive comparative effects on pain but some positive effects on patient global assessment were noted at individual time points in the healing therapy and magnet therapy studies. A small number of other outcomes showed comparative improvement in individual trials. There were no reports of major adverse events.The very limited evidence available indicates that for none of the practitioner-based complementary therapies considered here is there good evidence of efficacy or effectiveness in the management of RA.

Background: Inhalation of cotton-based particulate has been associated with respiratory symptoms and overt lung disease related to endotoxin exposure in some studies. This cross-sectional study measures personal exposure to inhalable dust and endotoxin in the textile industry of Nepal. Methods: This study was conducted in four sectors (garment making, carpet making, weaving, and recycling) of the textile industry in Kathmandu, Nepal. Personal exposure to inhalable dust and airborne endotoxin was measured during a full-shift for 114 workers. Results: Personal exposure to cotton dust was generally low [geometric mean (GM) 0.81 mg m−3) compared to the UK workplace exposure limit (WEL) (2.5 mg m−3) but with nearly 18% (n = 20) of the workers sampled exceeding the limit. Exposures were lowest in the weaving and the garment sector (GM = 0.30 mg m−3), higher in the carpet sector (GM = 1.16 mg m−3), and highest in the recycling sector (GM = 3.36 mg m−3). Endotoxin exposures were high with the overall data (GM = 2160 EU m−3) being more than 20-fold higher than the Dutch health-based guidance value of 90 EU m−3. The highest exposures were in the recycling sector (GM = 5110 EU m−3) and the weaving sector (GM = 2440 EU m−3) with lower levels in the garment sector (GM = 157 EU m−3). The highest endotoxin concentrations expressed as endotoxin units per milligram inhalable dust were found in the weaving sector (GM = 165 EU mg−1). There was a statistically significant correlation between inhalable dust concentrations and endotoxin concentrations (r = 0.37; P < 0.001) and this was particularly strong in the garment (r = 0.82; P = 0.004) and the carpet sector (r = 0.81; P < 0.001). Conclusions: Inhalable dust exposures measured in the weaving, carpet, and garment sectors were all below the UK WEL for cotton dust. A significant proportion of the measurements from the cotton recycling sector were above the UK WEL suggesting that better hygiene control measures are required. Airborne endotoxin concentrations in all sectors were found to exceed the Dutch health-based guidance limit of 90 EU m−3 and may be associated with respiratory health effects.

Objectives: to establish whether review articles provide consistent conclusions on associations between workplace psychosocial factors and musculoskeletal pain and, if differences exist, to explore whether this is related to the methods used.Methods: reviews, reported up to February 2007, that included consideration of workplace psychosocial factors and upper limb, back or knee pain were identified through searches of multiple databases. The specific work-related psychosocial factors considered were job demands, support, job autonomy and job satisfaction. The conclusions of each review on one or more of the psychosocial/musculoskeletal pain associations were extracted.Results: 15 review articles were identified that considered one or more of the regional pain syndromes included in the study. For back pain, the most consistent conclusions (four reviews positive out of six) were with high job demands and low job satisfaction. The studies of upper limb pain were exclusively related to shoulder and/or neck pain, and the most consistent positive conclusions were with high and low job demands (four reviews positive out of six and two reviews positive out of three, respectively). For knee pain, only a single review was identified. For individual reviews of back and upper limb pain, there were marked differences in the number of associations concluded to be positive between reviews.Conclusions: the reasons for reviews coming to different conclusions included that they were often evaluating different bodies of evidence (according to their search criteria, the year when the review was conducted, the role that quality assessment played in whether studies contributed to evidence, and the combination of risk factors addressed in individual studies), but more important was whether the review specified explicit criteria for making conclusions on strength of evidence. These conclusions emphasise the importance of developing standardised methods for conducting such evaluations of existing evidence and the importance of new longitudinal studies for clarifying the temporal relationship between psychosocial factors and musculoskeletal pain in the workplace

This study was designed to assess the knowledge, attitudes, and infection control practices among Nepalese health care workers (HCWs). The study comprised a questionnaire survey of 324 staff from acute care hospitals in Kathmandu, Nepal. A total of 158 doctors and 166 nurses participated, 27% of whom had received infection control training. Only 16%, 14%, and 0.3% of the respondents achieved maximum scores for knowledge, attitude, and practice items, respectively. Staff had good knowledge and positive attitude toward most aspects of infection control, although only half had heard of methicillin-resistant Staphylococcus aureus. Logistic regression revealed that profession, age, and having studied abroad significantly predicted markers of infection control knowledge, attitudes, and practice. This is the first survey of infection control practice among Nepalese HCWs and provides useful baseline data by professional group. There is ample opportunity for improvement in current practice, which should be recognized by hospital managers and Nepalese health authorities.

Background Asthma is a chronic inflammatory disorder affecting 334 million people worldwide. Conventional medicines are effective for managing asthma in children, but important concerns exist about potential side-effects, such as increased heartbeat, muscle shake, and hyperactivity. Consequently, many patients turn to complementary and alternative therapies to seek care with a more holistic approach. We systematically reviewed the available evidence on effectiveness of complementary therapies in the management of asthma in children and adolescents ( Methods We searched Medline, Embase, CINAHL, AMED, and the Cochrane Database of Systematic Reviews to identify articles in English published between Jan 1, 2000, and Dec 13, 2014. Keywords included 57 names of practitioner-based complementary therapies and were combined with "asthma" and either "randomised controlled trial" or "quasi-randomised trial". Identified abstracts were double screened. Primary outcome of interest was forced expiratory volume in 1 second (FEV 1 ). Heterogeneity was assessed with the I 2 statistic. Fixed-effect meta-analysis was done with RevMan software (version 5.2). Quality of the studies was assessed with the Cochrane Collaboration Risk of Bias Assessment Tool. Findings 1187 non-duplicate records were found, of which 62 full text articles were assessed for eligibility. 20 additional studies were identified from the bibliographies of studies found. Of these 82 articles screened, 12 trials covering eight therapies were eligible. The trials involved 605 patients, aged 5–17 years. Ten of the 12 studies were assessed to be at high risk of bias. Pooled data from two studies indicated that, compared with standard treatment, massage therapy significantly improved lung function (FEV 1 ) (standardised mean difference 0·43, 95% CI 0·04–0·82), and that, compared with placebo or standard treatment, acupuncture significantly improved quality of life (0·43, 0·05–0·81). The data could not be pooled for other outcomes. Results from individual trials showed that tai chi and osteopathy were beneficial for improving lung function, and art therapy for quality of life. Only one study assessed adverse events and found laser acupuncture to be safe and well tolerated. Interpretation Although meta-analysis from a small number of studies on massage and acupuncture showed some benefit for improving lung function and quality of life, most studies were small and of poor quality. Therefore, the evidence is insufficient to recommend that any of the practitioner-based complementary therapies should be used in the management of asthma in children and adolescents. Funding None.

Background Routine screening is key to prevention and control of sexually transmitted infections. Evidence suggests that clinic-based screening programmes capture only a small proportion of people with these infections. Self-sampling using non-invasive or or minimally invasive techniques might be beneficial for people who are reluctant to engage with conventional methods. We systematically reviewed studies of patients' experiences of obtaining self-samples to diagnose curable sexually transmitted infections. Methods We seached Medline, Embase, CINAHL, PsychINFO, BNI, and Cochrane Database of Systematic Reviews to identify relevant articles published in English between Jan 1, 1980, and March 28, 2014. Key words used were "self-sampl*" or "home-sampl*" or "self-test*" or "home-test*" or "self-swab*" or "home-swab*" or "self-collect*" or "home-collect*" and were combined with "acceptab*" or "prefer*" or "experience*" or "feasib*". Studies were included if participants self-sampled for the diagnosis of a curable sexually transmitted infection and had specifically sought participants' opinions of their experience, acceptability, preferences, or willingness to self-sample. Findings 45 studies were eligible for inclusion. Many variations existed, particularly of screening methods, settings of self-sampling (ranging from specialist centres to non-specialist health-care settings), and methods of ascertaining acceptability. 22 studies reported that the self-sampling experience was generally well received, highly acceptable, or comfortable. The 28 studies describing ease of self-sampling reported it as an easy procedure. Self-sampling was favoured over clinician sampling, and home sampling was preferred to clinic-based sampling. Female and older participants were more accepting of self-sampling than male and younger participants. Only a small minority of participants reported pain during self-sampling. Participants were willing to undergo self-sampling and recommend others to use self-sampling in the future. Safety was the most common concern followed by confidentiality and privacy. Only six studies used validated questionnaires. Interpretation Our systematic review found that self-sampling for diagnostic testing is well accepted, with most people having a positive experience and willingness to use it again. Most studies were conducted in non-specialist health-care settings, making the findings of our review more generalisable. Standardisation of self-sampling procedures and rigorous validation of outcome measurement will lead to better comparability across studies. Future studies need to conduct rigorous economic evaluations of self-sampling to develop an effective policy for the management of sexually transmitted infections. Funding None.

Introduction: The political preference of voters has been shown to be associated with their health status. We investigated the relationship between political preferences and mortality in Poland around the time of the last three general elections.Methods: We used the electoral data from the general elections held in 2001, 2005 and 2007. Indicators of political ideological preference were constructed based on the percentage of votes gathered by each party. Data on mortality, education and income level were obtained from 2002-2007 from the Polish Central Statistical Office. Pearson correlation was computed between standardised mortality ratios (SMR) and political preference. Finally, the influence of political preference on SMR was examined in a multivariate analysis controlling for socio-economic factors.Results: SMR was positively correlated with liberal political views (0.26; pConclusion: Our findings are consistent with earlier studies conducted in western countries showing a positive correlation between liberal political ideology and SMR, but differ in that an inverse relationship was found between conservative political orientation with education and income. The importance of socioeconomic and geographical factors in relation to political affiliation and health inequalities in Poland should be further explored.