Potential uses of Bayesian networks as tools for synthesis of systematic reviews of complex interventions

Bayesian networks (BNs) are tools for representing expert knowledge or evidence. They are especially useful for synthesising evidence or belief concerning a complex intervention, assessing the sensitivity of outcomes to different situations or contextual frameworks and framing decision problems that involve alternative types of intervention. Bayesian networks are useful extensions to logic maps when initiating a review or to facilitate synthesis and bridge the gap between evidence acquisition and decision-making. Formal elicitation techniques allow development of BNs on the basis of expert opinion. Such applications are useful alternatives to ‘empty’ reviews, which identify knowledge gaps but fail to support decision-making. Where review evidence exists, it can inform the development of a BN. We illustrate the construction of a BN using a motivating example that demonstrates how BNs can ensure coherence, transparently structure the problem addressed by a complex intervention and assess sensitivity to context, all of which are critical components of robust reviews of complex interventions. We suggest that BNs should be utilised to routinely synthesise reviews of complex interventions or empty reviews where decisions must be made despite poor evidence.

High incidence of contaminating maternal cell overgrowth in human placental mesenchymal stem/stromal cell cultures: A systematic review

Placenta is a readily accessible translationally advantageous source of mesenchymal stem/stromal cells (MSCs) currently used in cryobanking and clinical trials. MSCs cultured from human chorion have been widely assumed to be fetal in origin, despite evidence that placental MSCs may be contaminated with maternal cells, resulting in entirely maternally derived MSC cultures. To document the frequency and determinants of maternal cell contamination in chorionic MSCs, we undertook a PRISMA-compliant systematic review of publications in the PubMed, Medline, and Embase databases (January 2000 to July 2013) on placental and/or chorionic MSCs from uncomplicated pregnancies. Of 147 studies, only 26 (18%) investigated fetal and/or maternal cell origin. After excluding studies that did not satisfy minimal MSC criteria, 7 of 15 informative studies documented MSC cultures as entirely fetal, a further 7 studies reported cultured human chorionic MSC populations to be either maternal (n=6) or mixed (n=1), whereas 1 study separately cultured pure fetal and pure maternal MSC from the same placenta. Maternal cell contamination was associated with term and chorionic membrane samples and greater passage number but was still present in 30% of studies of chorionic villous MSCs. Although most studies assume fetal origin for MSCs sourced from chorion, this systematic review documents a high incidence of maternal-origin MSC populations in placental MSC cultures. Given that fetal MSCs have more primitive properties than adult MSCs, our findings have implications for clinical trials in which knowledge of donor and tissue source is pivotal. We recommend sensitive methods to quantitate the source and purity of placental MSCs.

Nutrition intervention approaches to reduce malnutrition in oncology patients: A systematic review

Purpose Malnutrition is a very common problem in oncology patients and is associated with many negative consequences including poorer prognosis, quality of life and survival. However, malnutrition in oncology patients is often overlooked although there is growing evidence showing that it can be prevented or reduced through nutrition intervention. This paper aims to provide an updated review on the effectiveness of different nutrition intervention approaches on nutrition status outcomes in oncology patients. Methods Randomised controlled trials (RCTs) published between 1994 and 2014 which examined the effects of nutrition intervention approaches—in particular, nutrition counselling (NC), oral nutrition supplements (ONS) and tube feeding (TF)—on nutrition status outcomes of oncology patients were identified and reviewed. Results Thirteen papers from 11 RCTs with a total of 1077 participants were included. The intervention approaches included NC (four studies), NC + ONS (five studies), ONS (three studies) and TF (three studies). The various results suggest that NC with or without ONS was associated with consistent improvements in several nutrition status outcomes. On the other hand, ONS and TF were associated with inconsistent improvements in few aspects of nutrition status outcomes. Conclusions The referral of oncology patients for NC is recommended given the strong evidence of its beneficial effects on the prevention and reduction of malnutrition. Other forms of nutrition support including ONS and TF may then be included if deemed suitable and necessary for the individual.

Systematic and Day-to-Day Effects of Chemical-Derived Population Estimates on Wastewater-Based Drug Epidemiology

Population size is crucial when estimating population-normalized drug consumption (PNDC) from wastewater-based drug epidemiology (WBDE). Three conceptually different population estimates can be used: de jure (common census, residence), de facto (all persons within a sewer catchment), and chemical loads (contributors to the sampled wastewater). De facto and chemical loads will be the same where all households contribute to a central sewer system without wastewater loss. This study explored the feasibility of determining a de facto population and its effect on estimating PNDC in an urban community over an extended period. Drugs and other chemicals were analyzed in 311 daily composite wastewater samples. The daily estimated de facto population (using chemical loads) was on average 32% higher than the de jure population. Consequently, using the latter would systemically overestimate PNDC by 22%. However, the relative day-to-day pattern of drug consumption was similar regardless of the type of normalization as daily illicit drug loads appeared to vary substantially more than the population. Using chemical loads population, we objectively quantified the total methodological uncertainty of PNDC and reduced it by a factor of 2. Our study illustrated the potential benefits of using chemical loads population for obtaining more robust PNDC data in WBDE.

The burden of child maltreatment in China: a systematic review

Objective To estimate the health and economic burdens of child maltreatment in China. Methods We did a systematic review for studies on child maltreatment in China using PubMed, Embase, PsycInfo, CINAHL-EBSCO, ERIC and the Chinese National Knowledge Infrastructure databases. We did meta-analyses of studies that met inclusion criteria to estimate the prevalence of child neglect and child physical, emotional and sexual abuse. We used data from the 2010 global burden of disease estimates to calculate disability-adjusted life-years (DALYs) lost as a result of child maltreatment. Findings From 68 studies we estimated that 26.6% of children under 18 years of age have suffered physical abuse, 19.6% emotional abuse, 8.7% sexual abuse and 26.0% neglect. We estimate that emotional abuse in childhood accounts for 26.3% of the DALYs lost because of mental disorders and 18.0% of those lost because of self-harm. Physical abuse in childhood accounts for 12.2% of DALYs lost because of depression, 17.0% of those lost to anxiety, 20.7% of those lost to problem drinking, 18.8% of those lost to illicit drug use and 18.3% of those lost to self-harm. The consequences of physical abuse of children costs China an estimated 0.84% of its gross domestic product – i.e. 50 billion United States dollars – in 2010. The corresponding losses attributable to emotional and sexual abuse in childhood were 0.47% and 0.39% of the gross domestic product, respectively. Conclusion In China, child maltreatment is common and associated with large economic losses because many maltreated children suffer substantial psychological distress and might adopt behaviours that increase their risk of chronic disease.

Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Background Up-to-date evidence about levels and trends in disease and injury incidence, prevalence, and years lived with disability (YLDs) is an essential input into global, regional, and national health policies. In the Global Burden of Disease Study 2013 (GBD 2013), we estimated these quantities for acute and chronic diseases and injuries for 188 countries between 1990 and 2013. Methods Estimates were calculated for disease and injury incidence, prevalence, and YLDs using GBD 2010 methods with some important refi nements. Results for incidence of acute disorders and prevalence of chronic disorders are new additions to the analysis. Key improvements include expansion to the cause and sequelae list, updated systematic reviews, use of detailed injury codes, improvements to the Bayesian meta-regression method (DisMod-MR), and use of severity splits for various causes. An index of data representativeness, showing data availability, was calculated for each cause and impairment during three periods globally and at the country level for 2013. In total, 35 620 distinct sources of data were used and documented to calculated estimates for 301 diseases and injuries and 2337 sequelae. The comorbidity simulation provides estimates for the number of sequelae, concurrently, by individuals by country, year, age, and sex. Disability weights were updated with the addition of new population-based survey data from four countries. Findings Disease and injury were highly prevalent; only a small fraction of individuals had no sequelae. Comorbidity rose substantially with age and in absolute terms from 1990 to 2013. Incidence of acute sequelae were predominantly infectious diseases and short-term injuries, with over 2 billion cases of upper respiratory infections and diarrhoeal disease episodes in 2013, with the notable exception of tooth pain due to permanent caries with more than 200 million incident cases in 2013. Conversely, leading chronic sequelae were largely attributable to non-communicable diseases, with prevalence estimates for asymptomatic permanent caries and tension-type headache of 2∙4 billion and 1∙6 billion, respectively. The distribution of the number of sequelae in populations varied widely across regions, with an expected relation between age and disease prevalence. YLDs for both sexes increased from 537∙6 million in 1990 to 764∙8 million in 2013 due to population growth and ageing, whereas the age-standardised rate decreased little from 114∙87 per 1000 people to 110∙31 per 1000 people between 1990 and 2013. Leading causes of YLDs included low back pain and major depressive disorder among the top ten causes of YLDs in every country. YLD rates per person, by major cause groups, indicated the main drivers of increases were due to musculoskeletal, mental, and substance use disorders, neurological disorders, and chronic respiratory diseases; however HIV/AIDS was a notable driver of increasing YLDs in sub-Saharan Africa. Also, the proportion of disability-adjusted life years due to YLDs increased globally from 21·1% in 1990 to 31·2% in 2013. Interpretation Ageing of the world’s population is leading to a substantial increase in the numbers of individuals with sequelae of diseases and injuries. Rates of YLDs are declining much more slowly than mortality rates. The non-fatal dimensions of disease and injury will require more and more attention from health systems. The transition to nonfatal outcomes as the dominant source of burden of disease is occurring rapidly outside of sub-Saharan Africa. Our results can guide future health initiatives through examination of epidemiological trends and a better understanding of variation across countries.

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk–outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990–2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8–58·5) of deaths and 41·6% (40·1–43·0) of DALYs. Risks quantified account for 87·9% (86·5–89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

The effect of ginger (Zingiber officinale) on platelet aggregation: A systematic literature review

Background The potential effect of ginger on platelet aggregation is a widely-cited concern both within the published literature and to clinicians; however, there has been no systematic appraisal of the evidence to date. Methods Using the PRISMA guidelines, we systematically reviewed the results of clinical and observational trials regarding the effect of ginger on platelet aggregation in adults compared to either placebo or baseline data. Studies included in this review stipulated the independent variable was a ginger preparation or isolated ginger compound, and used measures of platelet aggregation as the primary outcome. Results Ten studies were included, comprising eight clinical trials and two observational studies. Of the eight clinical trials, four reported that ginger reduced platelet aggregation, while the remaining four reported no effect. The two observational studies also reported mixed findings. Discussion Many of the studies appraised for this review had moderate risks of bias. Methodology varied considerably between studies, notably the timeframe studied, dose of ginger used, and the characteristics of subjects recruited (e.g. healthy vs. patients with chronic diseases). Conclusion The evidence that ginger affects platelet aggregation and coagulation is equivocal and further study is needed to definitively address this question.

The short-term impact of curative colorectal cancer treatment on physical activity, functional status and quality of life: A systematic review protocol

REVIEW QUESTION/OBJECTIVE The quantitative objectives are to identify the impact of curative colorectal cancer treatment (surgery or adjuvant therapy) on physical activity, functional status and quality of life within one year of treatment or diagnosis. INCLUSION CRITERIA Types of participants: This review will consider studies that include individuals aged 18 years and over who have been diagnosed with colorectal cancer. Types of intervention(s)/phenomena of interest: This review will consider studies that evaluate the impact of curative colorectal cancer treatment: surgery and/or adjuvant therapy. Types of outcomes: This review will consider studies that include the following outcome measures assessed within one year of diagnosis or treatment: Physical activity - any bodily movement produced by skeletal muscles resulting in energy expenditure. Physical activity is not exclusive to exercise; activities can also be walking, housework, occupational or leisure. Physical activity can be measured objectively using pedometers or accelerometers, or subjectively using self-reported measures. Functional status – measured as the capacity to perform all activities of daily living such as walking, showering, and eating; and instrumental activities of daily living such as (but not limited to) grocery shopping, housekeeping and laundry. Quality of life – defined as the individual meaning of mental, physical and psychosocial wellbeing, as measured by validated tools such as SF-36, EORTC-QLQ-C30, or FACT-C.

The effectiveness of peer-based interventions on health promoting behaviors in older people: A systematic review protocol of quantitative evidence

Peer-based interventions have the potential to enhance quality of life and functioning; however their role specifically within the older population has not been fully investigated. The objective of this review therefore is to locate, appraise and synthesise evidence on the effectiveness of peer-based interventions on changes in health behaviors, specifically for the older population. The specific question to be answered is: “what is the effectiveness of peer-based interventions on health promoting behaviors in older adults, when compared to non peer-based interventions?”

“Success in (Surviving) Bioscience and Pharmacology” – an eBook to improve the retention of diploma nurses transitioning to a Bachelor of Nursing course

Diploma students transitioning into the NS40 BNursing (BN) course at QUT withdraw from the bioscience and pharmacology units, and leave the university at higher rates than traditional students. The diploma students, entering in second year, have missed out on 2 units of bioscience taught to the traditional students in their first year, and miss out on a 3rd unit of bioscience taught to the traditional students in their 2nd year. Instead the diploma students receive one specialized unit in bioscience only i.e. a bridging unit. As a consequence, the diploma students may not have the depth of bioscience knowledge to be able to successfully study the bridging unit (LSB111) or the pharmacology unit (LSB384). Our plan was to write an eBook which refreshed and reinforced diploma students’ knowledge of bioscience aiming to prepare them with the concepts and terminology, and to build a level of confidence to support their transition to the BN. We have previously developed an intervention associated with reduced attrition of diploma nursing students, and this was our starting point. The study skills part of the initial intervention was addressed in the eBook, by links to the specialist services and resources available from our liaison librarian and academic skills adviser. The introductory bioscience/pharmacology information provided by the previous intervention involved material from standard textbooks. However, we considered this material too difficult for diploma students. Thus, we created simplified diagrams to go with text as part of our eBook. The outcome is an eBook, created and made available to the diploma students via the Community Website: “Surviving Bioscience and Pharmacology”. Using simplified diagrams to illustrate the concise text, definition to explain the concepts, the focus has been on encouraging self-awareness and help-seeking strategies and building students who take responsibility for their learning. All the nursing students in the second semester LSB384 Pharmacology Unit have been surveyed face-to-face to get feedback on their engagement with the eBook resource. The data has not been analysed to date. An important consideration is that the website be evaluated by the diploma students as they come into bioscience in first semester (LSB111), the student population for whom the eBook is primarily intended. To get a good response rate we need to do a face-to-face survey. However, we have not been able to do this, as the co-ordinator of the unit has changed since we started the project, and the present co-ordinator will not allow us access to these students.

Digital innovation in social marketing: A systematic literature of interventions using digital channels for engagement

Social marketing uses commercial marketing techniques to deliver interventions for social benefit in order to improve quality of life for individuals and communities. Behaviour change is the primary objective of social marketing interventions (Andreasen 2002). The aim of this systematic review is to provide insight into social marketing interventions and their evaluations published in peer-reviewed journals so as to identify the key elements of social marketing employed by these interventions. as well as understand the use of digital channels for engagement.

Exercise improves quality of life in ADT-treated prostate cancer: Systematic review of RCTs

Men receiving androgen deprivation therapy (ADT) for prostate cancer (PCa) are likely to develop metabolic conditions such as diabetes, cardiovascular disease, abdominal obesity and osteoporosis. Other treatment-related side effects adversely influence quality of life (QoL) including vasomotor distress, depression, anxiety, mood swings, poor sleep quality and compromised sexual function. The objective of this study was to systematically review the nature and effects of dietary and exercise interventions on QoL, androgen deprivation symptoms and metabolic risk factors in men with PCa undergoing ADT. An electronic search of CINAHL, CENTRAL, Medline, PsychINFO and reference lists was performed to identify peer-reviewed articles published between January 2004 and December, 2014 in English. Eligible study designs included randomised controlled trials with pre- and post-intervention data. Data extraction and assessment of methodological quality with the Cochrane approach was conducted by two independent reviewers. Seven exercise studies were identified. Exercise significantly improved QoL, but showed no effect on metabolic risk factors (weight, waist circumference, lean or fat mass, blood pressure, lipid profile). Two dietary studies were identified, both of which tested soy supplements. Soy supplementation did not improve any outcomes. No dietary counselling studies were identified. No studies evaluated androgen-deficiency symptoms (libido, erectile function, sleep quality, mood swings, depression, anxiety, bone mineral density). Evidence from RCTs indicates that exercise enhances health- and disease-specific QoL in men with PCa undergoing ADT. Further studies are required to evaluate the effect of exercise and dietary interventions on QoL, androgen deprivation symptoms and metabolic risk factors in this cohort.

Workplace acceptance and experiences of LGBTIQ health professionals: A systematic literature review

Background The purpose of this study was to explore the workplace acceptance and experiences of lesbian, gay, bisexual, transgender, intersex and queer (LGBTIQ) paramedics. Methods A systematic search of academic databases and reference lists from selected papers were the sources of the data. Inclusion criteria were research papers published in English, which focused on workplace acceptance and experiences of LGBTIQ health personnel. Results The initial focus of this systematic review was the workplace acceptance and experiences of LGBTIQ paramedics. However due to no published research specific to the paramedic profession the scope of the review was broadened to include of all LGBTIQ health personnel. Thirty-three papers were included in this review. Evidence indicated that LGBTIQ health professionals experienced discrimination from their patients, heterosexual colleagues and ‘closeted’ LGBTIQ peers. Positive contribution of LGBTIQ health professionals include improved patient care and role models for LGBTIQ peers. Inclusive policy is required for LGBTIQ health professional workforce retention. Conclusions The paramedic workforce is known to be a high risk occupational group for post-traumatic stress disorder and depression. Theoretically, LGBTIQ paramedics working in a heteronormative culture experience increased level of stress. While LGBTIQ health professionals receive legislative protection against discrimination, discrimination still exists in practice through lack of visibility. Effective and efficient integration of LGBTIQ health professionals could improve workplace satisfaction, workforce retention, and equity of access by marginalised groups. An inclusive workplace policy of LGBTIQ embraces and celebrates the value of diversity.

Multidisciplinary review of teaching and assessing competency attainment by non-medical prescribers

Background Prescribing is a complex task, requiring specific knowledge and skills, and the execution of effective, context-specific clinical reasoning. Systematic reviews indicate medical prescribing errors have a median rate of 7% [IQR 2%-14%] of medication orders [1-3]. For podiatrists pursuing prescribing rights, a clear need exists to ensure practitioners develop a well-defined set of prescribing skills, which will contribute to competent, safe and appropriate practice. Aim To investigate the methods employed to teach and assess the principles of effective prescribing in the undergraduate podiatry program and compare and contrast these findings with four other non-medical professions who undertake prescribing after training at Queensland University of Technology. Method The NPS National Prescribing Competency Standards were employed as the prescribing standard. A curriculum mapping exercise was undertaken to determine whether the prescribing principles articulated in the competency standards were addressed by each profession. Results A range of methods are currently utilised to teach prescribing across disciplines. Application of prescribing competencies to the context of each profession appears to influence the teaching methods used. Most competencies were taught using a multimodal format, including interactive lectures, self-directed learning, tutorial sessions and clinical placement. In particular clinical training was identified as the most consistent form of educating safe prescribers across all five disciplines. Assessment of prescribing competency utilised multiple techniques including written and oral examinations and research tasks, case studies, objective structured clinical examination exercises and the assessment of clinical practice. Effective and reliable assessment of prescribing undertaken by students in diverse settings remains challenging e.g. that occurring in the clinical practice environment. Conclusion Recommendations were made to refine curricula and to promote efficient cross-discipline teaching by staff from the disciplines of podiatry, pharmacy, nurse practitioner, optometry and paramedic science. Students now experience a sophisticated level of multidisciplinary learning in the clinical setting which integrates the expertise and skills of experience prescribers combined with innovative information technology platforms (CCTV and live patient assessments). Further work is required to establish a practical, effective approach to the assessment of prescribing competence especially between the university and clinical settings.