ISSN / EISSN : 2044-6055 / 2044-6055
Published by: BMJ (10.1136)
Total articles ≅ 22,776
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BMJ Open, Volume 11; https://doi.org/10.1136/bmjopen-2021-055435
Objectives The steroid hormone vitamin D has roles in immunomodulation and bone health. Insufficiency is associated with susceptibility to respiratory infections. We report 25-hydroxy vitamin D (25(OH)D) measurements in hospitalised people with COVID-19 and influenza A and in survivors of critical illness to test the hypotheses that vitamin D insufficiency scales with illness severity and persists in survivors. Design Cross-sectional study. Setting and participants Plasma was obtained from 295 hospitalised people with COVID-19 (International Severe Acute Respiratory and emerging Infections Consortium (ISARIC)/WHO Clinical Characterization Protocol for Severe Emerging Infections UK study), 93 with influenza A (Mechanisms of Severe Acute Influenza Consortium (MOSAIC) study, during the 2009–2010 H1N1 pandemic) and 139 survivors of non-selected critical illness (prior to the COVID-19 pandemic). Total 25(OH)D was measured by liquid chromatography-tandem mass spectrometry. Free 25(OH)D was measured by ELISA in COVID-19 samples. Outcome measures Receipt of invasive mechanical ventilation (IMV) and in-hospital mortality. Results Vitamin D insufficiency (total 25(OH)D 25–50 nmol/L) and deficiency (<25 nmol/L) were prevalent in COVID-19 (29.3% and 44.4%, respectively), influenza A (47.3% and 37.6%) and critical illness survivors (30.2% and 56.8%). In COVID-19 and influenza A, total 25(OH)D measured early in illness was lower in patients who received IMV (19.6 vs 31.9 nmol/L (p<0.0001) and 22.9 vs 31.1 nmol/L (p=0.0009), respectively). In COVID-19, biologically active free 25(OH)D correlated with total 25(OH)D and was lower in patients who received IMV, but was not associated with selected circulating inflammatory mediators. Conclusions Vitamin D deficiency/insufficiency was present in majority of hospitalised patients with COVID-19 or influenza A and correlated with severity and persisted in critical illness survivors at concentrations expected to disrupt bone metabolism. These findings support early supplementation trials to determine if insufficiency is causal in progression to severe disease, and investigation of longer-term bone health outcomes.
BMJ Open, Volume 11; https://doi.org/10.1136/bmjopen-2021-048922
Introduction Strengthening first-line mental healthcare services for youth remains a priority for the Swedish government. The government is currently investigating how different sectors involved can be strengthened, but evidence is scarce. Youth clinics play a key role in these discussions, being one of the most trusted services for youth. However, analysis of organisational functions and coordination with other services is important to strengthen youth clinics’ role in first-line mental healthcare. This study investigates these challenges and aims to analyse the integration of mental healthcare within youth clinics to identify strategies to strengthen first-line mental healthcare for youth in Sweden. Methods and analysis This study adopts a health policy and systems approach. In the first phase, a formative realist evaluation is conducted to ascertain what works in terms of integrating mental healthcare services within youth clinics, for what type of youth subpopulations and under what circumstances. National-level stakeholders will be interviewed to elicit the programme theory that explains how the intervention is supposed to work. The programme theory will then be tested in three–five cases. The cases will be comprised of youth clinics and their stakeholders. Quantitative and qualitative information will be gathered, including via visual methodologies and questionnaires. The second phase includes a concept mapping study, engaging stakeholders and young people to build consensus on strategies to strengthen the integration of mental healthcare into youth clinics. Ethics and dissemination The Swedish Ethical Review Authority has approved the study (2019-02910 and 2020-04720). The results will be published in open-access peer-reviewed journals and presented at scientific conferences.
BMJ Open, Volume 11; https://doi.org/10.1136/bmjopen-2020-046241
Introduction The functional consequences of the bacterial gut microbiome for child health are not well understood. Characteristics of the early child gut microbiome may influence the course of enteric infections, and enteric infections may change the composition of the gut microbiome, all of which may have long-term implications for child growth and development. Methods and analysis We are conducting a community-based birth cohort study to examine interactions between gut microbiome conditions and enteric infections, and how environmental conditions affect the development of the gut microbiome. We will follow 360 newborns from 3 sites along a rural–urban gradient in northern coastal Ecuador, characterising enteric infections and gut microbial communities in the children every 3 to 6 months over their first 2 years of life. We will use longitudinal regression models to assess the correlation between environmental conditions and gut microbiome diversity and presence of specific taxa, controlling for factors that are known to be associated with the gut microbiome, such as diet. From 6 to 12 months of age, we will collect weekly stool samples to compare microbiome conditions in diarrhoea stools versus stools from healthy children prior to, during and after acute enteric infections, using principal-coordinate analysis and other multivariate statistical methods. Ethics and dissemination Ethics approvals have been obtained from Emory University and the Universidad San Francisco de Quito institutional review boards. The findings will be disseminated through conference presentations and peer-reviewed journals.
BMJ Open, Volume 11; https://doi.org/10.1136/bmjopen-2021-052652
Objectives It is unclear whether kidney disease is a risk factor for developing dementia. We examined the association between kidney disease and risk of future dementia. Design and setting Nationwide historical registry-based cohort study in Denmark based on data from 1 January 1995 until 31 December 2016. Participants All patients diagnosed with kidney disease and matched general population cohort without kidney disease (matched 1:5 on age, sex and year of kidney disease diagnosis). Primary and secondary outcome measures All-cause dementia and its subtypes: Alzheimer’s disease, vascular dementia and other specified or unspecified dementia. We computed 5-year cumulative incidences (risk) and hazard ratios (HRs) for outcomes using Cox regression analyses. Results The study cohort comprised 82 690 patients with kidney disease and 413 405 individuals from the general population. Five-year and ten-year mortality rates were twice as high in patients with kidney disease compared with the general population. The 5-year risk for all-cause dementia was 2.90% (95% confidence interval: 2.78% to 3.08%) in patients with kidney disease and 2.98% (2.92% to 3.04%) in the general population. Compared with the general population, the adjusted HRs for all-cause dementia in patients with kidney disease were 1.06 (1.00 to 1.12) for the 5-year follow-up and 1.08 (1.03 to 1.12) for the entire study period. Risk estimates for dementia subtypes differed substantially and were lower for Alzheimer’s disease and higher for vascular dementia. Conclusions Patients diagnosed with kidney disease have a modestly increased rate of dementia, mainly driven by vascular dementia. Moreover, patients with kidney disease may be underdiagnosed with dementia due to high mortality and other comorbidities of higher priority.
BMJ Open, Volume 11; https://doi.org/10.1136/bmjopen-2020-045233
Introduction Recruitment to randomised trials (RCTs) is often challenging. Reviews of interventions to improve recruitment have highlighted a paucity of effective interventions aimed at recruiters and the need for further research in this area. Understanding the perspectives and experiences of those involved in RCT recruitment can help to identify barriers and facilitators to recruitment, and subsequently inform future interventions to support recruitment. This protocol describes methods for a proposed qualitative evidence synthesis (QES) of recruiters’ perspectives and experiences relating to RCT recruitment. Methods and analysis The proposed review will synthesise studies reporting clinical and non-clinical recruiters’ perspectives and experiences of recruiting to RCTs. The following databases will be searched: Ovid MEDLINE, CINAHL, EMBASE, PsycInfo, Cochrane Central Register of Controlled Trials, ORRCA and Web of Science. A thematic synthesis approach to analysing the data will be used. An assessment of methodological limitations of each study will be performed using the Critical Appraisal Skills Programme tool. Assessing the confidence in the review findings will be evaluated using the GRADE Confidence in Evidence from Reviews of Qualitative research (GRADE-CERQual) tool. Ethics and dissemination The proposed QES will not require ethical approval as it includes only published literature. The results of the synthesis will be published in a peer-reviewed journal and publicised using social media. The results will be considered alongside other work addressing factors affecting recruitment in order to inform future development and refinement of recruitment interventions. PROSPERO registration number CRD42020141297.
BMJ Open, Volume 11; https://doi.org/10.1136/bmjopen-2021-050109
Objectives To investigate experiences of implementing a new rapid sexual health testing, diagnosis and treatment service. Design A theory-based qualitative evaluation with a focused ethnographic approach using non-participant observations and interviews with patient and clinic staff. Normalisation process theory was used to structure interview questions and thematic analysis. Setting A sexual health centre in Bristol, UK. Participants 26 patients and 21 staff involved in the rapid sexually transmitted infection (STI) service were interviewed. Purposive sampling was aimed for a range of views and experiences and sociodemographics and STI results for patients, job grades and roles for staff. 40 hours of observations were conducted. Results Implementation of the new service required co-ordinated changes in practice across multiple staff teams. Patients also needed to make changes to how they accessed the service. Multiple small ‘pilots’ of process changes were necessary to find workable options. For example, the service was introduced in phases beginning with male patients. This responsive operating mode created challenges for delivering comprehensive training and communication in advance to all staff. However, staff worked together to adjust and improve the new service, and morale was buoyed through observing positive impacts on patient care. Patients valued faster results and avoiding unnecessary treatment. Patients reported that they were willing to drop-off self-samples and return for a follow-up appointment, enabling infection-specific treatment in accordance with test results, thus improving antimicrobial stewardship. Conclusions The new service was acceptable to staff and patients. Implementation of service changes to improve access and delivery of care in the context of stretched resources can pose challenges for staff at all levels. Early evaluation of pilots of process changes played an important role in the success of the service by rapidly feeding back issues for adjustment. Visibility to staff of positive impacts on patient care is important in maintaining morale.
BMJ Open, Volume 11; https://doi.org/10.1136/bmjopen-2021-050542
Objective To determine the prevalence and determinants of diabetes mellitus (DM) among tuberculosis (TB) patients and to assess the additional yield and number needed to screen (NNS) to obtain a newly diagnosed DM among TB patients. Design We undertook a cross-sectional analysis of the cohort data under Regional Prospective Observational Research for Tuberculosis-India consortium. Newly diagnosed TB patients recruited into the cohort between 2014 and 2018 were included. Pretested standardised questionnaires and tools were used for data collection. Prevalence of DM among TB patients was summarised as proportion with 95% CI. Type II DM was diagnosed if random blood sugar level was >200 mg/dL or if the participant had a documented history of DM. NNS by blood glucose testing to diagnose one new DM case among TB patients was also calculated. Setting Three districts of South India: Puducherry, Cuddalore and Villupuram Subjects Newly diagnosed sputum smear positive pulmonary TB patients aged ≥16 years Results In total, 1188 TB patients were included. Prevalence of DM among TB patients was 39% (95% CI: 36.2% to 41.8%). In unadjusted analysis, elderly TB, marital status, caste, gender, higher education level, household income and obesity had a significant association with DM. However, in adjusted analysis, only marital status (currently married aPR; 3.77 (95 CI: 2.20 to 6.49), widowed/separated/divorced aPR; 3.66 (95 CI: 1.96 to 6.83)) and body mass index category (normal weight aPR; 3.26 (95 CI: 2.55 to 4.16), overweight aPR; 3.86 (95 CI: 2.69 to 5.52), obesity aPR; 4.08 (95 CI: 2.81 to 5.94)) were found to be significant determinants. The number of TB patients needed to be screened to find a new DM case was 12. Conclusion We found that one in three TB patients had coexisting DM. The number of TB patients needed to be screened to obtain a newly diagnosed DM patients was also determined. The study supports and highlights the need of RNTCP’s effort in bidirectional screening of TB and DM.
BMJ Open, Volume 11; https://doi.org/10.1136/bmjopen-2021-049658
Objectives Despite WHO guidelines recommending household contact investigation, and studies showing the impact of active screening, most tuberculosis (TB) programmes in resource-limited settings only carry out passive contact investigation. The cost of such strategies is often cited as barriers to their implementation. However, little data are available for the additional costs required to implement this strategy. We aimed to estimate the cost and cost-effectiveness of active contact investigation as compared with passive contact investigation in urban Pakistan. Methods We estimated the cost-effectiveness of ‘enhanced’ (passive with follow-up) and ‘active’ (household visit) contact investigations compared with standard ‘passive’ contact investigation from providers and the programme’s perspective using a simple decision tree. Costs were collected in Pakistan from a TB clinic performing passive contact investigation and from studies of active contact tracing interventions conducted. The effectiveness was based on the number of patients with TB identified among household contacts screened. Results The addition of enhanced contact investigation to the existing passive mode detected 3.8 times more cases of TB per index patient compared with passive contact investigation alone. The incremental cost was US$30 per index patient, which yielded an incremental cost of US$120 per incremental patient identified with TB. The active contact investigation was 1.5 times more effective than enhanced contact investigation with an incremental cost of US$238 per incremental patient with TB identified. Conclusion Our results show that enhanced and active approaches to contact investigation effectively identify additional patients with TB among household contacts at a relatively modest cost. These strategies can be added to the passive contact investigation in a high burden setting to find the people with TB who are missed and meet the End TB strategy goals.
BMJ Open, Volume 11; https://doi.org/10.1136/bmjopen-2021-051390
Objectives The aim of this study was to assess the seroprevalence and associated factors of cytomegalovirus (CMV) among pregnant women in Southern Ethiopia. Design Cross-sectional study. Setting The study was conducted in Hawassa University comprehensive and specialised hospital. Hawassa, Southern Ethiopia. Participants A total of 600 consecutive pregnant women attending the delivery ward were recruited for the study from August to October 2020. Outcome measures The study assessed the rate of maternal anti-CMV IgG and IgM antibodies. The association of obstetric history, sociodemographic and behavioural characteristics with seropositivity of CMV was also evaluated based on the collected data using structured questioners. Results Seropositivity for CMV IgM antibodies was 8.2% (49/600) (95% CI 6% to 10.5%), whereas the CMV IgG was 88.7% (532/600), (95% CI 89.5% to 94.0%). Seroprevalence of CMV IgM was higher in women of older age, currently unmarried, having nursery schooled children and with any of the detected curable sexually transmitted infections, while seroprevalence of CMV IgG was significantly associated only with women having nursery schooled children. Seroprevalence was not significantly associated with previous adverse pregnancy outcome, gravidity, being a child daycare occupant mother and newborn birth weight. Conclusion In the present study, we identified a high rate of CMV IgM and CMV IgG seroprevalence among pregnant women in Southern Ethiopia. Given that there is no existing CMV diagnosis, special attention should be designed to pregnant women in parallel to the existing antenatal care facility. Besides, training healthcare professionals will support awareness conception among pregnant women concerning the sequels of CMV infection during pregnancy.
BMJ Open, Volume 11; https://doi.org/10.1136/bmjopen-2019-035315
Objectives The study aimed at identifying the determinants of adolescents’ access to healthcare services. Setting Intermediate and secondary schools across all 13 regions in the Kingdom of Saudi Arabia (KSA) from 2011 to 2012 through the Jeeluna national school-based survey. Participants Intermediate and secondary school students participated in the study. A multistage, cluster, random sampling technique was used. Participants responded to a self-administered questionnaire that addressed several domains. Main outcome measure Adolescents’ perception of access to healthcare services. Results Twenty-five per cent of participants reported difficulty in accessing healthcare. Women, early (younger) adolescents and adolescents with three siblings were less likely to report difficulty in accessing healthcare than men, late (older) adolescents and those with fewer than three siblings. Adolescents from low-income families and those with either mental or physical illness were more likely to report difficulty in accessing healthcare than adolescents from higher income families and those without mental or physical illnesses. Conclusions Disparities in access to care exist between certain subpopulations of adolescents. Efforts are needed to support enhancing access and making it more equitable. Training for healthcare professionals and targeted health policies are necessary to improve adolescents’ access to health services in the KSA. Trial registration number RC08-092; King Abdullah International Medical Research Centre.