Background Falls are the leading cause of fatal and non-fatal unintentional injuries in older people. The use of Exergames (active, gamified video-based exercises) is a possible innovative, community-based approach. This study aimed to determine the effectiveness of a tailored OTAGO/FaME-based strength and balance Exergame programme for improving balance, maintaining function and reducing falls risk in older people. Methods A two-arm cluster randomised controlled trial recruiting adults aged 55 years and older living in 18 assisted living (sheltered housing) facilities (clusters) in the UK. Standard care (physiotherapy advice and leaflet) was compared to a tailored 12-week strength and balance Exergame programme, supported by physiotherapists or trained assistants. Complete case analysis (intention-to-treat) was used to compare the Berg Balance Scale (BBS) at baseline and at 12 weeks. Secondary outcomes included fear of falling, mobility, fall risk, pain, mood, fatigue, cognition, healthcare utilisation and health-related quality of life, and self-reported physical activity and falls. Results Eighteen clusters were randomised (9 to each arm) with 56 participants allocated to the intervention and 50 to the control (78% female, mean age 78 years). Fourteen participants withdrew over the 12 weeks (both arms), mainly for ill health. There was an adjusted mean improvement in balance (BBS) of 6.2 (95% CI 2.4 to 10.0) and reduced fear of falling ( p = 0.007) and pain ( p = 0.02) in the Exergame group. Mean attendance at sessions was 69% (mean exercising time of 33 min/week). Twenty-four percent of the control group and 20% of the Exergame group fell over the trial period. The change in fall rates significantly favoured the intervention (incident rate ratio 0.31 (95% CI 0.16 to 0.62, p = 0.001)). The point estimate of the incremental cost-effectiveness ratio (ICER) was £15,209.80 per quality-adjusted life year (QALY). Using 10,000 bootstrap replications, at the lower bound of the NICE threshold of £20,000 per QALY, there was a 61% probability of Exergames being cost-effective, rising to 73% at the upper bound of £30,000 per QALY. Conclusions Exergames, as delivered in this trial, improve balance, pain and fear of falling and are a cost-effective fall prevention strategy in assisted living facilities for people aged 55 years or older. Trial registration The trial was registered at ClinicalTrials.gov on 18 Dec 2015 with reference number NCT02634736 . Electronic supplementary material The online version of this article (10.1186/s12916-019-1278-9) contains supplementary material, which is available to authorized users.

background Despite simpler regimens than vitamin K antagonists (VKas) for stroke prevention in atrial fibrillation (aF), adherence (taking drugs as prescribed) and persistence (continuation of drugs) to direct oral anticoagulants are suboptimal, yet understudied in electronic health records (ehrs). Objective We investigated (1) time trends at individual and system levels, and (2) the risk factors for and associations between adherence and persistence. Methods in UK primary care ehr (The health information network 2011-2016), we investigated adherence and persistence at 1 year for oral anticoagulants (Oacs) in adults with incident aF. Baseline characteristics were analysed by Oac and adherence/persistence status. risk factors for nonadherence and non-persistence were assessed using cox and logistic regression. Patterns of adherence and persistence were analysed. results among 36 652 individuals with incident aF, cardiovascular comorbidities (median cha 2 Ds 2 Vasc[congestive heart failure, hypertension, age≥75 years, Diabetes mellitus, stroke, Vascular disease, age 65-74 years, sex category] 3) and polypharmacy (median number of drugs 6) were common. adherence was 55.2% (95% ci 54.6 to 55.7), 51.2% (95% ci 50.6 to 51.8), 66.5% (95% ci 63.7 to 69.2), 63.1% (95% ci 61.8 to 64.4) and 64.7% (95% ci 63.2 to 66.1) for all Oacs, VKa, dabigatran, rivaroxaban and apixaban.One-year persistence was 65.9% (95% ci 65.4 to 66.5), 63.4% (95% ci 62.8 to 64.0), 61.4% (95% ci 58.3 to 64.2), 72.3% (95% ci 70.9 to 73.7) and 78.7% (95% ci 77.1 to 80.1) for all Oacs, VKa, dabigatran, rivaroxaban and apixaban. risk of non-adherence and non-persistence increased over time at individual and system levels. increasing comorbidity was associated with reduced risk of non-adherence and non-persistence across all Oacs. Overall rates of 'primary non-adherence' (stopping after first prescription), 'non-adherent nonpersistence' and 'persistent adherence' were 3.5%, 26.5% and 40.2%, differing across Oacs. Conclusions adherence and persistence to Oacs are low at 1 year with heterogeneity across drugs and over time at individual and system levels. Better understanding of contributory factors will inform interventions to improve adherence and persistence across Oacs in individuals and populations.on July 10, 2020 by guest. Protected by copyright.

Aims: This review aims to explore the prevalence and incidence rates of mental health conditions in healthcare workers during and after a pandemic outbreak and which factors influence rates.Background: Pandemics place considerable burden on care services, impacting on workers' health and their ability to deliver services. We systematically reviewed the prevalence and incidence of mental health conditions in care workers during pandemics.Design: Systematic review and meta-analysis. Data sources: Searches of MEDLINE, Embase, Cochrane Library and PsychINFO for cohort, cross-sectional and case-control studies were undertaken on the 31 March 2020 (from inception to 31 March 2020).Review methods: Only prevalence or incidence rates for mental health conditions from validated tools were included. Study selection, data extraction and quality assessment were carried out by two reviewers. Meta-analyses and subgroup analyses were produced for pandemic period (pre-and post), age, country income, country, clinical setting for major depression disorder (MDD), anxiety disorder and post-traumatic stress disorder (PTSD). Results:No studies of incidence were found. Prevalence estimates showed that the most common mental health condition was PTSD (21.7%) followed by anxiety disorder (16.1%), MDD (13.4%) and acute stress disorder (7.4%) (low risk of bias).For symptoms of these conditions there was substantial variation in the prevalence estimates for depression (95% confidence interval [CI]:31.8%; 60.5%), anxiety (95% CI:34.2%; 57.7%) and PTSD symptoms (95% CI,21.4%; 65.4%) (moderate risk of bias).Age, level of exposure and type of care professional were identified as important moderating factors. Conclusion:Mental disorders affect healthcare workers during and after infectious disease pandemics, with higher proportions experiencing symptoms.

Purpose Personalised information and support can be provided to cancer survivors using a structured approach. Needs assessment tools such as the Holistic Needs Assessment (HNA) in the UK and the Comprehensive Problem and Symptom Screening (COMPASS) questionnaire in Canada are recommended for use in practice; however, they are not widely embedded into practice. The study aimed to determine the extent to which nurses working in cancer care in the UK and Manitoba value NA and identify any barriers and facilitators they experience. Method Oncology nurses involved in the care of cancer patients in the UK (n = 110) and Manitoba (n = 221) were emailed a link to an online survey by lead cancer nurses in the participating institutions. A snowball technique was used to increase participation across the UK resulting in 306 oncology nurses completing the survey in the UK and 116 in Canada. Results Participants expressed concerns that these assessments were becoming bureaucratic “tick-box exercises” which did not meet patients’ needs. Barriers to completion were time, staff shortages, lack of confidence, privacy, and resources. Facilitators were privacy for confidential discussions, training, confidence in knowledge and skills, and referral to resources. Conclusion Many busy oncology nurses completed this survey demonstrating the importance they attach to HNAs and COMPASS. The challenges faced with implementing these assessments into everyday practice require training, time, support services, and an appropriate environment. It is vital that the HNA and COMPASS are conducted at optimum times for patients to fully utilise time and resources.

Background The aim of this study was to identify key indicator symptoms and patient factors associated with correct out of hospital cardiac arrest (OHCA) dispatch allocation. In previous studies, from 3% to 62% of OHCAs are not recognised by Emergency Medical Service call handlers, resulting in delayed arrival at scene. Methods Retrospective, mixed methods study including all suspected or confirmed OHCA patients transferred to one acute hospital from its associated regional Emergency Medical Service in England from 1/7/2013 to 30/6/2014. Emergency Medical Service and hospital data, including voice recordings of EMS calls, were analysed to identify predictors of recognition of OHCA by call handlers. Logistic regression was used to explore the role of the most frequently occurring (key) indicator symptoms and characteristics in predicting a correct dispatch for patients with OHCA. Results A total of 39,136 dispatches were made which resulted in transfer to the hospital within the study period, including 184 patients with OHCA. The use of the term ‘Unconscious’ plus one or more of symptoms ‘Not breathing/Ineffective breathing/Noisy breathing’ occurred in 79.8% of all OHCAs, but only 72.8% of OHCAs were correctly dispatched as such. ‘Not breathing’ was associated with recognition of OHCA by call handlers (Odds Ratio (OR) 3.76). The presence of key indicator symptoms ‘Breathing’ (OR 0.29), ‘Reduced or fluctuating level of consciousness’ (OR 0.24), abnormal pulse/heart rate (OR 0.26) and the characteristic ‘Female patient’ (OR 0.40) were associated with lack of recognition of OHCA by call handlers (p-values < 0.05). Conclusions There is a small proportion of calls in which cardiac arrest indicators are described but the call is not dispatched as such. Stricter adherence to dispatch protocols may improve call handlers’ OHCA recognition. The existing dispatch protocol would not be improved by the addition of further terms as this would be at the expense of dispatch specificity.

Background and Purpose— Identifying the etiology of acute ischemic stroke is essential for effective secondary prevention. However, in at least one third of ischemic strokes, existing investigative protocols fail to determine the underlying cause. Establishing etiology is complicated by variation in clinical practice, often reflecting preferences of treating clinicians and variable availability of investigative techniques. In this review, we systematically assess the extent to which there exists consensus, disagreement, and gaps in clinical practice recommendations on etiologic workup in acute ischemic stroke. Methods— We identified clinical practice guidelines/consensus statements through searches of 4 electronic databases and hand-searching of websites/reference lists. Two reviewers independently assessed reports for eligibility. We extracted data on report characteristics and recommendations relating to etiologic workup in acute ischemic stroke and in cases of cryptogenic stroke. Quality was assessed using the AGREE II tool (Appraisal of Guidelines for Research & Evaluation). Recommendations were synthesized according to a published algorithm for diagnostic evaluation in cryptogenic stroke. Results— We retrieved 16 clinical practice guidelines and 7 consensus statements addressing acute stroke management (n=12), atrial fibrillation (n=5), imaging (n=5), and secondary prevention (n=1). Five reports were of overall high quality. For all patients, guidelines recommended routine brain imaging, noninvasive vascular imaging, a 12-lead ECG, and routine blood tests/laboratory investigations. Additionally, ECG monitoring (>24 hours) was recommended for patients with suspected embolic stroke and echocardiography for patients with suspected cardiac source. Three reports recommended investigations for rarer causes of stroke. None of the reports provided guidance on the extent of investigation needed before classifying a stroke as cryptogenic. Conclusions— While consensus exists surrounding standard etiologic workup, there is little agreement on more advanced investigations for rarer causes of acute ischemic stroke. This gap in guidance, and in the underpinning evidence, demonstrates missed opportunities to better understand and protect against ongoing stroke risk. Registration— URL: https://www.crd.york.ac.uk/PROSPERO/ ; Unique identifier: CRD42019127822.

Background Mass outbreaks such as pandemics are associated with mental health problems requiring effective psychological interventions. Although several forms of psychological interventions may be advocated or used, some may lack strong evidence of efficacy and some may not have been evaluated in mass infectious disease outbreaks. This paper reports a systematic review of published studies (PROSPERO CRD:42020182094. Registered: 24.04.2020) examining the types and effectiveness of psychological support interventions for the general population and healthcare workers exposed to mass infectious disease outbreaks. Methods A systematic review was conducted. Randomised Controlled Trials (RCT) were identified through searches of electronic databases: Medline (Ovid), Embase (Ovid), PsycINFO (EBSCO) and the Cochrane Library Database from inception to 06.05.2021 using an agreed search strategy. Studies were included if they assessed the effectiveness of interventions providing psychological support to the general population and / or healthcare workers exposed to mass infectious disease outbreaks. Studies were excluded if they focused on man-made or natural disasters or if they included armed forces, police, fire-fighters or coastguards. Results Twenty-two RCTs were included after screening. Various psychological interventions have been used: therapist-guided therapy (n = 1); online counselling (n = 1); ‘Emotional Freedom Techniques’ (n = 1); mobile phone apps (n = 2); brief crisis intervention (n = 1); psychological-behavioural intervention (n = 1); Cognitive Behavioural Therapy (n = 3); progressive muscle relaxation (n = 2); emotional-based directed drawing (n = 1); psycho-educational debriefing (n = 1); guided imagery (n = 1); Eye Movement Desensitization and Reprocessing (EMDR) (n = 1); expressive writing (n = 2); tailored intervention for patients with a chronic medical conditions (n = 1); community health workers (n = 1); self-guided psychological intervention (n = 1), and a digital behaviour change intervention (n = 1). Meta-analyses showed that psychological interventions had a statistically significant benefit in managing depression (Standardised Mean Difference [SMD]: -0.40; 95% Confidence Interval [CI]: − 0.76 to − 0.03), and anxiety (SMD: -0.72; 95% CI: − 1.03 to − 0.40). The effect on stress was equivocal (SMD: 0.16; 95% CI: − 0.19 to 0.51). The heterogeneity of studies, studies’ high risk of bias, and the lack of available evidence means uncertainty remains. Conclusions Further RCTs and intervention studies involving representative study populations are needed to inform the development of targeted and tailored psychological interventions for those exposed to mass infectious disease outbreaks.

Background Digital health interventions (DHIs) can improve the provision of health care services. To fully account for their effects in economic evaluations, traditional methods based on measuring health-related quality of life may not be appropriate, as nonhealth and process outcomes are likely to be relevant too. Purpose This systematic review identifies, assesses, and synthesizes the arguments on the analytical frameworks and outcome measures used in the economic evaluations of DHIs. The results informed recommendations for future economic evaluations. Data Sources We ran searches on multiple databases, complemented by gray literature and backward and forward citation searches. Study Selection We included records containing theoretical and empirical arguments associated with the use of analytical frameworks and outcome measures for economic evaluations of DHIs. Following title/abstract and full-text screening, our final analysis included 15 studies. Data Extraction The arguments we extracted related to analytical frameworks (14 studies), generic outcome measures (5 studies), techniques used to elicit utility values (3 studies), and disease-specific outcome measures and instruments to collect health states data (both from 2 studies). Data Synthesis Rather than assessing the quality of the studies, we critically assessed and synthesized the extracted arguments. Building on this synthesis, we developed a 3-stage set of recommendations in which we encourage the use of impact matrices and analyses of equity impacts to integrate traditional economic evaluation methods. Limitations Our review and recommendations explored but not fully covered other potentially important aspects of economic evaluations that were outside our scope. Conclusions This is the first systematic review that summarizes the arguments on how the effects of DHIs could be measured in economic evaluations. Our recommendations will help design future economic evaluations. Highlights Using traditional outcome measures based on health-related quality of life (such as the quality-adjusted life-year) may not be appropriate in economic evaluations of digital health interventions, which are likely to trigger nonhealth and process outcomes. This is the first systematic review to investigate how the effects of digital health interventions could be measured in economic evaluations. We extracted and synthesized different arguments from the literature, outlining advantages and disadvantages associated with different methods used to measure the effects of digital health interventions. We propose a methodological set of recommendations in which 1) we suggest that researchers consider the use of impact matrices and cost-consequence analysis, 2) we discuss the suitability of analytical frameworks and outcome measures available in economic evaluations, and 3) we highlight the need for analyses of equity impacts.